Pelvic Inflammatory Disease (PID)
What is pelvic inflammatory disease?
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Pelvic inflammatory disease (PID) is caused by bacteria, often the same type of bacteria that is responsible for several sexually transmitted diseases, such as gonorrhea and chlamydia. In some cases, PID develops from bacteria that has traveled through the vagina and the cervix by way of an intrauterine device (IUD).
PID can affect the uterus, fallopian tubes, and/or the ovaries. It can lead to pelvic adhesions and scar tissue that develops between internal organs, causing ongoing pelvic pain and the possibility of an ectopic pregnancy (the fertilized egg becomes implanted outside the uterus). Left untreated, infertility can develop. In fact, one in 10 women with PID becomes infertile. If left untreated, PID can also lead to chronic infection. In addition, if PID is not diagnosed early enough, peritonitis and inflammation of the walls of the abdominal and pelvic cavity may develop.
Who is at risk for pelvic inflammatory disease?
Although women of any age can develop PID, sexually active women under age 25, and those of childbearing age are at the greatest risk of acquiring the disease through sexually transmitted bacteria. Women who use intrauterine devices (IUDs) are also at an increased risk.
What are the symptoms of PID?
The following are the most common symptoms of PID. However, each individual may experience symptoms differently. Symptoms of PID include:
· Diffuse pain and tenderness in the lower abdomen
· Pelvic pain
· Increased foul-smelling vaginal discharge
· Fever and chills
· Vomiting and nausea
· Pain during urination
· Abdominal pain (upper right area)
· Pain during sexual intercourse
Symptoms may be mild enough that the condition may go undiagnosed.
The symptoms of pelvic inflammatory disease may resemble other conditions or medical problems. Always consult your health care provider for a diagnosis.
How is PID diagnosed?
In addition to a complete medical history and physical and pelvic examination, diagnostic procedures for PID may include the following:
· Microscopic examination of samples from the vagina and cervix
· Blood tests
· Pap test. Test that involves microscopic examination of cells collected from the cervix, used to detect changes that may be cancer or may lead to cancer, and to show noncancerous conditions, such as infection or inflammation.
· Ultrasound. A diagnostic imaging technique which uses high-frequency sound waves to create an image of the internal organs.
· Laparoscopy. A minor surgical procedure in which a laparoscope, a thin tube with a lens and a light, is inserted into an incision in the abdominal wall. Using the laparoscope to see into the pelvic area, the physician can determine the locations, extent, and size of the endometrial growths.
· Culdocentesis. A procedure in which a needle is inserted into the pelvic cavity through the vaginal wall to obtain a sample of pus.
Treatment for PID
Specific treatment for cervicitis will be determined by your health care provider based on:
· Your age, overall health, and medical history
· Extent of the disease
· Type and severity of the symptoms
· Your tolerance for specific medications, procedures, or therapies
· Expectations for the course of the disease
· Your opinion or preference
Treatment for PID usually includes oral antibiotics, particularly if there is evidence of gonorrhea or chlamydia. In cases of severe infection, hospitalization may be required to administer intravenous antibiotics. Occasionally, surgery is necessary.
Click Online Resources of Women’s Health for more information.
I. Epidemiology
A. Incidence: 750,000 cases per year in United States
B. Age: Peaks between ages 15 to 29 years
II. Pathophysiology
. Intra-abdominal spread
1. Cervix to endometrium and via salpinx to peritoneal cavity
A. Lymphatic spread
1. Example: IUD related infection
B. Hematogenous spread (rare)
1. Example: Tuberculosis
III. Etiology
B. Mycoplasma hominis
C. Mycoplasma genitalium (associated with treatment failures, not currently covered by antibiotic regimens)
D. Facultative or anaerobic organisms
IV. Risk Factors
. Sexually Transmitted Disease (STD) history
1. Chlamydia is asymptomatic in 80-90% of women
2. Gonorrhea is asymptomatic in 10% of women
3. Untreated Chlamydia or Gonorrhea is associated with a 10-20% risk of PID
A. Age younger than 25 years
B. Onset sexual intercourse at a young age (younger than 15 years old)
C. Prior history of Pelvic Inflammatory Disease
D. High number of sexual partners
E. Non-barrier Contraception (e.g. IUD, Oral Contraceptives)
V. Symptoms: Onset usually in first half of Menstrual Cycle
. Abdominal Pain or Pelvic Pain or cramping (varying intensity)
A. Vaginal Discharge (new or abnormal)
