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Pelvic inflammatory disease (PID) (Risk factors (Early coitarche,…
Pelvic inflammatory disease
(PID)
Definition
Infection of upper genital tract,
causing inflammation of
fallopian tubes, ovaries, parametrium
Epidemiology
Commonest 15-24y
Risk factors
Early coitarche
Previous STI
Frequent partner change
Young age (<25y)
Contraception (IUD)
Pathophysiology
Agent
STI (chlamydia, gonorrhoea, mycoplasma)
Mechanism
STI ascends from endocervix
Inflammation of fallopian tubes, ovaries, peritoneum
(endometritis, salpingitis), parametritis, oophritis, peritonitis)
Spread to other organs via blood
Clinical
presentation
Discharge
Heavy periods
Pain
Character
Aching, abdominal muscle spasm
Radiation
Onset
Acute/insidious
Associated symptoms
Discharge, heavy period,
post coital bleeds
Site
Deep dyspareunia
Timing
Constant
Exacerbating/relieving factors
Severity
Variable
Post-coital bleeding
N+V (if peritonitic)
Diagnosis
Examination
Bimanual examination
Adnexal tenderness, cervical excitation
Speculum examination
Vaginitis/cervicitis, contact bleeding, discharge
Abdominal examination
Suprapubic tenderness/peritonism
Diagnosis
Urine
Pregnancy test
Dipstick (UTI)
Swabs
ECS/VVS (NG/CT NAAT)
HVS ( MCS for TV, candida, mycoplasma)
Bloods
FBC, CRP/ESR, U+E, LFTs
BBV screen (HIV, HBV, HCV, syphilis)
Imaging
Pelvic USS
MRI/CT abdo/pelvis (if unclear diagnosis)
Investigative laparotomy (gold standard)
Bedside
Obs (fever)
History
Repro H
Gynae: menses, IMB, PCB, contraception, smears, STIs
Obs: ?pregnancy, gravity/parity, deliveries, complications
PC/HPC
Chronic pelvic pain, abnormal bleeding,
abnormal discharge, RUQ pain, secondary dysmenorrhoea
SxH
Partners: regular/casual, age, gender
Type of sex: vaginal, anal, oral, passive/receptive
Contraception (UPSI, barrier)
Partners (last 3m and 12m)
BBV risk (abroad, IVDU, blood products, sex work)
SH
Occupation (sex work), living arrangements,
smoking, alcohol, drugs
Diagnostic criteria
(Jacobsen and Westrom)
Abdo pain plus 2+ of:
vaginal discharge
fever
vomiting
menstrual irregularity
urinary symptoms
tenderness on bimanual examination
adnexial swelling
ESR>15
Aetiology
Idiopathic
Post-instrumentation (TOP, IUD, IVF, etc.)
Post childbirth
Infection
STIs e.g. chlamydia, gonorrhoea, mycoplasma
Also TB, gram -ve/enteric organisms, staph
Management
Initial (ABCDE)
Definitive
Medical
Analgesia
Indication: pain
E.g. paracetamol, NSAID
Abx
Indication: suspected PID
E.g. doxycycline, ceftriaxone and metronidazole
Surgical
Investigative laparotomy
Indcation: If severe symptoms, peritonitic, abscess
Conservative
Information, advice, support
Avoid SI until self and partner tx
Partner notification and treatment
Discuss removal of IUD if needed
Follow up (symptoms, abx, contact tracing)
Admission
Home if stable
Admit if diagnostic uncertainty, severe symptoms,
tubo-ovarian abscess, immunocompromised, pregnant
Complications
Chronic pelvic pain
Ectopic pregnancy
Infertility
Tubo-ovarian/pelvic abscess
Peri-hepatitis (Fitz-Hugh-Curtis syndrome)