1. No category

Pelvic Inflammatory Disease
Hennie Williams
Senior Lecturer in Sexual Health
Sexual Health Physician
Melbourne Sexual Health Centre
School of Population Health
University of Melbourne
Why is PID a heart sink?
No one can agree
what it is
But we are certain that it is
important not to miss and
that it is often sexually
transmitted
how common it is
what causes it
how to recognise if a patient has it
how to test for it
how to treat it
how commonly it causes complications
Definition
Prevalence
Cause
Symptoms & signs
Diagnosis
Treatment
Complications
Definition
Prevalence
Cause
Symptoms & signs
Diagnosis
Treatment
Complications
Definition and terminology
Spectrum of disorders
endometritis
salpingitis
tubo-ovarian abscess
pelvic peritonitis
Salpingitis:
1. Organisms from cervix
or vagina to UGT
1. Blood borne (eg TB)
2. Post op
3. Puerperal (delivery or abortion)
‘laparoscopic diagnosis’
~2/3 women with clinical PID have salpingitis
remainder other conditions or normal pelvic
laparoscopic examination
Upper Genital Tract infection (UGTI)
.
Definition and terminology
Endometritis
Probably an early stage of PID
May be patchy so can be missed on endometrial sampling
Association with IMB acknowledged since 1985
Definition: > 5 polys /400x field with ≥1 plasma cell /120x field (Kiviat‘s)
40% of women with ‘cervicitis’
66% with chlamydial cervicitis
80-90% of women with salpingitits
have endometritis
30% of women with endometritis have salpingitis
Unknown if endometritis alone causes long term sequelae
Wolner-Hansen 1995, Paavonen 1985, Kiviat 1990, Paanoven 1985, Waaserheit
1986, Paavonen 1985 and 1987, Haggerty 2003, Wiesenfeld 2007)
Definition
Prevalence
Cause
Symptoms & signs
Diagnosis
Treatment
Complications
Prevalence
Probably main cause of gynaecological pelvic pain
Estimates
8-11% women of child bearing age in USA (Aral Jama 1991)
2% women < 25y in UK primary care (Simms 1999)
1.5% women attending Melbourne SHC (Doxanakis: 2008)
Chlamydia prevalence
often used as a surrogate marker
decreased rates in Scandinavia paralleled by falls in PID
(Australia mean community prevalence rates ~4%)
Definition
Prevalence
Cause
Symptoms & signs
Diagnosis
Treatment
Complications
Causative organisms
Normal vaginal flora
- mixed bacteria with lactobacilli predominating
- some ‘normal’ vaginal bacteria are potentially pathogenic
(eg E. coli, Klebsiella, Proteus, strep, staph, anaerobes)
Endocervical canal
- acts as a barrier protecting normally sterile UGT
Disturbance of this barrier provides access for these bacteria to UGT
- 75% of cases PID occur within 7d of menstruation (Eschenbach 1976)
Gonorrhoea and Chlamydia are initiators of PID
- ~15% of women with cervicitis develop PID ( Arya 1981, Forslin 1978)
Causative organisms
Most polymicrobial
1/3 Chlamydia trachomatis and/or Neisseria gonorrhoea
>50% no proven microbiological causes
With PID
Mycoplasma organisms (eg Ureaplasma urealyticum)
are more common in lower genital tract
Other STIs in vagina (eg Trichomonas) are more common
Role of normal vaginal flora (eg anaerobes, ecoli, proteus) unknown
NB effect of sampling techniques
Associations with PID
Association between BV and PID remains unclear
Do BV organisms cause PID?
or are they carried by Chlamydia and GC into UGT?