B. Fever or chills (fever may be high grade)
C. Dyspareunia
D. Dysuria
E. Heavy or prolonged Menses or post-coital bleeding
VI. Exam
. Bimanual exam and speculum exam in all suspected cases
1. Cervical motion tenderness
2. Uterine tenderness
3. Adnexal tenderness
A. See Diagnosis below for signs
B. Clinical diagnosis alone is accurate (when compared with imaging and laparoscopy)
1. Test Sensitivity: 87%
2. Test Specificity: 50%
3. Positive Predictive Value: 65-90%
VII. Diagnosis: 2002 CDC Criteria
. Major Criteria (Required)
1. Uterine or Adnexal tenderness to palpation or
2. Cervical motion tenderness
3. No other apparent cause
A. Minor Criteria (Supporting, but not required)
1. Fever >101 F (38.3 C)
2. Abnormal discharge per Cervix or vagina
3. WBCs on Gram Stain or Saline of Cervix swab
4. Gonorrhea or Chlamydia testing positive
5. Increased Erythrocyte Sedimentation Rate or C-Reactive Protein
6. PID findings on diagnostic study (see below)
B. Most specific findings (not required and rarely indicated unless refractory to management or unclear diagnosis)
1. Laparoscopy findings consistent with PID
2. Endometrial Biopsy with histology suggestive of Endometritis
3. Imaging (Transvaginal Ultrasound or MRI) with classic findings
a. Thickened, fluid filled tubes
b. Free pelvic fluid may be present
c. Tubo-ovarian complex
d. Tubal hyperemia on doppler Ultrasound
VIII. Differential Diagnosis
. See Acute Pelvic Pain
A. See Acute Pelvic Pain Causes
B. Ruptured Ovarian Cyst
1. Sudden onset of mid-cycle pain
1. Unilateral pain
2. Positive Pregnancy Test
3. Afebrile
4. White Blood Cell count normal
D. Appendicitis
1. Right Lower Quadrant Abdominal Pain
2. More bowel Symptoms
E. Urinary Tract Infection (including Pyelonephritis)
1. No Cervical Motion Tenderness or Vaginal Discharge
1. More localized pain
2. Sudden onset
3. Afebrile
4. White Blood Cell count normal
G. Other common causes
IX. Labs
. General
1. Do not delay treatment while waiting for labs
A. Inflammatory markers (if all normal, PID is very unlikely)
1. Complete Blood Count (CBC)
2. Erythrocyte Sedimentation Rate or C-Reactive Protein
3. Vaginal secretion exam (saline wet prep)
. Vaginal PMNs (Negative Predictive Value 95%)
a. Identifies Trichomonas vaginalis and Bacterial Vaginosis
B. Sexually Transmitted Disease screening
1. DNA probe PCR for Gonorrhea and Chlamydia
. Cervical specimen recommended over urine specimen
a. Test Sensitivity and Test Specificity are high
2. Rapid Plasma Reagin (RPR)
3. Human Immunodeficiency Virus Test (HIV Test)
C. Other initial labs
1. Urine Pregnancy Test
2. Blood Cultures
X. Diagnostics
. Endometrial Biopsy: Endometritis
1. Test Sensitivity: 74%
2. Test Specificity: 84%
A. Transvaginal pelvic Ultrasound
1. Efficacy
. Test Sensitivity: 30%
a. Test Specificity: 76%
2. Pelvic free fluid in cul-de-sac
3. Tubo-ovarian abscess may be present
4. Doppler demonstrates tubal hyperemia
5. Fallopian tube changes
. Thickened fallopian tube wall >5 mm
a. Fluid filled fallopian tubes
b. Incomplete septae in fallopian tube
i. Cogwheel sign on tube cross-section view
B. CT Pelvis
1. Other imaging modalities are preferred for PID evaluation
2. Pelvic floor fascial, Adnexal inflammation
3. Uterosacral ligament thickening
4. Pelvic free fluid
C. MRI Pelvis
1. Efficacy
. Test Sensitivity: 81-95%
a. Test Specificity: 89-100%
2. Tubo-ovarian abscess may be present
3. Pelvic free fluid
4. Fallopian tube changes
. Fluid filled fallopian tubes
a. Ovaries have polycystic appearance
5. References
. Tukeva (1999) Radiology 210:209-16
D. Laparoscopy
1. Indicated for unclear diagnosis
2. Pelvic Inflammatory Disease misdiagnosed 25% time
XI. Management: General
. Intrauterine Device (IUD) removal is controversial
1. IUD increases PID for only first 3 weeks following insertion
. Risks are similar between the Copper-T IUD and the Mirena IUD
2. Historically, IUD has been removed at time of PID diagnosis
3. No evidence supports removal of IUD in PID
4. Close follow-up is critical for those who developed PID with IUD in place
A. Treat patient’s sexual contacts within last 60 days
1. Abstain from sexual intercourse until patient and partner have completed treatment
B. Start empiric therapy if minimal criteria present
1. Do not delay treatment
2. Delay >3 days increases ectopic and Infertility risk
C. Antibiotic should cover Gonorrhea and Chlamydia
D. Fluoroquinole resistant Gonorrhea is increasing
1. Do not use Fluoroquinolones in high risk groups
2. Cohorts at risk for resistance
. Homosexual men and any female sexual contacts
a. Endemic areas
. Asia: China, Japan, Korea, Philippines, Vietnam
i. Other: England, Wales, Australia
ii. US: California
XII. Management: Special Populations
. HIV positive women
