Pelvic Infections Flashcards
(23 cards)
Define PID
A spectrum of inflammatory disorders characterised by the ascending spread of infections, unrelated to pregnancy and surgery, from the vagina and cervix to the endometrium and fallopian tubes and other contiguous structures.
What are the most common organisms that cause PID?
C trachomatis
N gonorrhoea
Endogenous flora (E coli, Staph, strep, G vaginalis)
H influenzae
Anaerobes
What is the pathophysiology of PID?
Sexually transmitted disease with infection by N gonorrhoea or C trachomatis which leads to secondary infection with normal inhabiting flora due to imbalance of organisms caused by initial infection
Ie POLYMICROBIAL
What are risk factors for PID?
> Young sexually active women
early sexual debut
unprotected sexual intercourse
HIV
new, multiple sexual partners
symptomatic partner
Hx of previous STI’s/PID
sex during menses
bacterial vaginosis
vaginal douching
IUD insertion
How do you lower your risk of PID?
> one sexual partner
condoms
treat sexual partners
use of Oral contraceptives/mirena instead of copper IUD
pregnancy =almost impossible PID
What are symptoms of PID?
1/3 = asymptomatic/non-specific
2/3 = symptomatic
>lower abdominal pain
>mucopurulent vaginal discharge
>cervical motion tenderness
>cervical friability
>postcoital bleeding
>inter-menstrual bleeding
>dyspareunia/dysuria
>fever
>flu like sx
>peritonism/septic shock
Chronic =
>chronic pelvic pain
>dyspareunia
>palpable mass
How do you make a diagnosis of PID?
1) lower abdo pain
AND
2) cervical excitation tenderness OR adnexal tenderness
AND
3) one of the following
>clinical = fever, vaginal discharge, mass, high risk partner
>biochemical = increased WCC, increased CRP/ESR, positive culture
>imaging = cul de sac fluid, pelvic abscesses, inflam mass on u/s
NB exclude other causes eg ovarian cyst, acute appendicitis, ectopic pregnancy, UTI, miscarriage
What will your clinical findings of PID be?
> fever and tachy
abdo = LAP, rebound tenderness, generalised peritonitis
bimanual exam = adnexial tenderness, adnexial mass
PV = purulent discharge, cervical excitation tenderness,
What investigations would you do in suspected PID?
Bloods
>FBC (WCC)
>CRP, ESR
>NB PREGNANCY TEST
>U&E
>blood cultures
>HIV screening
Specimen
>White blood cells on saline microscopy of vaginal fluid
>endometrial sampling - endometritis
Urine
>MC&S
>culture
Examination
>cervical excitation tenderness
>lower abdo pain
>speculum = vaginal smear for microscopy, cervical swam, endometrial biopsy
Pelvis ultrasound
>look for abscesses
>free fluid in cul de sac
>hydrosalpinx (fluid filled tubes)
>tubo-ovarian complex
>Doppler - tubal hyperemia
Laparoscopy (GOLD STANDARD)
>generalised peritonitis
>recurrent attracts
>failed antibiotic therapy
What are the stages of PID? What is the classification called?
Gainesville Staging
1 = acute salpingitis with local tenderness (no peritonitis)
2 = acute salpingitis with peritonitis of lower abdomen (guarding and rebound)
3 = acute salpingitis with superimposed tubal occlusion or tubo-ovarian complex
4 = ruptured tubo-ovarian abscess mass with free pus in abdomen with generalised peritonitis (acute abdomen)
5= advanced disease with septic shock and acute respiratory distress syndrome
What is your differential of a patient with PID that you must exclude?
1) pregnancy complications NB
>ectopic
>dysmenorrhea
>abortions
>ovarian cyst/torsion
2) Renal
>UTI
3) GIT
>appendicitis
>gastroenteritis
>bowel perforation
What are complications of PID?
I FACE PID
Infertility
Fitz-Hugh-Curtis syndrome
Abscesses, adhesions
Chronic pelvic pain
Ectopic pregnancy
Peritonitis
Intestinal obstruction
Disseminated infection (sepsis, endocarditis)
What staging is used to stage PID? Elaborate on the staging
Gainesville classification
Stage 1: early salpingitis (tenderness localised to adnexa)
Stage 2: stage 1 + pelvic peritonitis
Stage 3: stage 2 + abscess formation
Stage 4: stage 3 + ruptured abscess (acute abdomen)
Stage 5: ARDS
What are the common pathogens of the female genital tract?
Bacteria
>neisseria gonorrhoea (Gonorrhoea, PID)
>trep pallidum (syphilis)
>Group B strep
>gardenella vaginalis
>haemophilia ducrei (Chancroid)
>mycobacterium tuberculosis (Genital TB)
> chlamydia trachomatis
Viruses
>HPV
>CMV
>HSV
Fungus
>Candida albicans
Parasites
>sarcoptes scabiei (Scabies)
How do you treat PID?
Inpatient if
>acutely ill (acute abdomen)
>vomiting/fever >38
>no response to oral tx
Inpatient treatment
>ceftriaxone 1g IV daily
PLUS
Metronidazole 500mg IV 8hrly
When clinical response change to
>amoxicillin-clav 125mg 12hrly oral 10days
PLUS
Single dose azithromycin 1g
Outpatient
>ceftriaxone 250mg IMI stat
PLUS
Doxycycline 100mg PO BD for 14 days
+/-
Metronidazole 500mg PO BD for 14 days
How does syphilis present?
Primary stage - single painless lesion, resolves spon 1-8 weeks. Chancre. Serology negative. Highly infectious. Inguinal lymphadenopathy
Secondary - generalised maculopapular rash (palms, soles, trunk, limbs) 2-6 months after primary infection. Malaise, headache, anorexia. Serology positive. Condylomata late
Latent - serology positive. No symptoms (Early latent = <1year, Late latent = >1year) 25% get neurosyphilis
Tertiary - can affect any organ system. Neuro = meningitis, stroke, CN palsy, CVS = aortic aneurysm, Vulva = gumma: nodules enlarge, ulcerate and become necrotic) not infectious
How do you diagnose syphillis?
Nontreponemal tests
>RPR
>VDRL
Treponemal tests
>dark field microscopy
>FTA-ABS
>TPHA
>TPPA
How do you treat syphilis infection?
Depends on stage
First line drug = benzithine penecillin G
Primary/secondary = 1 dose IMI
Latent/pregnancy = IMI weekly x 3
Neuro = IV aqueous penicillin G 4hrly 10-14days
How do you treat genital herpes?
Primary = acyclovir 400mg orally TDS 7-10days
Recurrent = acyclovir 400mg orally TDS 7-10days
Suppressive (pts >6/year) = acyclovir 400mg orally BD 12months with 3 month break to observe for recurrence
Severe infection = acyclovir 5-10mg/kg 8hrly IVI 2-7days
What gynaecological infection is considered AIDS defining?
Persistent genital herpes simplex symptoms lasting more than a month
Cervical cancer
What gynae conditions are HIV patients more likely to get?
Syphilis
PID
Genital Tb
HPV
Cervical cancer
Menstrual disorders
Which part of the genital tract is most commonly involved in genital TB?
Fallopian tubes
Ovaries
Endometrium
How often much HIV positive females be HIV screened?
Anually
