Educational Materials

1. Pelvic Inflammatory Disease (PID)
Associate Clinical Professor Dr. Aisha M. Elbareg,
MBBS, DGO, MMedSci., ABOG, MD, PhD.
Senior Consultant in (Obs & Gyn) and Reproductive Medicine
Faculty of Medicine, MisrataUniversity. LIBYA
aishaelbareg@med.misuratau.edu.ly
2019

2. Overview
History:
 A relation between gonorrhoeae, pelvic inflammatory disease, and tubal
infertility was generally apparent in the preantibiotic era. In 1879, Neisser
discovered the gonococcus, and named after him (Neisseria Gonorrhoeae),
which became linked with adnexitis soon thereafter, upper genital tract
infection and severe tuboovarian abscess was feared to be associated with
gonococcal infection.
 With availability of penicillin in the 1940s, both lower and upper genital tract
infections could be more effectively treated, and the effects of their sequelae
were felt to be lessened.
 In the 1960s, Swedish Investigators laid the cornerstone for measuring the
impact of STDs on subsequent tubal infertility, importance of chlamydia as a
cause of tubal infertility, different risk factors on fertility prognosis, and the
effects of different antibiotic regimens.
 During 1970s, the role of Chlamydia trachomatis in PID became increasingly
appreciated.
 In recent years, the nature of pathophysiological process of PID became
increasingly understood, eventually its management.

4. Overview
 (PID) is usually the result of infection ascending from the endocervix,
(intercourse may contribute to the ascent of infection through rhythmic uterine
contractions occurring during orgasm), causing a spectrum of inflammatory
disorders of the upper female genital tract including any combination of :
Endometritis, Salpingitis, Parametritis, Oophoritis, Tuboovarian
Abscess(TOA) and/or pelvic Peritonitis, {in addition to perihepatic
structures (Fitz-Hugh−Curtis syndrome)}. Incidence steadily increased in
1970s due to rising rates of STDs and peaked in early 1980s. The annual rate
of PID in high-income countries has been reported to be as high as 10-20 per
1000 women of reproductive age. It could be acute, subacute, recurrent, or
chronic.
 Genetically mediated variation in immune response plays an important role
in susceptibility to PID. Variants in the genes that regulate toll-like receptors
(TLRs), an important component in the innate immune system, have been
associated with an increased progression of C trachomatis infection to PID.

8. Overview
Causative agents: (PID is polymicrobial): Chlamydia trachomatis, an
intracellular bacterial pathogen is the predominant sexually transmitted
organism associated with PID (50-65%), other organisms include : Neisseria
gonorrhea, (15-30%), more often produces more acute symptomatic disease,
Gardnerella vaginalis (which causes bacterial vaginosis (BV), Mycoplasma
hominis, Ureaplasma urealyticum, Trichomonas vaginalis, Haemophilus
influenzae, and anaerobes such as Peptococcus and Bacteroides species, Non-
hemolytic streptococcus, E. coli, Group-B streptococcus & staphylococcus. An
estimated 10-20% of untreated chlamydial or gonorrheal infections progress to
PID.

9. Overview : Mode of transmission
Through
uterine
lymphatics &
blood vessels
across
parametrium
Mycoplasma probably spreads across the parametrium to affect the tube

10. Chlamydia trachomatis
Neisseria gonorrhea
Neisseria gonorrhea
Haemophilus influenzae
Pe Peptococcus Bacteroides
PID is polymicrobial
Ureaplasma urealyticum Trichomonas vaginalis
Mycoplasma

11. Overview
Factors associated withPID :
 (Those related to sexual behaviours): Young age: {because of increased cervical
mucosal permeability, a larger zone of cervical ectopy, a lower prevalence of
protective antichlamydial antibodies, and increased risk-taking behaviors}.,
multiple partners, recent new partner, past history of sexually transmitted
infections in the patient or their partner.
Others: Instrumentation of the uterus/interruption of the cervical barrier,
termination of pregnancy, insertion of intrauterine device within the past three-six
weeks ( linked to a 2- to 9-fold increased risk ), hysterosalpingography(HSG),
hysteroscopy, saline infusion sonography & IVF. Frequent vaginal douching has
been considered a risk factor for PID, but studies reveal no clear association.