1. May be treated with same antibiotics and guidelines as non-HIV patients
2. More likely to be infected with Mycoplasma or Streptococcus than with Gonorrhea or Chlamydia
A. Pregnant women
1. PID is less common in pregnancy, but can occur in first trimester before formation of mucous plug
2. Pregnant women with PID have greater risk of complications including Preterm Labor
3. Admit and initiate parenteral antibiotics for initial PID treatment in pregnancy
XIII. Management Outpatient
. Step 1: Initial Treatment at Diagnosis (with step 2)
1. Cefoxitin 2g IM and Probenecid 1g PO or
2. Ceftriaxone 250 mg IM for 1 dose or
3. Other third generation Cephalosporin (e.g Cefotaxime, Ceftizoxime)
A. Step 2: Outpatient 14 day antibiotic course
1. Select general antibiotic coverage
. Doxycycline 100 mg PO bid for 14 days (75% cure)
a. Fluoroquinolones are no longer recommended
. Ofloxacin 400 mg PO bid for 14 days (95% cure) or
i. Levofloxacin 500 mg PO daily for 14 days or
2. Add anaerobic coverage (consider)
. Metronidazole 500 mg orally twice daily for 14 days or
a. Clindamycin 450 mg PO qid for 14 days
B. References
1. Workowski (2010) MMWR Recomm Rep 59(RR-12): 1-110
XIV. Management Inpatient
. Hospitalization Indications
1. Severe illness
. Toxic appearance
a. High fever
2. Unable to take oral fluids or oral medications
3. Unclear diagnosis
4. Pelvic abscess (tubo-ovarian abscess)
. Requires at least 24 hours of parenteral therapy inpatient
5. Pregnancy
6. HIV positive
7. Adolescents
8. Outpatient treatment failure
9. Unreliable patient
A. Inpatient treatment Regimens
1. General
. Treat for at least 48 hours IV
2. Regimen A (preferred)
. Cefoxitin 2g IV q6h OR Cefotetan 2g IV q12h and
a. Doxycycline 100 mg PO or IV q12h
3. Regimen B
. Clindamycin 900 mg IV q8h and
a. Gentamicin 2 mg/kg IV load, then 1.5 mg/kg IV q8h
. Alternative: Conversion to single daily dosing (at 3-5 mg/kg)
4. Alternative
. Unasyn 3g IV q6 hours and
a. Doxycycline 100 mg PO or IV q12 hours
5. Other options that are not recommended (listed for historical reasons)
. Regimen C
. Ofloxacin 400 mg IV q12h or Levoquin 500 IV qd and
i. Consider adding Metronidazole 500 IV q8 hours
6. Discharge Regimen (after IV antibiotics above)
. See Outpatient Management Step 2 above
a. Discontinue 24 hours after clinical improvement and complete therapy with oral antibiotics
. Doxycycline 100 mg orally twice daily for 14 days or
i. Clindamycin 450 mg PO qid for 14 days
B. References
1. Workowski (2010) MMWR Recomm Rep 59(RR-12): 1-110
XV. Course
. Expect clinical symptom improvement within first 72 hours of treatment
A. Lack of improvement after 72 hours requires additional evaluation
1. Consider inpatient parenteral therapy
2. Broaden antibiotic coverage
3. Consider Ultrasound to assess for tubo-ovarian abscess
XVI. Prevention
. Screen all sexually active women age <25 years for Chlamydia
A. Re-screen for STD 6 months after PID episode (Gonorrhea and Chlamydia)
B. Encourage barrier Contraception (Condom use)
XVII. Complications
. Infertility associated with tubal scarring (20%)
A. Chronic Pelvic Pain (18%)
B. Tubal Pregnancy (9%)
XVIII. References
. (2002) MMWR Recomm Rep 51(RR-6):1-78
A. Crossman (2006) Am Fam Physician 73(5):859-64
B. Gradison (2012) Am Fam Physician 85(8): 791-6
C. Miller (2003) Am Fam Physician 67(9):1915-22
D. Workowski (2010) MMWR Recomm Rep 59(RR-12): 1-110
Pelvic Inflammatory Disease (C0242172) |
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Definition (NCI) |
Pelvic inflammatory disease (PID) is an acute or chronic inflammation in the pelvic cavity. It is most commonly caused by sexually transmitted diseases, including chlamydia and gonorrhea that have ascended into the uterus, fallopian tubes, or ovaries as a result of intercourse or childbirth, or of surgical procedures, including insertion of IUDs or abortion. PID may be either symptomatic or asymptomatic. It may cause infertility and it may raise the risk of ectopic pregnancy. PID is a disease associated with HIV infection. |
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Definition (NCI) |
A disorder characterized by an infectious process involving the pelvic cavity. |
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Definition (NCI) |
Any pelvic infection involving the upper female genital tract beyond the cervix. |
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Definition (MEDLINEPLUS) |
Pelvic inflammatory disease (PID) is an infection and inflammation of the female reproductive organs. It can scar the tubes that carry eggs from the ovary to the uterus which can lead to infertility, ectopic pregnancy, pelvic pain and other problems. PID is the most common preventable cause of infertility in the United States. Gonorrhea and chlamydia are the most common causes, but other bacteria can also cause PID. You are at risk if you