BV more common in women with PID (Soper 1994)
Prospective study (1179 women with BV over 3y) : no increase in PID
(Ness 2004)
PID risk increased 2 fold in women with highest counts of BV
organisms in clusters (? STI cofactor for BV/PIG) (Ness 2005)
Douching: PID is more common in women who douche
but these women also have other risk factors for PID
(Wolner-Hanssen 1990, Rosenberg 1992)
Associations with PID
Case control study
140/381 patients with PID in GUM clinic
105 controls from general practice
136 controls from PID free tubal ligation group
age < 25 yrs
sexual intercourse < 20 yrs
self reported history of STI
non white-ethnicity
not having had children
exposure to Chlamydia
Definition
Prevalence
Cause
Symptoms & signs
Diagnosis
Treatment
Complications
Symptoms & Signs
Lower abdominal/pelvic pain
Lower abdominal and pelvic tenderness
Dyspareunia
Adenexal tenderness
Irregular vaginal bleeding
Cervical motion tenderness
(PCB or IMB)
Abnormal vaginal discharge
Muco-purulent cervicitis
Abnormal vaginal discharge
Fever
May be asymptomatic
Symptoms & Signs
Asymptomatic PID is still associated with reproductive morbidity
112 women with infertility
36 had adhesions and laparoscopic evidence of PID
only 11 had a history of clinical PID
(Obstets Gynecol 1995 86 321 Wolner Hanssen)
Women with tubal factor infertility
1/3 still have Chlamydia in UGT without a history of PID
(Keilani 1989, Separd 1989)
Diagnostic investigations
No ideal diagnostic test
Many investigations that help
but as specificity increases, sensitivity decreases ….
sensitivity more important than specificity?
- avoid missed diagnosis and prevent complications
Diagnostic investigations
Laparoscopy
“gold standard”: tubal oedema, erythema or purulent exudate
not very sensitive in early diagnosis invasive
(Jacobson 1969,
Method 1988)
variable sensitivity (as low as 50%)
and specificity (as low as 85%) compared to fimbrial biopsy
(Sellors Am J Obstet Gynecol1991)
Clinical diagnosis and laparoscopy triad:
low sensitivity (65%, 60%) (Peipert 1997)
Endometrial biopsy
histopathologic evidence of endometritis
Transvaginal sonography, Magnetic resonance imaging
and Doppler techniques
Clinical diagnosis
In day to day practice
1. LAP or pelvic pain (with no other cause) and
2. At risk of STI and
3. One or more of
cervical motion tenderness
uterine tenderness
adnexal tenderness
Specificity increased by presence of inflammation in LGT
Exclude
ectopic
appendicitis
endometriosis
ovarian cyst complication.
CDC Guidelines 2006:http://www.cdc.gov/std/treatment/2006/toc.htm
Clinical diagnosis
Additional helpful indicators
Temp > 38.3C
Abnormal cervical or vaginal mucopurulent discharge
Presence of abundant WBCs on saline microscopy of vaginal secretions,
Increased ESR,
Increased CRP
Lab documentation of cervical infection with Gonorrhoeae or Chlamydia
(but absence of these 2 infections does not exclude a diagnosis of PID)
Cervicitis
Clinical diagnosis
Value of microscopy of vaginal secretions
high number of WBCs (> epithelial cells)
abnormal vaginal flora
may not help in confirming the diagnosis
but
low number of WBCs
normal flora (lactobacilli ++)
may help in rejecting it (NPV 95%)
Clinical diagnosis
Other investigations
Endo cervical swab for Chlamydia, Gonorrhoea, MG
Vaginal swab for Trichomonas
Vaginal and cervical slides for micro (?polymorphs)
Pregnancy test
US scan
How good are we at diagnosing PID?
Retrospective review
325 cases with PID at MSHC 2002-06
21,785 unselected walk in female controls
Significant differences between doctors
in the proportion of women diagnosed with PID
4 times greater variation in diagnosis of PID than genital warts
Characteristics of women with PID similar between high diagnosing
and low diagnosing doctors
Definition
Prevalence
Cause
Symptoms & signs
Diagnosis
Treatment
Complications
Treatment
Australian National Management Guidelines for STIs (SHSOV) 2008
Azithromycin 1 g stat
+
Doxycycline 100 mg bd 14d
+
Metronidazole 400 mg bd 14d
+
if gonorrhoea suspected: Ceftriaxone 500 mg stat
[USA /UK /Europe: Cephalosporin (+/- Metronidazole)]
Partner notification
CDC - all partners; treat if sexual contact within 60 days
UK - contact tracing for 6 months prior to onset of symptoms and treat
831 patients with mild to moderate PID
- randomised to outpatient or inpatient treatment
with im cefoxitin and oral doxycycline.
