Pelvic Inflammatory Disease Lower genital tract infection

Pelvic Inflammatory Disease
(PID)Pelvic Inflammatory Disease (PID)
Pelvic Inflammatory Disease (PID) is an
ascending infection from the endocervix
causing:
1. Endometritis
2. Salpingitis
3. Oophoritis
4. Pelvic peritonitis
5. +/- tubo ovarian
abscess3
Normal Cervix with Ectopy
Source: Seattle STD/HIV Prevention Training Center at the University of Washington/
Claire E. Stevens
EpidemiologyPID Risk Factors
1. Young age at first intercourse
2. Multiple sexual partners (polygyny)
3. male partners with gonorrhea or chlamydia.
4. High frequency of sexual intercourse
5. High rate of acquiring new partners within
pervious 30 days
6. Alcohol/Drug use
7. Cigarette smoking (2x increased risk)
8. IUDs increase risk at point of insertion/removal
for a few weeks
9. History of PID or STD
10. Demographics (socioeconomic status)Causative Organisms of PID
Most cases are polymicrobial, the causative
M.O. Of PID:
1. Nesseria Gonorrhoea
Gram –‘ve intracellular diplococci
2. Chlamydia Trachomatis
Gram –‘ve obligate intracellular M.O
3. Bacterial Vaginosis
Anareobes, Enteric Gram –‘ve Bacteroides
4. Streptococci
5. Haemophillis Influenzae
6. Cytomegalovirus
7. Mycobacterium TuberculosisPathogenesis of PID
Infection of the cervix (endocervicitis) spreads, either directly
or via lymphatics to the endometrium, uterine tubes and
the pelvic peritoneum.
Factors associated with the ascent of the bacteria include:
o Instrumentation
– Cervical dilation, coil insertion (IUCD)
o Hormonal changes associated with menstruation
– Lowers bacteriostatic effect of cervical secretion
o Retrograde menstruation
– Infection more common after a period
o Virulence of the organisms in acute chlamydial & gonococcal
PID7
Pathway of Ascendant Infection
Cervicitis
Endometritis
Salpingitis/
oophoritis/ tuboovarian abscess
Peritonitis
Pathogenesis8
Normal Human Fallopian Tube Tissue
Source: Patton, D.L. University of Washington, Seattle, Washington
Pathogenesis9
C. trachomatis Infection (PID)
Source: Patton, D.L. University of Washington, Seattle, Washington
Pathogenesis10
PID Classification
Severe symptoms
4%
Mild to moderate symptoms
36%
Subclinical/silent
60%
Overt
40%
Clinical Manifestations11
Clinical criteria
• Abdominal, pelvic pain & dyspareunia
• Temperature >38°C
• Abnormal cervical mucopurulent
discharge.
• Heavy/intermenstrual bleeding
• Adenexal, pelvic tenderness &/or cervical
motion tenderness (cervical excitation).
• Pelvic mass
Diagnosis12
Mucopurulent Cervical Discharge
(Positive swab test)
Source:Seattle STD/HIV Prevention Training Center at the University of Washington/
Claire E. Stevens and Ronald E. Roddy
DiagnosisLaboratory Investigations of PID
• Pregnancy test
• Triple and urethral swabs
– High vaginal swab – Bacteria vaginosis organisms
– Endocervical swab – Neisseria gonorrhoea
– Endocervical swab - Chlamydia trachomatis
– Urethral swab – Chlamydia trachomatis (males
only)
• Midstream Urine
– Leucocytes and nitrates
• C-Reactive Protein and ESR
– Markers for acute infection / inflammation
• The presence of leucocytes on vaginal wet preparation.Sequelae of PID
• Immediate
– Tubo-ovarian abscess
– Pyo-salpinx
• Long Term
– Ectopic Pregnancy (1 episode of PID ! 7x
increased risk)
– Tubal infertility (1 episode of PID ! 12%
increase, 2 ! 25%, 3 episodes ! 50-75%)
– Dyspareunia (Painful sexual intercourse)
– Chronic PID / Chronic pelvic pain
– Pelvic adhesions15
Other investigations
1. Transvaginal sonography or MRI.
for pelvic mass
Diagnosis2. Laparoscopy
a. Left tubal hydrosalpinx c. Peritubal adhesions
b. Bilateral hydrosalpinxPerihepatic adehesions (Fitz-Hugh-Curtis
syndrome)Differential Diagnosis
1) Ectopic pregnancy
2) Acute appendicitis
3) Irritable Bowel Syndrome (IBS)
4) Ovarian cyst accidents (torsion, rupture,
haemorrhage)
5) Urinary Tract Infection (UTI)
6) Functional pelvic pain of unknown origin19
Criteria for Hospitalization
• Inability to exclude surgical emergencies
• Pregnancy
• Non-response to oral therapy
• Inability to tolerate an outpatient oral regimen
• Severe illness, nausea and vomiting, high fever
or tubo-ovarian abscess
• HIV infection with low CD4 count
Management20
Screening
• To reduce the incidence of PID, screen
and treat for chlamydia.
• Annual chlamydia screening is
recommended for:
– Sexually active women 25 and under
– Sexually active women >25 at high risk
• Screen pregnant women in the 1st
trimester.
Prevention21
General PID Considerations
• Regimens must provide coverage of N.
gonorrhoeae, C. trachomatis, anaerobes,
Gram-negative bacteria, and streptococci.
( A combination of ceftriaxone, doxicycline &
metronidazole)
• Treatment should be instituted as early as
possible to prevent long term sequelae.
• In the patient with a pelvic abscess,
surgery is warranted. For drainage of
abscess+/-salpingo-oopherectomy.
ManagementChronic Pelvic Inflammatory Disease
Symptoms > 6 Months Duration
• Pelvic pain
• Secondary dysmenorrhoea
• Deep dyspareunia
• Menstrual disturbance
• Recurrent acute painful exacerbations
Sequelae
• Infertility
• Ectopic pregnancy
• Chronic pelvic pain (pelvic cripple)
• Pelvic adhesions/ tubo-ovarian complex
• Abnormal / painful periods