Some women have no symptoms. Others have pain in the lower abdomen, fever, smelly vaginal discharge, irregular bleeding or pain during intercourse. Antibiotics can cure PID. Early treatment is important â“ waiting too long increases the risk of infertility. National Women’s Health Information Center |
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Definition (NCI) |
A condition in which the female reproductive organs are inflamed. It may affect the uterus, fallopian tubes, ovaries, and certain ligaments. Pelvic inflammatory disease is usually caused by a bacterial infection. It may cause infertility and an increased risk of an ectopic pregnancy (pregnancy in the fallopian tubes). |
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Definition (CSP) |
spectrum of inflammation involving the female upper genital tract and the supporting tissues; is usually caused by an ascending infection of organisms from the endocervix that may be confined to the uterus, fallopian tubes, ovaries, the supporting ligaments, or may involve several of the above uterine appendages; such inflammation can lead to functional impairment and infertility. |
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Definition (MSH) |
A spectrum of inflammation involving the female upper genital tract and the supporting tissues. It is usually caused by an ascending infection of organisms from the endocervix. Infection may be confined to the uterus (ENDOMETRITIS), the FALLOPIAN TUBES; (SALPINGITIS); the ovaries (OOPHORITIS), the supporting ligaments (PARAMETRITIS), or may involve several of the above uterine appendages. Such inflammation can lead to functional impairment and infertility. |
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Concepts |
Disease or Syndrome (T047) |
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MSH |
D000292 |
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ICD9 |
614.9, 614-616.99 |
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ICD10 |
N70-N77.9, N73.9, N70-N77 |
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SnomedCT |
155986001, 198131005, 37518008, 155967009, 198570007, 198244005, 266584000, 198130006, 198178006, 155968004, 266648001, 155974004, 266651008 |
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English |
P.I.D., Disease, Pelvic Inflammatory, Diseases, Pelvic Inflammatory, Inflammatory Disease, Pelvic, Inflammatory Diseases, Pelvic, Pelvic Inflammatory Diseases, DISEASE PELVIC INFLAMMATORY, INFLAMMATION PELVIC, PELVIC INFLAMMATION, Disease, Inflammatory Pelvic, Diseases, Inflammatory Pelvic, Inflammatory Pelvic Disease, Inflammatory Pelvic Diseases, Inflammatory disease of female pelvic organs and tissues, NOS, Pelvic Disease, Inflammatory, Pelvic Diseases, Inflammatory, Female pelvic inflam disease, Female pelvic inflam.dis.NOS, Female pelvic inflammatory disease NOS, Female pelvic inflammatory diseases NOS, Inflammatory diseases of female pelvic organs, Inflammtry dis/fem pelv org, [X]Inflammatory diseases of female pelvic organs, [X]Inflammtry dis/fem pelv org, Female pelvic inflammatory disease, unspecified, INFLAMMATORY DISEASES OF THE FEMALE GENITAL ORGANS AND TISSUES, PELVIC INFLAMM DIS, INFLAMM PELVIC DIS, PELVIC DIS INFLAMM, INFLAMM DIS PELVIC, pelvic inflammatory disease, pelvic inflammatory disease (diagnosis), 7-71 INFLAMMATORY DISEASES OF THE FEMALE GENITAL ORGANS AND TISSUES, pid, Female pelvic inflammatory disease NOS (disorder), Inflammatory disease of female pelvic organs AND/OR tissues (disorder), PID – pelvic inflammatory dis, Disease pelvic inflammatory, Pelvic inflammatory disease NOS, PID Pelvic inflammatory disease, Inflammation pelvic, Pelvic inflammation, [X]Inflammatory diseases of female pelvic organs (disorder), Pelvic Infection, Fem pelv inflam dis NOS, Female pelvic inflammatory diseases NOS (disorder), Pelvic inflammatory disease (PID), PID, PELVIC INFLAMMATORY DISEASE, PELVIC INFLAMMATORY DISEASE, DISEASE (PID), PELVIC INFLAMMATORY, INFLAMMATORY DISEASE (PID), PELVIC, PELVIC INFLAMMATORY DISEASE, (PID), Pelvic infection, Pelvic Inflammatory Disease [Disease/Finding], pelvic inflammation, pelvic inflammatory diseases, Disease;pelvic inflammatory, Infection;pelvic inflammatory, inflammatory pelvic disease, pelvic inflammatory disease (PID), Inflammatory diseases of female pelvic organs (N70-N77), PID, Pelvic inflammatory disease, Female pelvic inflammation, Female pelvic inflammatory disease, PID – pelvic inflammatory disease, Female pelvic inflammatory disease (disorder), Inflammatory disease of female pelvic organs AND/OR tissues, inflammation; pelvic, pelvic inflammatory disease; female, Female pelvic infection, Inflam. dis.- pelvic, Inflammatory disease of female pelvic organs AND/OR tissues [Ambiguous], Pelvic inflam. disease NOS, Pelvic Inflammatory Disease, Unspecified inflammatory disease of female pelvic organs and tissues, INFLAMMATORY DISEASE OF FEMALE PELVIC ORGANS, pelvic inflammatory infection |
