slide1 l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Hennie Williams Senior Lecturer in Sexual Health Sexual Health Physician Melbourne Sexual Health Centre School of Popula PowerPoint Presentation
Download Presentation
Hennie Williams Senior Lecturer in Sexual Health Sexual Health Physician Melbourne Sexual Health Centre School of Popula

Loading in 2 Seconds...

play fullscreen
1 / 39

Hennie Williams Senior Lecturer in Sexual Health Sexual Health Physician Melbourne Sexual Health Centre School of Popula - PowerPoint PPT Presentation


  • 192 Views
  • Uploaded on

Pelvic Inflammatory Disease. Hennie Williams Senior Lecturer in Sexual Health Sexual Health Physician Melbourne Sexual Health Centre School of Population Health University of Melbourne. Why is PID a heart sink?. No one can agree what it is how common it is what causes it

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Hennie Williams Senior Lecturer in Sexual Health Sexual Health Physician Melbourne Sexual Health Centre School of Popula' - lixue


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
slide1

Pelvic Inflammatory Disease

Hennie Williams

Senior Lecturer in Sexual Health

Sexual Health Physician

Melbourne Sexual Health Centre

School of Population Health

University of Melbourne

slide2

Why is PID a heart sink?

  • No one can agree
  • what it is
  • how common it is
  • what causes it
    • how to recognise if a patient has it
    • how to test for it
    • how to treat it
  • how commonly it causes complications

But we are certain that it is important not to miss and that it is often sexually transmitted

slide3

Definition

Prevalence

Cause

Symptoms & signs

Diagnosis

Treatment

Complications

slide4

Definition

Prevalence

Cause

Symptoms & signs

Diagnosis

Treatment

Complications

slide5

Definition and terminology

Spectrum of disorders

endometritis

salpingitis

tubo-ovarian abscess

pelvic peritonitis

Organisms from cervix

or vagina to UGT

Blood borne (eg TB)

Post op

Puerperal (delivery or abortion)

Salpingitis: ‘laparoscopic diagnosis’

~2/3 women with clinical PID have salpingitis

remainder other conditions or normal pelvic laparoscopic examination

Upper Genital Tract infection (UGTI)

.

slide6

Definition and terminology

Endometritis

Probably an early stage of PID

May be patchy so can be missed on endometrial sampling

Association with IMB acknowledged since 1985

Definition: > 5 polys /400x field with ≥1 plasma cell /120x field (Kiviat‘s)

40% of women with ‘cervicitis’

66% with chlamydial cervicitis have endometritis

80-90% of women with salpingitits

30% of women with endometritis have salpingitis

Unknown if endometritis alone causes long term sequelae

Wolner-Hansen 1995, Paavonen 1985, Kiviat 1990, Paanoven 1985, Waaserheit 1986, Paavonen 1985 and 1987, Haggerty 2003, Wiesenfeld 2007)

slide7

Definition

Prevalence

Cause

Symptoms & signs

Diagnosis

Treatment

Complications

slide8

Prevalence

Probably main cause of gynaecological pelvic pain

Estimates

8-11% women of child bearing age in USA (Aral Jama 1991)

2% women < 25y in UK primary care (Simms 1999)

1.5% women attending Melbourne SHC (Doxanakis: 2008)

Chlamydia prevalence

often used as a surrogate marker

decreased rates in Scandinavia paralleled by falls in PID

(Australia mean community prevalence rates ~4%)

slide9

Definition

Prevalence

Cause

Symptoms & signs

Diagnosis

Treatment

Complications

slide10

Causative organisms

Normal vaginal flora

- mixed bacteria with lactobacilli predominating

- some ‘normal’ vaginal bacteria are potentially pathogenic

(eg E. coli, Klebsiella, Proteus, strep, staph, anaerobes)

Endocervical canal

- acts as a barrier protecting normally sterile UGT

Disturbance of this barrier provides access for these bacteria to UGT

- 75% of cases PID occur within 7d of menstruation (Eschenbach 1976)

Gonorrhoea and Chlamydia are initiators of PID

- ~15% of women with cervicitis develop PID ( Arya 1981, Forslin 1978)

slide11

Causative organisms

Most polymicrobial

1/3 Chlamydia trachomatis and/or Neisseria gonorrhoea

>50% no proven microbiological causes

With PID

Mycoplasma organisms (eg Ureaplasma urealyticum)

are more common in lower genital tract

Other STIs in vagina (eg Trichomonas) are more common

Role of normal vaginal flora (eg anaerobes, ecoli, proteus) unknown

NB effect of sampling techniques

slide12

Associations with PID

  • Association between BV and PID remains unclear
  • Do BV organisms cause PID?
  • or are they carried by Chlamydia and GC into UGT?
  • BV more common in women with PID (Soper 1994)
  • Prospective study (1179 women with BV over 3y) : no increase in PID
  • (Ness 2004)
  • PID risk increased 2 fold in women with highest counts of BV organisms in clusters (? STI cofactor for BV/PIG) (Ness 2005)
  • Douching: PID is more common in women who douche
  • but these women also have other risk factors for PID
  • (Wolner-Hanssen 1990, Rosenberg 1992)
slide13

