AMC

1. PID
(Pelvic Inflammatory Disease)

2. PELVIC INFLAMATORY DISEASE
DEFINITION
ETIOLOGY
PATHOPHYSIOLOGY
RISK FACTORS
MODE OF TRANSMISSION
SYMPTOMS
DIAGNOSIS
INVESTIGATIONS
TREATMENT
PREVENTION

3. PID
• Clinical syndrome associated with ascending spread of
microorganisms from the vagina or cervix to the
endometrium, fallopian tubes, ovaries, and contiguous
structures
• A common and serious complication of STDs (Sexual
Transmitted Diseases)

4. What is PID ?
• An infection of
– vagina (Colpitis)
– Cevix (Endocervicitis)
– Uterus ( Endometritis)
– Fallopian tubes
( Salpingitis)
– Ovaries (oophoritis),
– Pelvic peritonitis
– Tubo-ovarian abscess

5. Pathway of Ascendant Infection
Cervicitis
Endometritis
Salpingitis/
oophoritis/ tubo-ovarian abscess
Peritonitis

6. Female reproductive organ

7. Microbial Etiology
• Most cases of PID are polymicrobial
• Most common pathogens:
– N. gonorrhoeae: recovered from cervix in 30%-80% of women
with PID
– C. trachomatis: recovered from cervix in 20%-40% of women
with PID
– N. gonorrhoeae and C. trachomatis are present in combination
in approximately 25%-75% of patients

8. How do women get PID?
Bacteria move upward from vagina or cervix
into reproductive organs.

9. Acute PID : Pathology
Cervicitis
Endometritis
Salpingitis
Oophoritis
Tubo-ovarian abscess
Peritonitis

10. PID : Epidemiology
Risk factors
ACCEPTED PROPOSED
1. Menstruating teens 1. Low socio-economic status
2. Multiple sex partners 2. Early age of sexual activity
3. Prior H/O PID 3. Urban living
4. Sexually Transmitted Infection 4. High frequency of coitus
5. Non-use of barrier
contraceptive
5. Use of IUCD
6. Cigarette smoking
7. Substance abuse
8. Douching

11. PID : Mode of transmission
Ascending infection (Canalicular spread)
 Ascend of gonococcal & chlamydial organisms by
surface extension from the lower genital tract through
the cervical canal by way of the endometrium to the
fallopian tubes
 Facilitated by the sexually transmitted vectors such as
sperms & trichomonads
 Reflux of menstrual blood along with gonococci into the

12. PID : Mode of transmission
Through uterine lymphatic & blood vessels across
parametrium
 Mycoplasma hominis
 Secondary organisms

13. PID : Mode of transmission
Gynecological procedures favoring ascend of infection
 E.g. D&C, D&E
Blood-borne transmission
 Pelvic tuberculosis
Direct spread from contaminated structures in abdominal
cavity
 E.g. Appendicitis, cholecystitis

15. Abnormal discharge

16. Symptoms
• lower abdomen pain, may worse when move
• pain during or after sex
• bleeding between periods or after sex
• lower back pain
• sense of pressure or swelling in the lower abdomen
• fever (often with chills)
• feeling tired or unwell
• abnormal vaginal discharge
• nausea, vomiting and dizziness
• leg pain
• increased period pain
• increased pain at ovulation
• dysuria, frequently urination

17. Acute PID : CDC DiagnosisCriteria
3
5
3

18. Acute PID : Staging
(I-IDSOG-USA recommends following stages)
Stage I
 Women who fulfil the CDC major diagnostic criteria and
>1 of its minor criteria but who do not have overt
peritonitis (as demonstrated by the absence of rebound
tenderness) and who have not had any prior
documented STD upper tract infections
Stage II
 The above criteria, with peritonitis
Stage III
 Women with demonstrable tubo-ovarian complex or
tubo-ovarian abscess evident on either physical or
ultrasonographic examination
Stage IV
 Women with ruptured tubo-ovarian abscesses

19. Investigation
• Laboratory may be entirely normal
• An elevated leukocyte count does not distinguish PID from other diagnoses
• Cervical cultures for gonorrhea or Chlamydia require 3-7 days for results
• HIV and syphilis testing should be recommended
• Pelvic ultrasonography can detect pelvic abscesses
• Laparoscopy when the diagnosis is unclear or when the patient fails to
improve.