Lower genital tract infection

Vulvovaginal Candidiasis

• It is caused by fungi (yeast) from the candida species
(most commonly C.albicans) which is normal flora in the
gut & genital tract (in balance with bacteria). In case of
over-growth of the yeast this will lead to candidiasis.
• Risk Factors
– Antibiotics, oral contraceptives, pregnancy,
obesity, steroids, diabetesClinical features
• Vulvovaginal itching.
• Vulvovaginal erythema, irritation or
soreness.
• Vaginal White curdy vaginal discharge.
• Dyspareunia & dysuria.• By taking high vaginal swab (finding
pseudohiphea under microscopic examinations).
Culture might be needed.Treatment
• Topical imidazole (E.g.clotrimazole cream or pessaries).
• Oral imidazole (e.g. fluconazole).
• Vaginal nystatin
• Is there any need to treat asymptomatic partner?
• What is the general & supportive care needed in
patients with vulvovaginal candidiasis?
• How would you manage recurrent infection?
• What are the drugs that are safe for vulvovaginal
candidiasis during pregnancy?• One of STI.
• caused by flagellated protozoa“Trichomonus
vaginalis”.
• Frothy yellowish green offensive vaginal discharge .
• Vulvovaginal soreness & itching.
• Dysparunia.
• Dysurea & abdominal discomfort
O/E: Strawberry cervix.Trichomoniasis
Frothy vaginal discharge Strawberry cervixDiagnosis : take a vaginal swab for:
• Wet mount preparation
• Gram stain &
• Culture Treatment
• Metronidazole tablets 500mg twice daily
for 5_7 days.
• Treat sexual partner.
• Abstain from intercourse during
treatment.• It is vaginal condition caused by overgrowth of
anaerobic species (Enteric Gram –‘ve
Bacteroides, Gardenella vaginalis...) with
simultaneous reduction in the lactobacilli in the
vaginal flora.
• Not vaginitis (no inflammation of vaginal wall)charecteristics
• Thin homogenous adherent greyish-white discharge.
• Fishy odour
• More prominent during and following menstruation
• Vaginal pH more alkaline (4.5 to 7.0).
• Asymptomatic carriers
• Diagnosis
– pH > 4.5, KOH whiff test
– High Vaginal Smear – Gram variable coccobacilli, reduced
numbers of lactobacilli
-Presence of clue cells on microscopic
examination.Treatment
• Metronidazole, orally or vagnal cream.
• clindamycin vaginal cream.
Bacterial vaginosis during pregnancy can
lead to late second trimester miscarriages
and preterm labour so it should be
treated. • Symptoms:
– Pain in the perineum, lower abdomen, testicles, penis, and with
ejaculation, bladder irritation, bladder outlet obstruction, and
sometimes blood in the semen
• Diagnosis:
– Typical clinical history (fevers, chills, dysuria, malaise, myalgias,
pelvic/perineal pain, cloudy urine)
– The finding of an edematous and tender prostate on physical
examination
– Will have an increased PSA
– Urinalysis, urine culture
• Treatment:
– Trimethoprim/sulfamethoxazole, fluroquinolone or other broad
spectrum antibiotic
– 4-6 weeks of treatment
• Risk Factors:
– Trauma
– Sexual abstinence
– Dehydration