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Dutch |
ontsteking bekken, niet-gespecificeerde ontstekingsziekte van de vrouwelijke bekkenorganen en -weefsels, bekkenontstekingsziekte NAO, ontstekingsziekte bekken, PID Pelvic inflammatory disease, bekkenontsteking, Ontstekingen kleine bekken/PID, Ontsteking kleine bekken/ PID, bekkenontsteking; vrouw, ontsteking; bekken, Ontstekingsprocessen in vrouwelijk bekken, niet gespecificeerd, bekkenontstekingsziekte, Adnexitis, PID, Pelvic inflammatory disease |
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French |
Pelvi-péritonite, Inflammation pelvienne SAI, PID, Maladie inflammatoire pelvienne (MIP), Maladie inflammatoire non précisée des organes et tissus pelviens chez la gemme, Inflammation pelvienne, Atteinte inflammatoire pelvienne, AIP (Atteinte inflammatoire pelvienne), MIP (Maladie inflammatoire pelvienne), Syndrome inflammatoire pelvien, INFLAMMATION PELVIENNE, Maladie pelvienne inflammatoire, Maladie inflammatoire pelvienne, Inflammation du pelvis |
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German |
Beckenentzuendung NNB, Entzuendung des Beckens, PID, PID Beckenentzuendung, unspezifische Entzuendungen der Organe und Gewebe des weiblichen Beckens, BECKENENTZUENDUNG, Entzuendliche Krankheit im weiblichen Becken, nicht naeher bezeichnet, Entzuendung im kleinen Becken, Beckenentzuendung, Entzündliche Erkrankung des Beckens |
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Italian |
Infiammazione pelvica, Malattia infiammatoria non specificata degli organi e dei tessuti pelvici femminili, Malattia infiammatoria pelvica NAS, Malattia infiammatoria della pelvi, Malattia infiammatoria pelvica |
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Portuguese |
Inflamação pélvica, Doença inflamatória pélvica, Doença inflamatória pélvica NE, DIP, Doença inflamatória NE dos órgãos e tecidos pélvicos femininos, Doenca inflamatoria pelvica, INFLAMACAO PELVICA, Doença pélvica inflamatória, Doença Inflamatória da Pelve, Doença Inflamatória Pélvica, Doença Pélvica Inflamatória |
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Spanish |
Enfermedad inflamatoria no especificada de los órganos y tejidos pélvicos femeninos, Inflamación pélvica, Enfermedad inlamatoria pélvica, Enfermedad inflamatoria de la pelvis NEOM, Enfermedad inflamatoria pélvica EIP, Pyosalpinx, Inflam. dis.- pelvic, Pelvic inflammatory disease NOS, Pelvic inflam. disease NOS, Chronic pelvic inflammatory disease, Female pelvic infection, Pelvic inflammatory disease, PID – pelvic inflammatory disease, Female pelvic inflammatory disease, Female pelvic inflammatory diseases NOS, Pelvic inflam disease,chronic, PID, Enfermedad inflamatoria pelvica, PELVIS, INFLAMACION, [X]enfermedades inflamatorias de órganos pélvicos femeninos (trastorno), [X]enfermedades inflamatorias de órganos pélvicos femeninos, Female pelvic inflammatory disease NOS, EIP, EPI, enfermedad inflamatoria de los órganos Y/O tejidos pelvianos, enfermedad inflamatoria de los órganos Y/O tejidos pélvicos (concepto no activo), enfermedad inflamatoria de los órganos Y/O tejidos pélvicos, enfermedad inflamatoria pelviana, enfermedad inflamatoria pélvica en la mujer (trastorno), enfermedad inflamatoria pélvica en la mujer, enfermedad inflamatoria pélvica femenina, SAI (trastorno), enfermedad inflamatoria pélvica femenina, SAI, enfermedad inflamatoria pélvica femenina, enfermedad inflamatoria pélvica, enfermedad pélvica inflamatoria, enfermedades inflamatorias pélvicas femeninas, SAI (trastorno), enfermedades inflamatorias pélvicas femeninas, SAI, inflamación pélvica femenina, Enfermedad inflamatoria pélvica, Enfermedad Inflamatoria Pelvica, Enfermedad Inflamatoria Pélvica |
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Japanese |
骨盤内炎症性疾患ＮＯＳ, 骨盤内炎症, ｺﾂﾊﾞﾝﾅｲｴﾝｼｮｳｾｲｼｯｶﾝ, ｺﾂﾊﾞﾝﾅｲｴﾝｼｮｳ, ｺﾂﾊﾞﾝﾅｲｴﾝｼｮｳｾｲｼｯｶﾝNOS, 骨盤内炎症性疾患, 子宮付属器炎, 付属器炎 |
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Czech |
pánev – zánětlivé nemoci, Pánevní zánětlivé onemocnění, Pánevní zánětlivé onemocnění NOS, Zánět v pánvi, Zánětlivé onemocnění orgánů malé pánve, Pánevní zánět, Blíže neurčené zánětlivé onemocnění ženských pánevních orgánů a tkání |
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Finnish |
Sisäsynnytintulehdus, PID/SISASYNNYTTIMIEN TULEHDUS |
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Russian |
TAZOVYKH ORGANOV VOSPALITEL’NYE BOLEZNI, ADNEKSIT, АДНЕКСИТ, ТАЗОВЫХ ОРГАНОВ ВОСПАЛИТЕЛЬНЫЕ БОЛЕЗНИ |
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Swedish |
