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Flashcards in PID Deck (49):
1

What is PID?

Pelvic inflammatory disease- acute and subclinical infection of the upper genital tract in women. It comprises a spectrum of inflammatory diseases involving any combo of the uterus, fallopian tubes, ovaries. Often accompanied by involvement of neighboring pelvic organs

2

what does PID result in?

Results in endometritis, salpingitis, oophoritis, pelvic peritonitis, perihepatitis, and/or tubo- ovarian abcess (TOA)

3

Acute PID hard to diagnose because of the wide variation in s/s, which are?

unilateral or bilateral lower abdominal or pelvic pain
fever
vomiting
abnormal vaginal discharge
irregular vaginal bleeding
pain with intercourse

4

*many episodes of PID go undiagnosed and untreated because ??

the patient and/or practitioner fails to recognize the implications of mild or nonspecific signs and symptoms

5

Silent PID

term that can be applied to women with very minimal or no symptoms, represents a large portion of all PID cases

6

what is happening in subclinical PID

mild inflammation is occurring within the reproductive tract at a very low level, yet damage to the fallopian tubes or surrounding structures is occurring

7

important for clinicians to recognize the implication of mild/ non specific findings, especially

in young female patients who might give an incomplete or inaccurate sexual history

8

how can PID occur (less likely)

can be blood- borne, ie. TB or result from an intra- abdominal process or gyn procedures that disrupt the protective cervical barrier

9

how does PID usually occur

most often develops when bacteria ascend from the vagina or cervix into the endometrium, fallopian tubes, and pelvic peritoneum. majority (85%) of cases caused by sexually transmitted pathogen or bacterial vaginosis- associated pathogens

10

risk factors for PID

a previous h/o of PID
higher numbers of lifetime sex partners
douching
h/o bacterial STD
age younger than 25
having a partner with an STI

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gyn procedures that disrupt the protective cervical barrier

pregnancy termination
IUD insertion
dilation and curettage
hysterosalpingography
- all elevate the risk of PID and may lead to PID in the absence of the classic sexually transmitted pathogen

12

time course of presentation of PID

typically acute over several days but can be weeks to months

13

clinical diagnosis remains..

the most important practical approach

14

15% of cases of PID are NOT sexually transmitted and instead are associated with..

enteric pathogens (E.coli, bacteroides fragilis, group B strep, and campylobacter spp) or respiratory pathogens (h. influenzae, strep pneumoniae, group A strep, and staph aureus) that have colonized in the lower GI tract

15

what other things can produce a similar clinical picture

post- op pelvic cellulitis and abscess, pregnancy- related pelvic infection, injury or trauma- related pelvic infection, and pelvic infection secondary to spread of another infection

16

who is at risk?

any sexually active female is at risk for STI associated PID
-those w/ multiple partners at higher risk

17

PID during pregnancy rare because

the mucus plug and decidua seal off the uterus from ascending bacteria.

18

PID rare during pregnancy but possible

- can occur within first 12 weeks of gestation before the mucus plug seals off the uterus

19

our level of suspicion should always be high, especially

in adolescents

20

what is the goal of the initial evaluation of women with suspected PID?

to establish a presumptive diagnosis of PID
- assess for additional findings that increase the liklihood of that diagnosis
- evaluate for other potential causes of pelvic pain

21

issues pertaining to high- risk sexual behavior and acquisition of STI are common to both adolescents and adults but

are intensified among adolescents because of both behavioral and biological predispositions

22

behavioral factors that put adolescents and young women at high risk for STI's and PID are

inconsistent use of barrier protection
douching
greater number of current/ lifetime sexual partners
use of ETOH and other substances that may impair judgement while engaging in sexual activity

23

what to use to reduce risk of PID

latex condoms

24

use of oral contraceptives

may also reduce risk of PID (associated with a decrease in the severity of inflammation)