12. Overview
Protective factors associated with PID:
Barrier methods: Specially condom with spermicidal chemicals, Oral steroidal
contraceptives: -Thick mucus plug (preventing ascent of sperm and bacterial
penetration, decreasing menstrual anterograde and retrograde flow, and modifying local
immune responses), Tubal ligation, Uncommon in women who are not menstruating,
Pregnancy.
Tubal ligation

13. Pathology:
 Involvement of the tube is almost always bilateral and usually following
menses due to loss of genital defense.
 Pathological process is initiated primarily in the endosalpinx.
 There is gross destruction of the epithelial cells, cilia and microvilli and may
becomes edematous and hyperemic (in severe infection).
 The exfoliated cells along with the exudate pour into the lumen of the tube and
agglutinate the mucosal folds. The abdominal ostium is closed by the
indrawing of the edematous fimbriae and by inflammatory adhesions, uterine
end is closed by congestion. Closure of both the ostia results in built up of the
exudate inside the tube. The exudate may be watery producing hydrosalpnix
(Acute catarrhal salpingitis, Serous fluid, thin wall, mild adhesions) or purulent
producing pyosalpinx, (suppurative salpingitis, thickened tube, full of pus,
dense adhesions ), which changes the microenvironment and favors growth of
other organisms resulting in deeper penetration and more tissue destruction.

14. Pathology:
 There will be adhesions of the tube with the surrounding structures.
 On occasions, the exudate pours through the abdominal ostium to produce
pelvic peritonitis and pelvic abscess or may affect the ovary producing ovarian
abscess.

16. tuboovarian abscess& Hydrosalpnix

20. Acute Salpingitis with abundant inflammatory
infiltrate/pus in the Lumen

21. Clinical features of
PID Clinical Features

22.  PID may be symptomatic or asymptomatic. Clinical symptoms and signs lack
sensitivity and specificity (the positive predictive value of a clinical diagnosis is
65–90% compared to laparoscopic diagnosis).
 Symptoms usually appear at the time and immediately after the menstruation.
 Bilateral lower abdominal and pelvic pain which is dull in nature, aching or
crampy, and constant; tends to be accentuated by motion, exercise, or coitus.
 Rebound lower abdominal tenderness and involuntary guarding may be noted
and suggest associated peritonitis.
 Fever (>38°C found in 30% of cases), lassitude and headache.
 Irregular and excessive vaginal bleeding, often postcoital, is reported in about
40% of cases, is usually due to associated endometritis.
 Abnormal vaginal discharges present in approximately 75% of cases which
becomes purulent and or copious.
Clinical features:

23. Clinical features:
 Nausea and vomiting, manifest late in the clinical course of the disease.
 Deep dyspareunia.
 Pain and discomfort in the right hypochondrium due to concomitant
perihepatitis (Fitz-Hugh-Curtis syndrome) may occur in 5–10% of cases of
acute salpingitis
 Congested external urethral meatus or openings of Bartholin’s ducts through
which pus may be seen escaping out on pressure.
 Vaginal speculum examination shows congested cervix with purulent discharge
from the canal.
 Bimanual examination reveals bilateral tenderness on fornix palpation, which
increases more with movement of the cervix. There may be thickening or a
definite mass felt through the fornices.

24. Differential diagnosis:
 The differential diagnosis of lower abdominal pain in a young woman
includes:
 Acute appendicitis.
 Ectopic pregnancy.
 Urinary tract infection/Interstitial cystitis.
 Diverticulitis.
 Endometriosis.
 complications of an ovarian cyst, i.e. rupture, torsion.
 Adnexal tumors
 Cholecystitis.
 Functional pain (pain of unknown physical origin).

25. Differential diagnosis of Acute PID: (Acute appendicitis and disturbed
ectopic pregnancy, (MOSTCOMMON), must be ruled out, because both conditions require
urgent laparotomy)!!
DD
Acute salpingitis
Symptoms and
signs
Acute Salpingitis Acute Appendicitis Disturbed ectopic
Pregnancy

26. Differential diagnosis of Acute PID:
Torsion Ovarian cyst:
 Sudden pain in the abdomen
 Occasional vomiting.
 Pyrexia usually absent
 No menstrual irregularities
 Vaginal discharge absent.
 Tender abdominal Lump.
 Ultrasound: confirm
Ruptured Endometriotic Cyst:
 Patient is afebrile.
 No vaginal Discharge.
 Dysmenorrhea, menorrhagia,
and pelvic pain before acute episode.

