Acute PID

Pelvic Infections
Dr DOHBIT/Prof MBOUDOU
Acute PID
Objectives
At the end of this lecture, the student
should be able to:
1. Give 2 symptoms and 2 signs of PID
2. State 3 risk factors of PID
3. Give two treatment protocols of PID
4. State 3 complications of PID
Prerequisite
Anatomy and physiology of the female
genital tract
Vaginal flora
Plan
Introduction 3. Diagnosis
1. Generalities 1. Positive diagnosis
2. Classification
1.Definition 3. Differential
2. Interest 4. Treatment
3. Epidemiology 1. Aim
1. Risk factors 2. Means
2. Incidence
3. Treatment
2. Clinical protocols
presentation 5. Complications
Conclusion
Generalities
1.1. Definition
Pelvic inflammatory disease (PID) is a
general term for acute, subacute, recurrent,
or chronic infection of the oviducts and
ovaries, often with involvement of adjacent
tissues.
Most infections seen in clinical practice are
bacterial, but viral, fungal, and parasitic
infections occur.
Polymicrobial infection
PID is a vague term
Generalities
1.2. Interest: Diagnostic,
Therapeutic and
Prognostic
1.3. Epidemiology
Pelvic Inflammatory Disease
Infection of the upper genital tract not
associated with pregnancy or
intraperitoneal operation
99% results from ascending infection
from bacterial flora of the vagina & cerix
Occurs in 1-2% of all young, sexually
active women
Most common serious infection in
women ages 16-25
Extremely rare in women who are
amenorrheic or not sexually active
 ↑ the risk for ectopic pregnancy 6-10 fold
 ↑ the infertility rate by 6-60%
 Etiology: acute PID: N. gonorrhea, C.
trachomatis
 Risk factors: - younger age at 1st contact
- older sex partner
- alcohol use before
intercourse
- current C. trachomatis
infection
- multiple sexual partners
2. Clinical Presentation
Clinical presentation
Onset of lower abdominal and pelvic pain,
Usually following onset or cessation of
menses and
Associated with
vaginal discharge,
abdominal, uterine, adnexal, and cervical
motion tenderness,
Clinical and paraclinical
Plus one or more of the following:
a. Temperature above 38.3 °C (101 °F).
 b. Leukocyte count greater than 10,000/L or
elevated C-reactive protein.
c. Inflammatory mass (examination or
sonography).
d. Gram-negative intracellular diplococci in
cervical secretions.
e. Purulent material (white blood cells) from
peritoneal cavity (culdocentesis or
laparoscopy).
f. Elevated erythrocyte sedimentation rate.
3. Diagnosis
3.1 Positive Dg
Clinical Criteria for Diagnosis
 Abdominal direct
tenderness w/ or w/o
rebound tenderness
 Tenderness w/ motion of All 3 necessary for
cervix & uterus diagnosis
 Adnexal tenderness
Plus
 Gram stain of endocervix +
for gram – intracellular
diplococci
 T (>38° C)
1 or more necessary
 Leukocytosis (>10,000) for diagnosis
 Purulent material from
peritoneal cavity by
culdocentesis or
laparoscopy
 Pelvic abscess on bimanual
exam or sonography
Positive Diagnosis
Laparoscopy
Endometrial biopsy
High vaginal swab cultures
3.2 Laparoscopic classification
Laparoscopic Images of PID
27/10/2024
Severity of PID by Laparoscopic Examination
Severity Findings
Mild Erythema, edema, no spontaneous

purulent exudates; tubes freely
movable
Moderate Gross purulent material evident;

erythema & edema, more marked;
tubes may not be freely movable &
fimbria stoma may not be patent
Severe Pyosalpinx or inflammatory complex

abscess
Microorganisms Isolated from the Fallopian Tubes of
Patients with Acute PID
Type of agent Organisms
Sexually transmitted disease Chlamydia trachomatis

Neisseria gonorrhea
Mycoplasma hominis
Endogenous Agent aerobic or Streptococcus sp

facultative Staphylococcus sp
Haemophilus sp
Escherichia coli
Anaerobic Bacteroides sp
Peptococcus sp
Peptostreptococcus sp
Clostridium sp
Actinomyces sp
3.3 Differential Dg
Low abdominal pain- other causes
Fever
Vaginal discharges – vaginitis, cervicitis etc
etc
4. The Treatment
Preventive and Curative