25

what will your PID pt possible look like? exam findings vary but may include:

oral temp >101F
lower abdominal tenderness w/ or w/o peritoneal signs
cervical or vaginal discharge
tenderness with lateral motion of the cervix
uterine tenderness
unilateral or bilateral adnexal tenderness and adnexal fullness
pyuria- abundant WBCs on saline microscopy of vaginal fluid
elevated c- reactive protein
and/ or adnexla mass demonstrated by abdominal or transvaginal US

26

where does PID come from/ most common pathogens

studies from europe and US from the 80's found its caused by C trachomatis and N. gonorrhoeae or both about 50% of cases

27

M. genitalium has been associated with

endometritis and PID

28

Actinomyces israelli is a cause of

PID in women with IUDs

29

most common pathogens of PID

neisseria gonorrhoeae and chlamydia trachomatis

30

other organisms from upper genital tract that can cause PID

anaerobes such as bacteroides species and peptostreptococcus species
facultative anaerobes such as gardnerella vaginalis, haemophilus influenzae, strep species, actinomyces
enteric gram negative bacilli and
cytomegalovirus

31

genital mycoplasms also associated with PID including

mycoplasma genitalium, mycoplasma hominis, and ureaplasma urealyticum

32

etiology of PID

polymicrobial common, but in more than half the cases, no organism is identified in the specimen

33

complications of PID

perihepatitis (fitz- hugh- curtis syndrome) and tubo- ovarian abscess/ complex formation

34

long term sequelae

tubal scarring that can cause
- infertility in 20% of females
- ectopic pregnancy in 9%
chronic pelvic pain in 18%

35

factors that may increase the likelihood of infertility

delay in diagnosis or initiation of antimicrobial therapy
younger age at time of infection
chlamydial infection
PID determined to be severe by laparoscopic exam

36

*perihepatitis aka fitz- hugh- curtis syndrome

occurs in setting of PID when there is inflammation of the liver capsule and peritoneal surfaces of the anterior right upper quadrant
- there is generally minimal stromal hepatic involvement
- was first associated with gonococcal salpingitis in 1920 and subsequently C trachomatis

37

perihepatitis aka fitz- hugh- curtis syndrome cont

occurs in approximately 10% of women with acute PID and is chracterized by RUQ abdominal pain with a distinct pleuritic component, sometimes referred to as the right shoulder
- marked tenderness at RUQ on exam
- the severity of pain in this location may mask PID and lead to concerns of cholecystitis
- aminotransferase are usually normal or only slightly high
- on laparoscopy or visual inspection, it manifests as "violin string"- patchy purulent and fibrinous exudate, most commonly affecting the anterior surfaces of the liver (not the liver parenchyma)

38

ABX of choice for coverage of c. trachomatis

1st choice doxycycline. azithromycin has shown activity against this pathogen too

39

has moderate in vitro activity against n. gonorrhoeae and c. trachomatis

the combo clindamycin and gentamicin

40

have excellent in vitro activity against n. gonorrhoeae and c. trachomatis

second generation cephalosporin (cefoxitin, cefotetan) plus doxy

41

what do you NOT give to treat gonorrhea or associated conditions

fluoroquinolones bc of increased resistance

42

if you suspect PID

you should treat- even if you are not sure

43

CDC recommends initiating treatment of PID in who?

all sexually active young women with adenexal tenderness or cervical motion tenderness (these criteria are sensitive but not specific)

44

treatment against PID directed at what?

c. trachomatis, n. gonorrhoeae, gram negative facultative anaerobes, vaginal anaerobes, and stretococci

45

2 most important sexually transmitted organisms associated with acute PID

c. trachomatis, n. gonorrhoeae- these should be the target of tx. However negative endocervical screeening for either of these pathogens does not rule out upper tract infection

46

diagnosis of PID difficult to make because

studies have been unable to identify any single clinical finding or constellation of findings that allow accurate identification of women with PID

47

most cases of PID

probably go undiagnosed

48

when PID diagnosis is made clinically

might not be supported by laparoscopic evidence/ surgical findings

49

treatment guidelines from CDC 2015

make chart on paper!