27. Differential diagnosis of Acute PID:
 Cholecystitis:
 History of flatulent dyspepsia.
 Severe pain in the right hypochondrium
radiating to the top of right shoulder.
 Nausea and vomiting with fever.
 Pain, jaundice, and rigor.
 No Vaginal discharge.
 Menstrual irregularities absent.
Diverticulitis.
 Usually occurs after the age of 50 years.
 Infection Signs confined to left iliac fossa.
 No Vaginal discharge.
 Menstrual irregularities absent.

28. Clinical diagnostic criteria of PID:
o MinimumCriteria:
 Adnexal tenderness.
 Cervical motion tenderness.
 Uterine tenderness.
o Definitive Criteria:
 Endometrial biopsy with histopathological evidence of endometritis.
 Transvaginal sonography or magnetic resonance imaging techniques showing
thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian
complex, or Doppler studies suggesting pelvic infection (e.g., tubal
hyperemia).
 Laparoscopic findings consistent with PID.
o Additional Criteria:
 Temperature (>38.3°C).
 Abnormal cervical mucopurulent discharge or cervical friability.

29. Clinical diagnostic criteria of PID:
o Additional Criteria:
 Presence of abundant numbers of WBC on saline microscopy of vaginal fluid.
 Elevated ESR, Elevated CRP(supports the diagnosis but is non-specific and often
normal in mild/moderate PID).
 laboratory documentation of cervical infection with N. gonorrhoeae or C.
trachomatis.
Investigations:
 A pregnancy test to exclude, the possibility of ectopic pregnancy.
 High vaginal and endocervical swabs, should be sent for aerobic, anaerobic
culture, drug sensitivity testing and gram stain.
 Midstream specimen of urine for microscopy and culture.
 Full blood count and C-reactive protein, and total bio.
 Serological test for syphilis for both partners.
 Ultrasound might be useful to confirm pelvic abscess, hydrosalpinx, and
(TOAs), while (CT) or {MRI, has relatively high specificity (95%) and
sensitivity (95%)}, it can help rule out other causes of peritonitis.

30. Ultrasonographic findings in PID may include the following:
 The uterus may be ill defined because of inflammation.
 Endometritis may result in central-endometrial-cavity echo thickening and
heterogeneity
 Hydrosalpinx is depicted as a fluid-filled fallopian tube – If the fallopian tube walls
are thickened and if debris is present within the tube, pyosalpinx should be
considered in the differential diagnosis.
 Oophoritis results in enlarged ovaries with ill-defined margins that often appear
adherent to the uterus; adjacent free fluid may be present in the adnexa or cul-de-
sac.
 TOAs are depicted as complex adnexal masses with thickened walls and central
fluid. Imaging findings in TOAs must be distinguished from: Endometriomas,
Ectopic pregnancies, Hemorrhagic cysts, Ovarian tumors, Abscesses from adjacent
organs.
 Pelvic infection, with findings of tubal inflammation and hydrosalpinx detected by
Doppler studies, is one of the most specific criteria in diagnosing PID.

31. CT findings in PID may include the following:
o In early PID are typically subtle, Often the only findings are fluid in the pouch of
Douglas and pelvic fat inflammation. As the infection progresses, CT features of
PID include fluid filled fallopian tubes with thick walls and enlarged ovaries with a
heterogeneous or partly cystic appearance. A tubo-ovarian abscess represents a more
advanced stage of PID.
o CT findings of perihepatitis: capsular enhancement (due to increased blood flow)
along the surface of the liver most commonly seen on the right-anterior hepatic
surface.
o Hepatomegaly, intra-parenchymal reversible dynamic perfusion abnormalities.

32. Investigations:
 Laparoscopy(Gold standard) is indicated if the diagnosis is unclear or there is
no response to treatment after 48 hours, Findings: hyperemia and edema of
tubes, purulent exudates from fimbrial ends, tubes are not freely movable,
pyosalpinx, violin string like adhesions in the pelvis and around the liver.
 Culdocentesis: to rule out ectopic pregnancy and to establish diagnosis of
pelvic abscess.
 Investigations are also to be extended to male partner and smear and culture
are made from urethral secretion.
Hydrosalpinx on Ultrasound

33. anechoic tubular structures in adnexa; hydrosalpinx tubular structure with debris in left adnexa : pyosalpinx
bilateral complex masses in patient who had
pyometrium: tubo-ovarian abscess
echogenic region within endometrium with dirty shadowing;
finding is compatible with air in endometrium and
endometritis

