1
Pelvic inflammatory diseases
Def: is infection of the upper genital tract.
Causes: its most commonly caused by ascending infection from the endocervix
or may occur from descending organ such as the appendix ,the most common
organism are Chlamydia & gonococcus but an aerobes also involved.
Pathophysiology:
Once the infection has ascended to the uterus , the fallopian tubes are
commonly damaged, there is inflammation of the mucosa which if progressive
will destroy cilia followed by scarring in the lumen & this can cause pocketing
with partial obstruction of tubes this may predispose to ectopic pregnancy*.
in severe infection mucopurulent discharge exudes through the fimbrial end
causing peritoneal inflammation , scarring & adhesion formation*. It can
affect the ovary & form tubo-ovarian abscess*. Infection are usually contained
by omentum causing omental adhesion*.CT & GC can cause perihepatitis
leading adhesion between liver & peritoneum this gives violin string
appearance at laparoscopy & is called the Fitz-Hugh-Curtis syndrome.
Risk factors :
1-age < 25 years. 2-previous STDs. 3-IUCD.
4-multiple sexual partners. 5-TOP. 6-HSG.
7-IVF. 8-postpartum endometritis. 9-bacterial vaginosis.
Protective factors :
The use of barrier contraception, marina& COCP.
Sign & symptoms:
a-may be asymptomatic diagnose during infertility investigation.
b-lower abd, pain & dyspareunia .
c-abnormal vaginal discharge & unscheduled vaginal bleeding .
2
d-pyrexia > 38 C., cervical excitation & adnexal tenderness .
investigations:
1-endocervical & HVS . 2-WBC &CRP may be elevated.
3-U/S to detect adnexial mass. 4- laparoscopy gold standard.
Treatment:
1-rest is advised & PT is done to rule out ectopic pregnancy.
2-an IUCD should be removed , adequate hydration & analgesia.
3-sexual intercourse should be avoided during treatment & the partner should
be treated.
4-most patients can be treated as outpatient but inpatient treatment may
indicated in:
a-surgical causes not excluded.
b-severe infection& generalized sepsis .
c- failure to response to outpatient treatment.
d-severe pelvic & abdominal pain requiring strong analgesic.
e-suspicion of tubo –ovarian abcess.
Outpatient treatment :
*Oral ofloxacin (400mg)twice/day + oral metronidazole (400mg) twice/day for
14 days .
*ceftrixone (250mg) single dose i.m + oral doxycycline (100mg) twice/day
+oral metronidazole (400mg) twice/day for 14 days .
Inpatient treatment:
*ceftriaxone (2gm i.v)+i.v or oral doxycycline (100mg)twice/day + i.v
metronidazole (500mg) twice/day this continue until the patient improved
usually within 24 hours, then changes to oral drugs for 14 days.
3
*clindamycin (900mg i.v) three times /day+ gentamycin i.v (loading dose
2mg/kg followed by 1.5mg/kg three times /day) followed by oral ofloxacin
(400mg)twice/day + oral metronidazole (400mg) twice/day for 14 days .
* i.vofloxacin (400mg)twice/day + i.v metronidazole (400mg) three times/day
for 14 days .
5-Surgical treatment in form of abscess drainage under U/S guidance or by
laparoscopy.
6-Advise patient about used barrier contraception & seek early medical advice
if pregnant due to risk of ectopic pregnancy.
Chlamydia :
C.trachomatis its obligate intracellular parasite & it’s the commonest STDs it
affect the columnar epithelium of the genital tract .there are several serovars
of Chlamydia
A_C infect the conjunctiva causing trachoma & D_K infect the genitourinary
systems .other species infect the lung causing pneumonia & there is a
lymphogranulomavenereum strain( L1_L2) causing rectal infection &proctitis.
Signs & symptoms :
1-asymptomatic with detrimental effect on tubal function .
2-vaginal discharge &muco purulent cervical discharge .
3-postcoital bleeding &inter menstrual bleeding .
4-dysuria &urethral discharge & lower abdominal pain .
Diagnosis :
1-endocervical swabs & urethral swab & urine for PCR
2-nucleic acid amplification technique.
3-culture .
4
Treatment :
1-Avoid sexual intercourse & the partner should be treated.
2-Test of cure should be done 6 weeks after treatment .
3-drugs treatment .
a-doxycycline (100mg) orally twice/day for 7days.
b-azithromycin (1gm)orally single dose(recommended in pregnancy .
c-ofloxacin (400mg) once/day for 7days.
complications :
1-PID 2-perihepatitis
3-tubal infertility4-risk of ectopic pregnancy
5-Reiter s syndrome ( arthritis +urethritis + conjunctivitis).
Implications in pregnancy :
1-PROM & preterm lobar . 2- low birth wt.
3-postpartum endometritis . 4-neonatal conjunctivitis .
5-neonatal pneumonia .
Gonorrhea :
Its STDs caused gram –ve intracellular diplococcus Neisseeria gonorrheae its
effect mucous membrane & the columnar epithelium in the endocervical&
urethral mucosa , it also effect the rectal & oropharyngeal mucosa .
Signs & symptoms :
1-asymptomatic 2-greenish vaginal discharge &abd , pain .
3- mucopurulentendocervical discharge & contact bleeding .
4-dysuria &mucopurulent urethral discharge .
5
5-proctitis & rectal bleeding , discharge & pain .
Diagnosis :
1-triple swabs : ( endocervix , urethra ,rectum) for gram stain & culture also
pharyngeal swab .
2-NAAT & NAHT .
Treatment :
1-ceftriaxone (250mg) i.m single dose .
2-cefixime (400mg) oral dose .
3-spectinomycin ( 2gm) i.m single dose .
Complications :
1-PID 2-bartholin' s abscess &skene's abscess .
3-disseminated gonorrhea which cause fever , pustular rash ,migratory poly
arthralgia ,& septic arthritis .
4-tubal infertility . 5- risk of ectopic pregnancy .
Implications in pregnancy :
1-PROM & preterm lobar 2- chorioamnionitis .
3-postpartum endometritis . 4-ophthalmia neonatrum .
This lecture by Dr .Nadia AL-Assady
CABOG-FIBOG