INFLAMMATION I BACKENORG, Bäckeninflammation |
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Norwegian |
UNDERLIVSINF/PELVIC INFL DISEASE |
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Danish |
Underlivsbetaendelse |
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Hungarian |
gyulladasos nogyogy. betegsegek, Kismedencei gyulladás, kismedencei gyulladásos betegség k.m.n., PID, PID (kismedencei gyulladásos betegség), pelvikus gyulladás, kismedencei gyulladásos betegség, pelvikus gyulladásos betegség, Női kismedencei szervek és szövetek nem meghatározott gyulladásos betegsége |
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Korean |
상세불명의 여성 골반의 염증성 질환 |
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Croatian |
UPALNE BOLESTI ZDJELICE, ZDJELICA, UPALNA BOLEST |
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Basque |
PELBISEKO ERITASUN HAUNDIGARRIA |
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Hebrew |
daleket haagan PID |
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Polish |
Choroba zapalna miednicy |
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Sources |
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ENDOMETRITIS
I. See Also
II. Causes
A. Postpartum
2. Endometritis
a. Early Postpartum (<48 hours) after C-Section
b. Late Postpartum (48 hours – 6 weeks) after NSVD
B. Uterine instrumentation
III. Pathophysiology
. Bacterial infection of the Uterus
1. Bacteroides
6. M. hominis
IV. Symptoms
. Lower abdominal cramps
A. Foul Vaginal Discharge
V. Signs
. Fever
A. Lower abdominal tenderness and muscle spasm
B. Cervical motion tenderness
VI. Labs
1. Leukocytosis
A. Gram Stain and culture of cervical discharge
C. Chlamydia swab
VII. Management
. Inpatient (Indicated in most cases)
1. Option 1
. Cefoxitin OR Timentin OR Imipenem OR Unasyn AND
a. Doxycycline
2. Option 2
. Clindamycin AND
a. Ceftriaxone OR Cefotaxime OR Gentamycin
A. Outpatient (Indicated for late Postpartum Endometritis)
1. Non-lactating mother
. Doxycycline 100 mg q12h IV or PO for 14 days
2. Lactating mother
i. Pump and dispose of milk
a. Clindamycin may be effective
Endomyometritis (C0269050) |
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Definition (MSH) |
Inflammation of both the ENDOMETRIUM and the MYOMETRIUM, usually caused by infections after a CESAREAN SECTION. |
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Concepts |
Disease or Syndrome (T047) |
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MSH |
D004716 |
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SnomedCT |
198193005, 88027004 |
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English |
Endomyometritis, NOS, Endomyometritis unspecified, Endomyometritis, endomyometritis, endomyometritis (diagnosis), ENDOMYOMETRITIS, Endomyometritis unspecified (disorder), Endomyometritis (disorder) |
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Dutch |
endomyometritis |
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Italian |
Endomiometrite |
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Spanish |
Endrometritis, Endomiometritis, endomiometritis (trastorno), endomiometritis, no especificada (trastorno), endomiometritis, no especificada, endomiometritis |
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Japanese |
子宮内膜筋層炎, ｼｷｭｳﾅｲﾏｸｷﾝｿｳｴﾝ |
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Czech |
endomyometritida, Endomyometritida |
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Portuguese |
Endomiometrite |
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French |
Endomyométrite |
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German |
Endomyometritis |
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Hungarian |
Endomyometritis |
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Sources |
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BACTERIAL VAGINOSIS
I. See also
A. Vaginitis
II. Epidemiology
. Accounts for 35-50% of Vaginitis
III. Etiology
. Marked reduction iormally predominant lactobacillus
A. Polymicrobial infection: facultative Anaerobic Bacteria
1. Peptostreptococcus
2. Corynebacterium vaginale (Haemophilus vaginalis)
3. Bacteroides
4. Mobiluncus species
5. Mycoplasma hominis
IV. Symptoms
. Often asymptomatic, or mild
A. Musty or fishy odor to genitalia or Vaginal Discharge
B. Profuse thin gray-white, non-clumping Vaginal Discharge
V. Signs: Amsel’s Criteria (3 of 4 needed for diagnosis)
. Vaginal pH > 4.5 (more alkaline thaormal)
1. See Vaginal pH for differential diagnosis
2. Test Sensitivity: 77%
3. Test Specificity: 35%
a. False positive with Cervical Mucus, Menses or semen
A. Clue Cells present (on >20% of cells) on saline preparation
1. Bacteria adhered to vaginal epithelial cells
2. Test Sensitivity: 53-90%
3. Test Specificity: 40-100%
4. Images
. 
