Makindo Medical Notes

Lower abdominal pain and adnexal tenderness are the most consistent findings.

About Acute Pelvic Inflammatory Disease

Acute Pelvic Inflammatory Disease (PID) is an infectious and inflammatory condition of the female upper genital tract, including the uterus, fallopian tubes, and ovaries. It is primarily caused by ascending infections from the lower genital tract, often resulting from sexually transmitted infections (STIs). PID is a significant cause of pelvic pain, infertility, ectopic pregnancy, and chronic pelvic pain if left untreated.

Aetiology

The primary causative agents of PID are bacteria that ascend from the vagina and cervix into the upper genital tract. These infections can result from sexually transmitted or non-sexually transmitted pathogens.

• Sexually Transmitted Infections:
  • Chlamydia trachomatis
  • Neisseria gonorrhoeae
• Polymicrobial Infections:
  • Escherichia coli
  • Anaerobic and haemolytic streptococci
  • Staphylococci
  • Clostridium welchii

Clinical Presentation is mild to severe and may include

• Systemic Symptoms:
  • Pyrexia (fever) > 38°C
  • Pelvic pain
  • Abnormal vaginal bleeding
  • Deep dyspareunia (painful intercourse)
• Local Symptoms:
  • Suppurative otitis media (if associated with respiratory infections)
  • Associated vaginal discharge
  • Lower back pain
  • Adnexal tenderness, masses, or swelling
• Neurological Symptoms:
  • Cervical excitation (pain on manipulation of the cervix)

Differential Diagnosis

• Appendicitis
• Crohn's disease
• Ulcerative colitis
• Ectopic pregnancy
• Renal stones
• Urinary tract infection

Complications

• Tubal damage and infertility
• Pelvic inflammatory disease
• Septicaemia
• Abscess formation, which may require surgical drainage

Long-Term Complications

• Infertility
• Increased risk of ectopic pregnancy (approximately 5-fold)
• Painful intercourse (dyspareunia)
• Chronic pelvic pain
• Painful menstrual periods (dysmenorrhea)
• Peritonitis
• Abscess formation

Investigations

• Laboratory Tests:
  • Complete Blood Count (FBC): Raised White Cell Count (WCC) and Erythrocyte Sedimentation Rate (ESR)
  • Urea & Electrolytes (U&E)
  • Liver Function Tests (LFTs)
  • C-Reactive Protein (CRP)
• Imaging Studies:
  • Pelvic ultrasound: To assess for tubo-ovarian abscesses, hydrosalpinx, or other pelvic masses
  • Laparoscopy: Considered the gold standard for diagnosis, especially in complicated cases

Management

• Antibiotic Therapy:
  • Empirical Treatment: Initiate broad-spectrum antibiotics covering common causative pathogens.
    • For non-pregnant women without tubo-ovarian abscess:
      • Cefoxitin 2 g IV plus Doxycycline 100 mg orally twice daily for 14 days
      • Or Ceftriaxone 250 mg IM plus Doxycycline 100 mg orally twice daily for 14 days
    • For pregnant women:
      • Gentamicin 5 mg/kg IV every 8 hours plus Clindamycin 900 mg IV or orally twice daily for 14 days
      • Or Cefoxitin 2 g IV plus Doxycycline (not if pregnant)
  • Specific Antibiotics:
    • Chlamydia coverage with Doxycycline (100 mg orally twice daily)
    • Gonococcal coverage with Ceftriaxone (250 mg IM single dose)
    • Coverage for anaerobes with Metronidazole (500 mg orally twice daily)
  • Adjust Antibiotics Based on Culture Results: Tailor antibiotic therapy according to microbiological findings and sensitivities.
• Addressing Underlying Risk Factors:
  • Educate patients on safe sexual practices to prevent STIs.
  • Encourage partner notification and treatment to prevent reinfection.
  • Promote smoking cessation and reduction of alcohol intake to improve overall health.
• Referral and Follow-Up:
  • Refer patients to local genitourinary medicine clinics for contact tracing and management of sexual partners.
  • Ensure compliance with the antibiotic regimen to prevent relapse and complications.
• Surgical Intervention:
  • Consider surgical drainage or apical petrosectomy if symptoms do not resolve within 72 hours of antibiotic therapy.
  • Consult gynecological specialists for management of tubo-ovarian abscesses or other complications.
• Supportive Care:
  • Manage pain with appropriate analgesics.
  • Provide hydration and nutritional support as needed.

Prognosis

The prognosis of Acute Pelvic Inflammatory Disease largely depends on the timeliness and adequacy of treatment. Early intervention can lead to complete resolution of symptoms and prevent long-term complications. However, delayed diagnosis and treatment increase the risk of severe complications such as infertility, ectopic pregnancy, and chronic pelvic pain.

• Early Treatment: High likelihood of symptom resolution and prevention of complications.
• Delayed Treatment: Increased risk of tubal scarring, infertility, ectopic pregnancy, and chronic pelvic pain.
• Compliance with Treatment: Essential for successful eradication of infection and prevention of recurrence.

Conclusion

Acute Pelvic Inflammatory Disease is a significant cause of pelvic pain and reproductive morbidity in women. Prompt recognition, appropriate antibiotic therapy, and comprehensive evaluation are crucial for effective management and prevention of long-term complications. Healthcare providers should maintain a high index of suspicion, especially in sexually active women presenting with lower abdominal pain and adnexal tenderness, to ensure timely diagnosis and treatment.

References

• Centers for Disease Control and Prevention (CDC). Pelvic Inflammatory Disease (PID). Available at: https://www.cdc.gov/std/pid/default.htm.
• Asch SM, et al. Pelvic Inflammatory Disease. Lancet. 2005;366(9499):1227-1237.
• Bradshaw CS, et al. Incidence of pelvic inflammatory disease in the United States, 2002-2007. Obstet Gynecol. 2012;120(2):387-396.
• Hillier SL, et al. The Centers for Disease Control and Prevention infertility work group: evidence-based treatment of infertility. J Womens Health. 2006;15(8):961-970.
• Shaw RE, et al. Clinical practice. Pelvic inflammatory disease. N Engl J Med. 2005;352(18):1899-1907.
• Wilson TJ, et al. Diagnosis and management of pelvic inflammatory disease: a review. BMJ. 2018;361:k2135.