39. Hydrosalpinx on Ultrasound

46. Laparoscopy Findings of PID

47. Laparoscopy Findings of PID

49. Acute Salpingitis: edema, erythema, and exudate
of the fallopian tube

50. Complications:
 Tuboovarian abscesses and pelvic peritonitis, formation of adhesions, hydrosalpinx
or pyosalpinx.
 Dyspareunia.
 Right upper quadrant pain associated with perihepatitis (Fitz-Hugh–Curtis
syndrome) can occur and may be the dominant symptom.
 In pregnancy, PID is uncommon but has been associated with an increase in both
maternal and fetal morbidity.
 Women with HIV may have more severe symptoms associated with PID.
 Infertility rate is 12%, after two episodes increases to 25% and after three raises to
50%. It is due to tubal damage or tubo-ovarian mass.
 Chronic pelvic inflammation is due to recurrent or associated pyogenic infection.
 Increased risk of ectopic pregnancy.

52. Fitz-Hugh–Curtis syndrome:

54. Fitz-Hugh–Curtis syndrome:
 Fitz-Hugh-Curtis syndrome(FHCS) was named after Thomas Fitz-Hugh and
Arthur Hale Curtis in 1930 and in 1934 when they saw the purulent patch and
“violin-string” like fibrous adhesions between the liver and anterior
peritoneum or the diaphragm, also known as perihepatitis.
 (FHCS) occurs in 4–27% of patients with PID. It is an acute perihepatitis
caused by Chlamydia trachomatis or Neisseria gonorrhoeae, al-though 30%-
40% of cases are polymicrobial and thought to represent ascending infection
from PID. Bacteria spread by means of direct extension along the right
paracolic gutter or through the lymphatic system causing inflammation of the
right upper quadrant peritoneal surfaces of the liver.
 It poses a diagnostic challenge when presenting with isolated right upper
quadrant abdominal pain, and without signs and symptoms of PID, as the
symptoms of primary pelvic inflammation are either subtle or have resolved
by the time of presentation.

55. Fitz-Hugh–Curtis syndrome:
 (FHCS) can be misdiagnosed as it may present like many other disorders
including pulmonary embolism, pneumonia, Cholecystitis, renal colic, and
perforated ulcer.
 A diagnostic gold standard for (FHCS) has not been established. Although
laparoscopy has been suggested for definitive diagnosis of (FHCS) in the past,
with the far less invasive multislice contrast-enhanced (CT) now widely
available, it has become less frequently used, especially in emergency settings.
 The management of (FHCS) is similar to that of PID. In addition, the lysis of
the adhesion bands may be done laparoscopically for symptomatic relief. The
long-term complications include abdominal pain, small bowel obstruction,
and infertility.
 (FHCS) should always be considered in women with infertility and the under
surface of the liver should always be visualized during laparoscopy for tubal
patency in all cases of infertility especially with background of PID.

57. Fitz-Hugh–Curtis syndrome

58. Violin String adhesions of Fitz-Hugh-Curtis Syndrome

60. lysis of the adhesion bands are
performed laparoscopically

61. PID Treatments:
 The choice of an appropriate treatment regimen may be influenced
by:
 local antimicrobial sensitivity patterns.
 local epidemiology of specific infections in this setting.
 Cost.
 Patient preference and compliance.
 severity of disease.
 Most patients with PID are managed as outpatients, but hospitalization should be
considered for patients with the following conditions:
 Uncertain diagnosis.
 Pelvic abscess on Ultrasonographic scanning, and confirmed by CT or MRI.
 Surgical emergencies cannot be excluded.

62. PID Treatments:
 Pregnancy.
 Inability to tolerate outpatient oral antibiotic regimen.
 Severe illness, severe nausea, vomiting, or a fever >38.5ºC.
 Immunodeficiency.
 Failure to improve clinically after 48/72 hours of outpatient therapy.
It has to be noted that:
• Delaying treatment increases the risk of long-term sequelae such as ectopic
pregnancy, infertility and pelvic pain.
• In inpatients, the treatment response can be monitored by changes in C-reactive
protein and white cell count.
• Intravenous therapy, when given, should be at least continued until 24 hrs after
clinical improvement and then switched to oral.
• Dosage recommendations may need to be adjusted depending on local licensing
regulations and the availability of drug formulations.
• The optimal duration of treatment is not known but most clinical trials report a
response to 10–14 days of therapy.