B. Positive whiff test (Amine Test)
1. Test Sensitivity: 67%
2. Test Specificity: 93%
3. Volatile amines produce a fishy odor with 10% KOH
4. Also present with Trichomonal Vaginitis
C. Discharge characteristics
1. Thin, non-clumping, gray-white, adherent discharge
VI. Labs: New tests
. Fem Exam Card 1 (pH and amine) and 2 (proline aminopeptidase)
1. Rapid, 2 minute test with high sensitivity (91%) but low Specificity
A. Trimethylamine Card for pH
1. Rapid test with Low sensitivity, but high Specificity (97%)
VII. Management
. Non-Pregnant
1. First-Line: Oral Metronidazole (Flagyl)
. Flagyl 500 mg PO bid for 7 days ($5)
2. Other oral options
. Clindamycin 300 mg twice daily for 7 days
3. Topical options (higher recurrence rate, does not cover Trichomoniasis)
. MetroGel (0.75%) 5g intravaginally at bedtime for 5 days ($29)
a. Clindamycin Cream (2%) 5g intravaginally at bedtime for 7 days ($31)
A. Pregnancy:
1. First Trimester
. Avoid treatment if possible in first trimester
a. Clindamycin (Cleocin) 300 mg PO bid for 7 days
b. Clindamycin Cream 5 grams PV qhs for 7 days
c. Metronidazole Gel PV bid for 5 days
2. After First Trimester (prefer after 37 weeks)
. Metronidazole (Flagyl) 500 mg twice daily for 7 days
a. Metronidazole (Flagyl) 250 mg three times daily for 7 days
b. Clindamycin 300 mg PO bid for 7 days ($28)
B. Resistant or Refractory Cases
1. Metronidazole 500 mg PO bid for 14 days (preferred) or
2. Consider treating sexual partner and patient (not recommended)
. Male Urethra may be co-infected
a. Based on anecdotal reports (evidence lacking)
3. Other options
. Clindamycin at above dose
a. Povidone-iodine gel OR suppository (Betadine)
i. Apply vaginally bid for 14 to 28 days ($59)
C. Recurrent Bacterial Vaginosis
1. Treat as refractory cases above
2. Consider maintenance therapy
. Induction: Metronidazole gel 0.75% (Metrogel) nightly for 10 days
a. Maintenance: When wet prep with no clues, pH lower
. Metronidazole gel twice weekly for 3-6 months
i. Treat concurrent Candida if present
i. Fluconazole 150 mg qWeek
3. References
. Sobel (2006) Am J Obstet Gynecol 194(5): 1283-9
VIII. Complications
. Associated with higher risk of HIV Transmission
1. Martin (1999) J Infect Dis 180(6):1863-8
A. Associated with preterm delivery (23-26 weeks)
1. Hillier (1995) N Engl J Med 333: 1737-42
2. Hauth (1995) N Engl J Med 333: 1732-6
B. Early second trimester with better pregnancy outcomes
1. Reduces preterm birth and late Miscarriage rate
2. Study used Clindamycin
3. Ugwumadu (2003) Lancet 361:983-8
IX. References
. (1998) MMWR Morb Mortal Wkly Rep 47:1-115
A. Gutman (2005) Obstet Gynecol 105(3): 551-6
B. Hainer (2011) Am Fam Physician 83(7): 807-15
C. Larimore (2000) Prim Care 27(1):35-53
D. Majeroni (1998) Am Fam Physician 57(6):1285-9
E. Miller (1997) Fam Pract 19(3):33-52
Bacterial Vaginosis (C0085166) |
|
|
Definition (MSH) |
Polymicrobial, nonspecific vaginitis associated with positive cultures of Gardnerella vaginalis and other anaerobic organisms and a decrease in lactobacilli. It remains unclear whether the initial pathogenic event is caused by the growth of anaerobes or a primary decrease in lactobacilli. |
|
Concepts |
Disease or Syndrome (T047) |
|
MSH |
D016585 |
|
SnomedCT |
237092002, 198221007, 155981006, 266655004, 85569008, 419760006 |
|
English |