Associations with PID

  • age < 25 yrs
  • sexual intercourse < 20 yrs
  • self reported history of STI
  • non white-ethnicity
  • not having had children
  • exposure to Chlamydia

Case control study

140/381 patients with PID in GUM clinic

105 controls from general practice

136 controls from PID free tubal ligation group

slide14

Definition

Prevalence

Cause

Symptoms & signs

Diagnosis

Treatment

Complications

slide15

Symptoms & Signs

Lower abdominal/pelvic pain

Dyspareunia

Irregular vaginal bleeding

(PCB or IMB)

Abnormal vaginal discharge

Lower abdominal and pelvic tenderness

Adenexal tenderness

Cervical motion tenderness

Muco-purulent cervicitis

Abnormal vaginal discharge

Fever

May be asymptomatic

slide16

Symptoms & Signs

Asymptomatic PID is still associated with reproductive morbidity

112 women with infertility

36 had adhesions and laparoscopic evidence of PID

only 11 had a history of clinical PID

(Obstets Gynecol 1995 86 321 Wolner Hanssen)

Women with tubal factor infertility

1/3 still have Chlamydia in UGT without a history of PID

(Keilani 1989, Separd 1989)

slide17

Diagnostic investigations

No ideal diagnostic test

Many investigations that help

but as specificity increases, sensitivity decreases ….

sensitivity more important than specificity?

- avoid missed diagnosis and prevent complications

slide18

Diagnostic investigations

Laparoscopy

“gold standard”: tubal oedema, erythema or purulent exudate

not very sensitive in early diagnosis invasive

(Jacobson 1969, Method 1988)

variable sensitivity (as low as 50%)

and specificity (as low as 85%) compared to fimbrial biopsy

(Sellors Am J Obstet Gynecol1991)

Clinical diagnosis and laparoscopy triad:

low sensitivity(65%, 60%) (Peipert 1997)

Endometrial biopsy

histopathologic evidence of endometritis

Transvaginal sonography, Magnetic resonance imaging

and Doppler techniques

slide19

Clinical diagnosis

  • In day to day practice
  • 1. LAP or pelvic pain (with no other cause) and
  • 2. At risk of STI and
  • 3. One or more of
    • cervical motion tenderness
    • uterine tenderness
    • adnexal tenderness
  • Specificity increased by presence of inflammation in LGT
  • Exclude
  • ectopic
  • appendicitis
  • endometriosis
  • ovarian cyst complication.
  • CDC Guidelines 2006:http://www.cdc.gov/std/treatment/2006/toc.htm
slide20

Clinical diagnosis

Additional helpful indicators

Temp > 38.3C

Abnormal cervical or vaginal mucopurulent discharge

Presence of abundant WBCs on saline microscopy of vaginal secretions,

Increased ESR,

Increased CRP

Lab documentation of cervical infection with Gonorrhoeae or Chlamydia

(but absence of these 2 infections does not exclude a diagnosis of PID)

slide23

Clinical diagnosis

Value of microscopy of vaginal secretions

high number of WBCs (> epithelial cells)

abnormal vaginal flora

may not help in confirming the diagnosis

but

low number of WBCs

normal flora (lactobacilli ++)

may help in rejecting it (NPV 95%)

slide24

Clinical diagnosis

Other investigations

Endo cervical swab for Chlamydia, Gonorrhoea, MG

Vaginal swab for Trichomonas

Vaginal and cervical slides for micro (?polymorphs)

Pregnancy test

US scan

how good are we at diagnosing pid
How good are we at diagnosing PID?
  • Retrospective review
  • 325 cases with PID at MSHC 2002-06
  • 21,785 unselected walk in female controls
  • Significant differences between doctors
  • in the proportion of women diagnosed with PID
  • 4 times greater variation in diagnosis of PID than genital warts
  • Characteristics of women with PID similar between high diagnosing and low diagnosing doctors
slide26

Definition

Prevalence

Cause

Symptoms & signs

Diagnosis

Treatment

Complications

slide27

Treatment

Australian National Management Guidelines for STIs (SHSOV) 2008

Azithromycin 1 g stat

+

Doxycycline 100 mg bd 14d

+

Metronidazole 400 mg bd 14d

+

if gonorrhoea suspected: Ceftriaxone 500 mg stat

[USA /UK /Europe: Cephalosporin (+/- Metronidazole)]