Preventive Approach
Health Education
Barriers like condom and +/- spermicide
Dual protection contraception in teenagers
Treatment and notification of Partners
Vaccination; HPV, HBV etc.
Methods of Preventing STDs, Mechanism of
Action & Efficacy
Mechanism Efficacy
Method
Behavioral
Monogamy ↓likelihood of exposure to infected Not well studied; theoretic efficacy
person
↓likelihood of exposure to infected
Reducing # of partners person
Avoiding certain sexual

practices
Inspecting & questioning
partners
Barrier
Condom Protects partner from direct contact Effective in vitro barrier to
with semen, urethral discharge or Chlamydia, CMV& HIV, partial
penile lesion protection HSV
Protects wearer from direct contact ↓ risk for acquiring GC,PID, partial
with partner’s mucosal secretions HPV protection, effect on acquiring
NGU not well established
Chemically inactivates infectious Nonvaginal use has not been studied
Spermicide agents Inactivates gonococci, syphilis
spirochetes,trichomonads, HSV,
ureaplasma and HIV
100mg gel dose & contraceptive
sponge associated with epithelial
ulcers & abrasions
Decreases risk of acquiring cervical
Mechanical barrier, covers the cervix GC & PID
Diaphragm
Methods of Preventing STDs, Mechanism of
Action & Efficacy
Method Mechanism Efficacy
Vaccines Induce antibody response that Commercially available hepa B

renders host immune to the vaccine safe & effective
disease Results of clinical trials on
gonococcal & herpes simplex
vaccine ongoing
Gonnococcal, HIV & HSV
vaccines research in progress
Quadrivalent HPV vaccine safe
& effective
Oral Antibiotics
Penicillin Kill infectious agent on or No studies among women or
shortly after exposure before civilian men
Sulfathioazole infection is established
↓risk of acquiring GC and hard
Tetracycline analogues and soft chancre but use not
recommended
Local
Postcoital urination Flushes infectious agents out of Poorly studied
Postcoital washing urethra & washes infectious
agents of genital skin &
mucous membrane
Postcoital antiseptic douching Poorly studied, not
Inactivates & washes infectious recommended, increased risk
Curative treatment
Treatment
Aim:Relieve pain and cure infection
Means:
Non medical; Ice-blocks on the
abdomen
Medical:
Antibiotherapy
NSAID
Surgical
Laparoscopy + medical treatment
27
CDC Ambulatory Management for Acute PID
 Regimen A:
Levofloxacin 500mg PO OD x 14 days or
Ofloxacin 400 mg PO OD x 14 days w/ or w/o
Metronidazole 500 mg PO BID x 14 days
 Regimen B:
Ceftriaxone 250mg IM SD
or
Cefoxitin 2gm IM SD, & probenicid 1 gm PO SD
or
other parenteral third-generation cephalosporins
plus
doxycycline 100mg PO BID x 14 days
w or w/o
Metronidazole 500 mg PO BID x 14 days
Indications for Hospitalizing Patients
with Acute PID
Surgical emergencies cannot be
excluded
The patient is pregnant
The patient does not respond clinically
to oral antimicrobial therapy
The patient is unable to follow or
tolerate an outpatient oral regimen
The patient has severe illness, nausea &
vomiting, or high fever
The patient has tubo-ovarian abscess
CDC Inpatient Management of Acute PID
 Parenteral Regimen  Altenative
A Parenteral
Cefotetan 2 gm IV z 12 Regimens:
hrs Levofloxacin 500 mg IV
or OD
Cefoxitin 2 gm IV q 6 hrs or
plus Ofloxacin 400 mg IV q
12 hrs
Doxycycline 100mg
PO/IV q 12 hrs w/ or w/o
 Parenteral Regimen Metronidazole 500mg IV
B: q 8 hrs
Clindamycin 900mg IV q
8 hrs Ampicillin/Sulbactam 3
plus gm IV q 6 hrs
plus
Treatment of other clinical forms
Cellulitis with IUCD
– Remove the IUCD
– Treat as above
Tubo-ovarian abscess (TOA)
– Hospitalisation
– Medical treatment ++
– Surgery if the evolution is slow
Pelvic abscess
– Same as TOA
31
5. Complications
 Sequelae/Complications: Due to scarring
and adhesion formation
1. Ectopic pregnancy
2. Chronic pain – most common sequelae
3. Infertility – PID is one of the major causes
of female infertility, 12 -18% after one
episode
NB: These complications can be reduced

when treatment is initiated early.
Conclusion
PID remains a main concern in our practice
Multiple microbial involvement
The germ spectrum has greatly changed
over the last years
Presumptive treatment remains a mainstay
Early treatment is essential to limit
sequelae
Thank you
Merci

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Acute PID

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Pelvic Infections

Mild Erythema, edema, no spontaneous

Moderate Gross purulent material evident;

Severe Pyosalpinx or inflammatory complex

Sexually transmitted disease Chlamydia trachomatis

Endogenous Agent aerobic or Streptococcus sp

Preventive and Curative

Avoiding certain sexual

Vaccines Induce antibody response that Commercially available hepa B

NB: These complications can be reduced

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