63. PID Treatments:
• Recommended regimens:
1- Outpatient regimens:
A- Regimen:
-oral ofloxacin 400 mg twice daily or levofloxacin 500 mg once daily
+ oral metronidazole 500 mg twice daily for 14 days.

64. PID Treatments:
• 1- Outpatient regimens:
• B- Regimen:
• -I.M ceftriaxone 500 mg single dose, followed by oral doxycycline
100 mg twice daily + metronidazole 500 mg twice daily for 14
days
 Metronidazole is included to improve coverage for anaerobic bacteria that may
have a role in the pathogenesis of PID, however, it might be discontinued in
patients with mild or moderate PID , or those who are unable to tolerate it.
 Oral moxifloxacin 400 mg once daily for 14 in patients who are positive for M.
genitalium.

65. PID Treatments:
• OR: Cefoxitin 2 g IM once as a single dose concurrently with
probenecid 1 g orally in a single dose, or ‎another single-dose
parenteral third-generation cephalosporin (eg. cefotaxime)+ ‎
doxycycline 100 mg orally twice daily for 14 days.
 Metronidazole 500 mg orally twice daily for 14 days can be
added ‎if there is evidence or ‎suspicion of vaginitis or if the
patient underwent gynecologic instrumentation in the
preceding ‎‎2-3 weeks‎.

66. PID Treatments:
• 2-Inpatient regimens:
A- Regimen:
Cefoxitin 2 g IV every 6 hours plus i.v. doxycycline 100 mg
twice daily(oral doxycycline may be used if tolerated). This regimen
is continued for 24 hours after the patient remains clinically
improved, after which doxycycline 100 mg is given orally twice daily
for a total of 14 days

67. PID Treatments / Inpatient regimens:
2-Inpatient regimens:
B- Regimen:
-Clindamycin 900 mg IV every 8 hours plus Gentamicin IV in a loading dose of
2 mg/kg, followed by a maintenance dosage of 1.5 mg/kg q8h.
- IV therapy may be discontinued 24 hours after the patient improves clinically,
and oral therapy with 100 mg doxycycline twice daily should be continued for a
total of 14 days.
-If TOA is present, clindamycin or metronidazole may be used with doxycycline
for more effective anaerobic coverage.
-If ceftriaxone is not readily available, cefixime 400 mg can be given orally in
combination with either azithromycin or doxycycline.
-if ceftriaxone cannot be given because of severe allergy, azithromycin 2 g can be
given orally in a single dose.

68. PID Treatments :
 The following Key Points should be taken into consideration:
 Current partners of women with PID should be contacted and offered health advice
and screening for gonorrhoeae and Chlamydia, and if diagnosed, should be treated
appropriately.
 Partners should be advised to avoid unprotected intercourse until they and their
partner have completed the treatment course.
 If tubo-ovarian abscess does not respond in (48–72 hours) to antimicrobial therapy,
surgery (Colpotomy, Percutaneous drainage/aspiration, or Exploratory laparotomy)
might be considered, also in cases of ruptured abscess.
 The patient should be educated to avoid reinfection and the potential hazards of
it,(warned against multiple sexual partners and to use condoms).
 Follow-up: Review at 72 h is recommended. Failure to improve suggests the need
for further investigation and management including repeating microbiology
testing.
 Repeating smears and cultures are to be done after 7 days following the full course
of treatment and following each menstrual period until it becomes negative for
three consecutive reports.

69. PID Treatments
 The following Key Points should be taken into consideration:
 While triad of lower abdominal pain, adnexal tenderness and tender cervical
movements are considered to be the most important clinical features of Acute
PID, chronic PID presents as chronic abdominal pain, congestive
dysmenorrhea, deep dyspareunia, menstrual abnormalities and infertility, with
signs of tenderness on one or both iliac fossa, an irregular tender pelvic mass,
PR examination - Involvement of parametrium & uterosacral ligament.
 In management of Chronic Pelvic Infection, Investigations, imaging &
diagnostic procedures are similar to acute PID. Broad spectrum Antibiotics for
3 weeks/ based on culture sensitivity. Surgery is indicated in case of:
-Persistence of symptoms despite conservative management.
-Recurrence of acute attack.
-Increase in size of pelvic mass despite treatment.
-Persistent menorrhagia & deterioration in general health.