Pelvic inflammatory disease (PID) infection
- 1-2% of sexually active women
- In Russia every year, more than half of the women who go to antenatal clinics are diagnosed with PID; 50% of them will need hospital treatment. The predominant age is 16-25 years. Etiology
- Sexually transmitted diseases
- Intra-uterine devices (IUD)
- PID – polymicrobial infections
- Neisseria gonorrhoeae
- Chlamydia trachomatis
- Endogenous aerobic bacteria: Escherichia coli, Proteus, Klebsiella, Streptococcus
- Endogenous anaerobic bacteria: Bacteroides, Peptostreptococcus, Peptococcus
- Mycoplasma hominis and Ureaplasma urealyticum
- Actinomyces israelii
- Granulomatous salpingitis
- Tuberculous salpingitis – 10-11% of patients with PID
- Leprosy salpingitis
- Actinomycosis develops secondary to acute appendicitis, gastrointestinal disease, or IUD use.
- Salpingitis due to the presence of a foreign body (use of a hydrophobic contrast agent for hysterosalpingography; introduction of starch, talc, mineral oil into the vagina)
- Non-granulomatous salpingitis occurs secondary to any other bacterial infection of the abdominal cavity: acute appendicitis, diverticulitis, Crohn’s disease, cholecystitis.
- PID is traditionally preceded by colonization of the vagina and cervix by opportunistic flora
- Asymptomatic carriage can last for months or years
- Under the influence of a provoking factor, bacteria penetrate through the uterine cavity into the lumen of the fallopian tubes.
- The process is traditionally two-sided. Provoking factors
- Menstruation. Blood and rejected endometrium are a good nutrient medium. 60% of cases of acute PID begin immediately after menstruation
- Sexual intercourse. Contractions of the myometrium contribute to the development of ascending infection
- Yat-rogenic causes (medical abortion, dilation of the cervical canal and curettage, insertion of an IUD, hysterosalpingography, introduction of radioactive substances into the uterine cavity for therapeutic purposes). Pathomorphology
- Hyperemia, edema, microcirculation disorders with subsequent destruction of the cells of the mucous membrane of the fallopian tubes and their fringes by bacterial toxins
- The process is traditionally bilateral, although it is likely that the fallopian tube is affected only on one side.
- Inflammation extends to the muscular and serosa
- Possible penetration of infection into the abdominal cavity through the abdominal end of the fallopian tube and damage to the integumentary epithelium of the ovaries and adjacent peritoneum
- Development of the process on the plane of the ovaries
- Subsequent infection of the granular membranes of the follicles with the formation of microabscesses inside the ovaries
- Pelvioperitonitis develops when the infectious process spreads throughout the abdominal cavity, either by direct or lymphogenous routes.
- Perihepatitis with adhesions in the right upper quadrant of the abdomen (Fitz Hugh-Curtis syndrome)
- Tuberculous lesion
- Macroscopically: the fallopian tube is in the form of a pouch, enlarged, dilated, the uterine end is closed, the fringes are edematous and enlarged
- Microscopically: epithelioid reaction in tuberculous tubercles, productive inflammation with presence of giant cells, scarring
- Leprosy: Langerhans giant cells, epithelioid cells
- Macroscopically: inflammation, necrosis of the appendages
- Microscopically: actinomycosis sulfur granules, radial club-shaped filaments with a thickening at the end (actinomycetes), monocyte infiltration, giant cells
- Macroscopically: nonspecific inflammation of the tubes, testicles
- Microscopically: granulomatous formations, giant cells.
- The symptoms of PID are relatively nonspecific, which often leads to misdiagnosis.
- Symptoms often worsen during or immediately after menstruation
- Pain in the lower abdomen
- Pain in the appendages
- Nausea and vomiting
- Vaginal discharge with an unpleasant odor
- Tumor-like formations in the area of the uterine appendages.
- With tuberculous salpingitis
- History of pulmonary tuberculosis
- Cases of tuberculosis in the family
- Intense pain in the lower abdomen
- Seals in the cervical, vaginal and uterine areas.
- In 50% of women with acute PID, the number of leukocytes exceeds 10×109/l
- ESR is elevated in 75% of women with a confirmed diagnosis of PID. Special Studies
- Coloring smear of cervical mucus according to Grom
- In case of a torpid or chronic course of the disease, they resort to provocation with the subsequent taking of smears from all alleged foci after 24, 48 and 72 hours (see Gonococcal Infection)
- Ultrasound helps in the diagnosis of adnexal masses, normal or ectopic pregnancy
- Determination of the concentration of the p-subunit of chorionic gonadotropin helps to exclude ectopic pregnancy (low content in the early periods)
- Ectopic pregnancy
- Rupture of an ovarian cyst
- Acute appendicitis
- Inflammatory Bowel Disease
- Fibromyoma necrosis
- Spontaneous abortion
Indications for hospitalization
- Doubts about the diagnosis
- The need to exclude acute surgical pathology
- Severe condition of the patient (vomiting, dehydration, hyperthermia or signs of peritonitis)
- Failure of outpatient treatment.
Ambulatory treatment. Antibacterial therapy, taking into account the sensitivity of the microflora. The most commonly used products are:
- Benzylpenicillin sodium salt 4800000 IU intravenously and twice
- Ampicillin nbsp;3.5 r/day IM
- Probenecid 1 g orally, then ampicillin or tetracycline 500 mg 4 times a day orally for 7 days. Hospital treatment
- At the initial stages – conservative therapy.
- Antibiotics in high doses
- Doxycycline hydrochloride 100 mg IV drip 2 r / day
- Cefoxitin 2 g IV 4 times a day
- Clindamycin 600 mg IV drip 4 times a day
- Gentamicin 2.0 mg/kg/day IV
- Metronidazole – 1.0 g IV 2 r / day.
- With clinical improvement, maintenance therapy with gentamicin (1.5 mg/kg IV 3 times a day).
- Treatment is continued until the symptoms disappear (within 7-14 days).
- The criterion for the cure of gonorrhea is the absence of gonococci in smears after a complex provocation during 3 menstrual cycles.
- Treatment of tuberculous salpingitis – see Tuberculosis.
- Surgical treatment is indicated for the ineffectiveness of antibiotic therapy within 48-72 hours.
- Colpotomy followed by drainage of pelvic abscesses
- Laparotomy with unilateral salpingo-oophorectomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy and drainage of the pelvic cavity.
Complications occur in 25% of women with acute PID
- Partial obstruction of the fallopian tubes
- Complete obstruction of the fallopian tubes and infertility
- Ectopic pregnancy
- Peritubal and periovarian adhesions
- Tubal-ovarian abscesses
- Ruptured abscesses leading to peritonitis and sepsis.
- Mortality is low
- In advanced cases, septic shock can develop with a fatal outcome.
- With tuberculosis, the prognosis is favorable, but very often infertility begins. Prevention
- Oral contraceptives protect against PID for the following reasons:
- Reduce blood loss during menstruation
- Change in the characteristics of the cervical mucus, preventing the penetration of bacteria
- Barrier methods of contraception (diaphragm, condom, sponge)
- Spermicides are bactericidal
- IUDs increase the risk of developing PID (5.21 cases per 100 women per year).
- PID is an inflammatory disease of the pelvic organs.
See also Gonococcal Infection, ICD Tuberculosis. N70-N77 Inflammatory diseases of female pelvic organs