20. Complications and long-term problems
• Recurrent PID
• Ruptured abscess
• Chronic pain
• Ectopic pregnancy
• Infertility
• Perihepatic adhesions ( Fitz-Hugh-
Curtis syndrome)

21. • Perihepatic adhesions (arrow) usually associated with
pelvic gonorrhoeal or chlamydial infection (Fitz-Hugh-
Curtis syndrome).

22. Acute PID : Most common DD
Most common DD of acute PID
1. Appendicitis
2. Ectopic pregnancy
3. Endometritis
4. Ovarian cyst
5. Ovarian torsion

23. Rupture tubo-ovarian abscess

24. Acute PID : Management
(Antibiotics for specific pathogen)
Organism Antibiotics
N. gonorrhea Cephalosporins, Quinolones
Chlamydia
Doxycycline, Erythromycin &
Quinolones (Not to
cephalosporins)
Anaerobic organisms
Flagyl, Clindamycin &
in some cases to Doxycycline
ß-Haemolytic
streptococci.
&
E. coli
Penicillin derivatives,
Tetracyclines, and
Cephalosporins.,
E. Coli is most often treated with

25. Parenteral Treatment
• Regimen A
Cefoxitin 2 g IV every 6
hours
+
Doxycycline 100
mg
orally or IV every
12 hours
14 days

26. •Regimen B
Clindamycin
900 mg IV every
8 hours
+
Gentamicin loading dose
(2 mg/kg ) IV or IM
followed by a maintenance
dose (1.5 mg/kg)
every 8 hours

27. Oral Treatment
• Regimen A
Levofloxacin 500
mg once daily
for 14 days
OR
+
Metronidazole 500 mg
twice a day
for 14 daysOfloxacin 400 mg
twice daily
for 14 days

28. •Regimen B
1. Ceftriaxone 250 mg IM in a single dose
+ Doxycycline 100 mg orally twice a day for 14 days
WITH OR WITHOUT
Metronidazole 500 mg orally twice a day for 14 days
2. Cefoxitin 2 g IM single dose and Probenecid, 1 g
orally administered concurrently single dose
+ Doxycycline 100 mg orally twice a day for 14 days
WITH OR WITHOUT
Metronidazole 500 mg orally twice a day for 14 days
3. Third-generation cephalosporin
+ Doxycycline 100 mg orally twice a day for 14 day
WITH OR WITHOUT
Metronidazole 500 mg orally twice a day for 14 days

29. Management & Follow-up
Out-patient
Oral regimen
In-patient
Parenteral regimen
3 Days (72 hours)
Substantial clinical improvement ????
 Defervescence
 Reduction in direct or rebound abdominal tenderness
 Reduction in uterine, adnexal & cervical motion
tenderness
NO
 Reassessment of patient & treatment
 Additional diagnostic testing
After 6 - months
Repeat testing of all women who have been diagnosed with chlamydia or
gonorrhoea
Yes
 Switch to oral from parenteral after
24 hours of clinical improvement
 If on oral – continue the same
Admit Out-patient

30. Prevention

31. 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.

32. Management of Sex Partners
• Male sex partners of women with PID should be
examined and treated
• Male partners of women who have PID caused by C.
trachomatis and/or N. gonorrhoeae frequently are
asymptomatic.

33. Partner Management (continued)
• Sex partners should be treated empirically with regimens
effective against both C. trachomatis and N. gonorrhoeae,
regardless of the apparent etiology of PID or pathogens
isolated from the infected woman.

34. Patient Counseling and Education
• Nature of the infection
• Transmission
• Risk reduction
– Assess patient's behavior-change potential
– Discuss prevention strategies
– Develop individualized risk-reduction plans

35. Thank you