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Pelvic Inflammatory Disease

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by

Leah Durkin

on 9 December 2013

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Transcript of Pelvic Inflammatory Disease

Polymicrobial Disease
84% of cases are from infections caused by a mixture of bacteria
Infection & Inflammation Affects:


1. Cervix
2. Uterus
3. Fallopian Tubes
4. Ovaries
5. Peritoneal Cavity
Microbial Infection Triggers:
1. Inflammatory response
2. Mucous plug & naturally occurring antimicrobials degraded
3. Normal vaginal flora replaced by anaerobic bacteria
Concept Map of Disease Process
Pelvic Inflammatory Disease
By: Leah Durkin
Baylor University
Louise Herrington School of Nursing

Diagnosis based on:
1. History
2. Physical Exam
3. Laboratory Findings
4. Imaging
Common Bacterial Causes:
*Bacterial Vaginosis
(present in 2/3rds of cases)
*Chlamydia Trachomatis
*Neisseria Gonorrhea

Less Common Culprits:
Respiratory Pathogens
*H. Influenzae
*Strep. Pneumoniae
Other Pathogens
* Mycoplasma Genitalium
* Trichomonas & Gardnerella Vaginalis
* Herpes Simplex Virus
* Anaerobes
Inflammatory Response Triggers:
1. Mast Cell Degranulation
2. Release of Cellular Products
3. Activation of plasma systems:
* Complement
*Clotting
*Kinin

Combined Effect =
Changes to columnar epithelial cells
End Result:
*Epithelium damaged
*Further invasion by microorganisms
*Tubonecrosis with repeated infection
Cervix
Cervical Inflammation = endocervicitis
Facilitates ascending infection by cervical and vaginal microorganisms
Uterus
Inflammation of endometrium = endometritis
Acute or chronic;
Typically resolves without long-term complications
Fallopian Tubes
Inflammation = salpingitis
Epithelial degeneration
Deciliation of fallopian tube cells
Submucosal inflammation
Edema of fallopian tubes
Dysfunctional, partially, or totally obstructed fallopian tubes
Ovaries
Tubo-ovarian abscess formation
Life-threatening if ruptures
Peritoneal Cavity
Inflammation = peritonitis
Exudate formation on serosal surfaces & adhesion of tubes, ovaries, uterus, bowel & omentum to pelvic structures and each other
Chronic Pain
History
Majority of patients are
ASYMPTOMATIC!
Patient characteristics
Female, <25yrs old
History of Uterine Procedure
(Hysteroscopy, Dilation & Curettage, IUD placement)
Sexually Active
(Multiple partners, Hx of STI, Lack of barrier contraceptive use, promiscuous partner)
Related to inflammation of cervix, uterus, and/or fallopian tubes:
Low back pain
Lower abdominal pain
(bilateral, dull, steady, gradual but recent onset)
Dyspareunia
(pain with intercourse)
Intermenstrual and/or postcoital bleeding
Systemic Infection causes:
Fever
Dysuria & Frequency
(pain with urination)
Nausea/Vomiting
Physical Exam
Laboratory Findings
Imaging
1. Bimanual Pelvic Exam
2. Visual Exam of Vagina & Cervix
3. Vital Signs
Visual Exam of Vagina & Cervix
Vital Signs
Bimanual Pelvic Exam
Fever/Chills
*Temp. >101 indicates severe infection
Abnormal Discharge
(r/t cervicitis, endometritis, STI, and/or bacterial vaginosis
Friability - Endocervical bleeding
(after gentle passage of cotton swab through cervical os - r/t cellular damage & inflammation)
Uterine Tenderness
(r/t endometritis)
Cervical Motion Tenderness
(r/t cervicitis)
Adnexal Tenderness
(r/t salpingitis)
Adnexal Mass Palpable
(mass felt on fallopian tube or ovary = possible abcess
1. Microscopy of vaginal secretions
2. Serum blood sample
3. Endometrial biopsy
Microscopy of Vaginal Secretions
Evaluate for STI

Evaluate for Bacterial Vaginosis
Malodorus discharge
Clue cells
Copious discharge
Increased pH - Neutral or alkalotic
(d/t disruption of normal flora)
Other Findings
Exudate at cervical os
(green, yellow, mucopus r/t infectious process)
Leukorrhea
(Increased WBC on Gram stain - indicates infection)
Endometrial Biopsy
Histiopathic evidence of endometritis
(cellular changes to endothelium of uterus)
Serum Blood Sample
Pregnancy test
(r/o ectopic or threatened abortion)
Serum WBC
(Typically normal even with active PID; but may have leukocytosis if severe)
Erythrocyte Sedimentation Rate & C-Reactive Protein
(Elevated d/t inflammation; especially salpingitis)
Screen for HIV
(Increases susceptibility to infection and recurrent infections)
Visualize Problems & Rule Out Competing Differential Diagnoses
Visualize Problems
Laparoscopy
Gold Standard
(But lacks sensitivity - will accurately identify 65% of cases)
Acute fallopian tubal inflammation
(evidenced by erythema, edema & purulent exudate)
Ultrasound or MRI
Tubo-ovarian abcess
Thickened, fluid-filled fallopian tubes
(but lacks sensitivity for PID)
Rule Out Competing Diagnoses
Ultrasound
CT Scan
Rule out Appendicitis
Rule out:
*Ovarian Cysts
* Ovarian Torsion
Acute inflammatory disease caused by infection
Take Home Message:
1. Inflammatory process of upper reproductive tract caused primarily by bacteria
2. Difficult to diagnose
- often asymptomatic
- tests lack sensitivity for PID
3. Long-term Consequences:
*Infertility
*Ectopic Pregnancy
*Chronic Pelvic Pain
*Tubo-ovarian abscess formation
Ectopic Pregnancy
Infertility
Nucleic acid amplification indicates:
Gonorrhea and/or Chlamydia
Full transcript