Partner notification

CDC - all partners; treat if sexual contact within 60 days

UK - contact tracing for 6 months prior to onset of symptoms and treat

slide28
831 patients with mild to moderate PID
  • - randomised to outpatient or inpatient treatment
  • with im cefoxitin and oral doxycycline.
  • - follow up 35 months
  • - no difference in pregnancy rates, frequency of recurrence of PID, chronic pelvic pain or ectopic pregnancy
slide29

RCT of 106 women outpatient treated PID

Ceftriaxone 250 mg then

either Azithromycin 1 g weekly for 2 weeks

or Doxycycline 100 mg bd for 2 weeks

Clinical cure rate at 14 days

98.2% (CI =0.9-0.99)

85.7% (CI = 0.72-0.93)

slide30

Retrospective review of case notes

Clinical cure rates:

Doxycycline and Metronidazole 55% (18% non responders)

Doxycycline and Metronidazole 72% (8% non responders)

plus Ceftriaxone stat im dose

slide31

Relationships between CCR and reproductive morbidity?

Treatment regimens all look at short term clinical cure rates, very little on long term reproductive morbidity.

PEACH Study: endometritis not associated with reproductive morbidity (Haggerty 2003)

FUP (despite eradication of UGT Chlamydia and GC) rates of infertility, pelvic pain and recurrent PID were still elevated (Ness 2002)

Need to eliminate maybe other PID pathogens?

Reproductive morbidity worse withnon gonococcal infection

Overall PEACH study demonstrates that although current treatment eradicates UGT GC and Chlamydia these are still at risk of long term morbidity greater than if they hadn’t had PID

slide32

Treatment for Anaerobes

Is anaerobic cover necessary to prevent sequelae?

Compliance with metronidazole poor

Relevance of anaerobes unclear:

? contamination from sampling

? responsible for sequelae

Fluoroquinolones no anaerobic cover

Azithromycin some anaerobic cover but not ideal for GC

Moxifloxacin some anaerobic cover (poor Gram+)

but covers Chlamydia, MG and GC.

Clinical cure rates of anaerobic PID

Azithromycin (97%) vs Azithromycin and Metronidazole (96%)

Azithrom not ideal for GC with resistance patterns ( Bevan 2003)

Animal models: ? Repeat doses Azithromycin shows possibility

slide33

Definition

Prevalence

Cause

Symptoms & signs

Diagnosis

Treatment

Complications

slide34

Complications

Infertility, pelvic pain and ectopic pregnancy

What is the excess risk of infertility in women after genital chlamydial infection? A systematic review of the evidence

slide35

Complications

Infertility proportional to severity of laparoscopic findings but not clinical symptoms (Jacobson 1969 and Bernstein 1987)

Tubal Infertility after mild, moderate and severe PID is 10, 25 and 50% respectively (Jacobson 1969)

Ectopics: 10-15% of conceptions will be ectopic after mild PID and 50% after severe PID(Bernstein 1987)

Delay in treatment > 48 hours increases risk of infertility and ectopic pregnancy by 3 fold (Hillis 1993 Am J obstet Gynecol)

1/3-1/2 women will develop pelvic pain (Bernstein 1987 and Stacey 1992)

slide36

Complications

Is serology helpful in identifying those at risk of complications?

Generally believed that ChHSP60 Abs were predictive of complications

PEACH study contradicts this

mild to moderate PID risk of complications

related to Chlamydia EB Abs (not Chsp60 Abs)

(Ness 2008 STD)

slide37

Complications

MG associated with PID but does it cause infertility?

PEACH study

- positive MG PCR not predictive of complications

- but MG Abs more common in women with TFI

Evidence still conflicting!

(Haggerty 2007)

slide38

Take Home Messages

Mild to moderate PID is a clinical diagnosis but may be asymptomatic!

1/3 cases are caused by Chlamydia or Gonorrhoea

Partners need testing and treatment

Even mild PID may cause significant long-term morbidity

Severity of symptoms is not related to the risk of complications

Maintain a low threshold for diagnosis in young sexually active women

Delaying treatment increases the risk of reproductive morbidity

Diagnosis remains unsatisfactory - no perfect diagnostic test

and the outcome in individual patients is uncertain

Condoms to prevent STIs are important

sexual health education
Sexual Health Education
  • 1. PG Certificate in Sexual Health
  • 4 post graduate subjects by distance or in classroom at MSHC
  • 2. Masters of Public Health (with a specialised Sexual Health Stream)
  • 3. Nurses Pap Smear Accredited course
  • Clinical Sexual and Reproductive Health for Nurses (incl HIV counselling)
  • 4. Short Courses on STIs
  • 5. Pre and Post test HIV counselling courses
  • MSHC and Melbourne School of Population Health, University of Melbourne
  • http://www.sph.unimelb.edu.au http://www.mshc.org.au
  • Contact: Hennie Williams 03 9341 6249 hwilliams@mshc.org.au