- follow up 35 months
- no difference in pregnancy rates, frequency of recurrence of PID,
chronic pelvic pain or ectopic pregnancy
RCT of 106 women outpatient treated PID
Ceftriaxone 250 mg then
either
or
Azithromycin 1 g weekly for 2 weeks
Doxycycline 100 mg bd for 2 weeks
Clinical cure rate at 14 days
98.2% (CI =0.9-0.99)
85.7% (CI = 0.72-0.93)
Retrospective review of case notes
Clinical cure rates:
Doxycycline and Metronidazole
55% (18% non responders)
Doxycycline and Metronidazole
plus Ceftriaxone stat im dose
72% (8% non responders)
Relationships between CCR and
reproductive morbidity?
Treatment regimens all look at short term clinical cure rates, very little
on long term reproductive morbidity.
PEACH Study: endometritis not associated with reproductive morbidity
(Haggerty 2003)
FUP (despite eradication of UGT Chlamydia and GC) rates of infertility,
pelvic pain and recurrent PID were still elevated (Ness 2002)
Need to eliminate maybe other PID pathogens?
Reproductive morbidity worse with non gonococcal infection
Overall PEACH study demonstrates that although current treatment
eradicates UGT GC and Chlamydia these are still at risk of long term
morbidity greater than if they hadn’t had PID
Treatment for Anaerobes
Is anaerobic cover necessary to prevent sequelae?
Compliance with metronidazole poor
Relevance of anaerobes unclear:
? contamination from sampling
? responsible for sequelae
Fluoroquinolones
Azithromycin
Moxifloxacin
no anaerobic cover
some anaerobic cover but not ideal for GC
some anaerobic cover (poor Gram+)
but covers Chlamydia, MG and GC.
Clinical cure rates of anaerobic PID
Azithromycin (97%) vs Azithromycin and Metronidazole (96%)
Azithrom not ideal for GC with resistance patterns ( Bevan 2003)
Animal models: ? Repeat doses Azithromycin shows possibility
Definition
Prevalence
Cause
Symptoms & signs
Diagnosis
Treatment
Complications
Complications
Infertility, pelvic pain and ectopic pregnancy
What is the excess risk of infertility in women
after genital chlamydial infection? A
systematic review of the evidence
Complications
Infertility proportional to severity of laparoscopic findings but not
clinical symptoms (Jacobson 1969 and Bernstein 1987)
Tubal Infertility after mild, moderate and severe PID is 10, 25 and 50%
respectively (Jacobson 1969)
Ectopics: 10-15% of conceptions will be ectopic after mild PID and
50% after severe PID (Bernstein 1987)
Delay in treatment > 48 hours increases risk of infertility and ectopic
pregnancy by 3 fold (Hillis 1993 Am J obstet Gynecol)
1/3-1/2 women will develop pelvic pain (Bernstein 1987 and Stacey 1992)
Complications
Is serology helpful in identifying those at risk of complications?
Generally believed that ChHSP60 Abs were predictive of complications
PEACH study contradicts this
mild to moderate PID risk of complications
related to Chlamydia EB Abs (not Chsp60 Abs)
(Ness 2008 STD)
Complications
MG associated with PID but does it cause infertility?
PEACH study
- positive MG PCR not predictive of complications
- but MG Abs more common in women with TFI
Evidence still conflicting!
(Haggerty 2007)
Take Home Messages
Mild to moderate PID is a clinical diagnosis but may be asymptomatic!
1/3 cases are caused by Chlamydia or Gonorrhoea
Partners need testing and treatment
Even mild PID may cause significant long-term morbidity
Severity of symptoms is not related to the risk of complications
Maintain a low threshold for diagnosis in young sexually active women
Delaying treatment increases the risk of reproductive morbidity
Diagnosis remains unsatisfactory - no perfect diagnostic test
and the outcome in individual patients is uncertain
Condoms to prevent STIs are important
Sexual Health Education
1. PG Certificate in Sexual Health
4 post graduate subjects by distance or in classroom at MSHC
2. Masters of Public Health (with a specialised Sexual Health Stream)
3. Nurses Pap Smear Accredited course
Clinical Sexual and Reproductive Health for Nurses (incl HIV counselling)
4. Short Courses on STIs
5. Pre and Post test HIV counselling courses
MSHC and Melbourne School of Population Health, University of Melbourne
http://www.sph.unimelb.edu.au
http://www.mshc.org.au
Contact: Hennie Williams 03 9341 6249 [email protected]