Bacterial Vaginitis, Bacterial Vaginoses, Bacterial Vaginosis, Nonspecific Vaginitis, Vaginitis, Bacterial, Vaginitis, Nonspecific, Vaginoses, Bacterial, Vaginosis, Bacterial, Bacterial Vaginitides, Vaginitides, Bacterial, BACTERIAL VAGINOSIS, NONSPECIFIC VAGINITIS, VAGINOSES BACT, BACT VAGINOSES, VAGINOSIS BACT, VAGINITIDES BACT, BACT VAGINITIS, BACT VAGINOSIS, BACT VAGINITIDES, VAGINITIS BACT, bacterial vaginitis (diagnosis), nonspecific vaginitis (diagnosis), vaginitis bacterial, bacterial vaginitis, nonspecific vaginitis, bacterial vaginosis, Vaginitis bacterial NOS, Vaginosis bacterial, Vaginosis bacterial NOS, VAGINOSIS BACTERIAL, VAGINITIS NON SPECIFIC, VAGINOSIS NON SPECIFIC, Vaginosis, Bacterial [Disease/Finding], gardnerella vaginitis, bacterial vaginoses, gardnerella infection, gardnerella vaginosis, non-specific vaginitis, gardnerella vaginalis vaginitis, bacteria infection of the vigina, gardnerella, non specific vaginitis, bactria infection of the vagina, Vaginitis bacterial, Non-specific vaginitis, AV – Anaerobic vaginosis, BV – Bacterial vaginosis, Bacterial vaginosis, Bacterial vaginitis, NSV – Nonspecific vaginitis, Nonspecific vaginitis, Bacterial vaginosis (disorder) |
|
Spanish |
vaginosis bacteriana (trastorno), vaginosis bacteriana, Vaginosis bacteriana, Vaginitis bacteriana NEOM, Vaginitis inespecífica, Vaginosis bacteriana NEOM, NSV – Nonspecific vaginitis, Gardnerella vaginalis infection, Bacterial vaginosis, AV – Anaerobic vaginosis, BV – Bacterial vaginosis, Gardnerella infection, Bacterial vaginitis, Nonspecific vaginitis, Vaginitis bacteriana, Vaginitis Bacteriana, Vaginitis no Específica, Vaginosis Bacteriana, Vaginitis no Especifica |
|
Dutch |
vaginose bacterieel, bacteriële vaginose, niet-specifieke vaginitis, vaginitis bacterieel NAO, vaginose bacterieel NAO, vaginitis bacterieel, Vaginitis, niet-specifieke, Bacteriële vaginosis, Vaginitis, bacteriële, Vaginosis, bacteriële |
|
French |
Vaginite bactérienne SAI, Vaginose bactérienne SAI, Vaginite non précisée, Vaginite bactérienne, Vaginite non spécifique, Vaginose bactérienne |
|
German |
Kolpitis bakteriell NNB, nicht-spezifische Vaginitis, bakterielle Kolpitis, Bakterielle Vaginosen, Bakterielle Vaginosis, Bakterielle Vaginitiden, Bakterielle Vaginitis, Unspezifische Vaginitis, Kolpitis bakteriell, Bakterielle Vaginose, Vaginitis, bakterielle, Vaginitis, unspezifische, Vaginose, bakterielle |
|
Italian |
Vaginite batterica NAS, Vaginosi batterica NAS, Vaginite non specifica, Vaginiti aspecifiche, Vaginosi batterica, Vaginosi batteriche, Vaginite batterica |
|
Portuguese |
Vaginite bacteriana NE, Vaginose bacteriana NE, Vaginose bacteriana, Vaginite inespecífica, Vaginite bacteriana, Vaginite Bacteriana, Vaginite não Específica, Vaginose Bacteriana |
|
Japanese |
細菌性腟症ＮＯＳ, 細菌性腟炎ＮＯＳ, ｻｲｷﾝｾｲﾁﾂｴﾝ, ｻｲｷﾝｾｲﾁﾂｼｮｳ, ｻｲｷﾝｾｲﾁﾂｼｮｳNOS, ﾋﾄｸｲｾｲﾁﾂｴﾝ, ｻｲｷﾝｾｲﾁﾂｴﾝNOS, 腟症–細菌性, 細菌性腟炎, 細菌腟症, 腟炎–細菌性, 非特異性腟炎, 細菌性腟症, 細菌性膣炎, 細菌性膣症, 腟炎–非特異性, 膣炎–細菌性, 膣炎–非特異性, 膣症–細菌性, 非特異性膣炎 |
|
Swedish |
Vaginos, bakteriell |
|
Czech |
vaginitida nespecifická, vaginitida bakteriální, vaginóza bakteriální, Blíže neurčená vaginitida, Vaginóza bakteriální NOS, Bakteriální vaginóza, Aminová kolpitis, Bakteriální vaginitida, Bakteriální vaginitida NOS |
|
Finnish |
Bakteerivaginoosi |
|
Russian |
VAGINIT NESPETSIFICHESKII, VAGINIT BAKTERIAL’NYI, BAKTERIAL’NYI VAGINIT, VAGINOZ BAKTERIAL’NYI, БАКТЕРИАЛЬНЫЙ ВАГИНИТ, ВАГИНИТ БАКТЕРИАЛЬНЫЙ, ВАГИНИТ НЕСПЕЦИФИЧЕСКИЙ, ВАГИНОЗ БАКТЕРИАЛЬНЫЙ |
|
Croatian |
VAGINOZA, BAKTERIJSKA |
|
Polish |
Waginoza pochwy, Waginoza bakteryjna, Bakteryjne zakażenie pochwy |
|
Hungarian |
Nem specifikus vaginitis, Bacterialis vaginosis, Bacterialis vaginosis k.m.n., bacterialis vaginitis k.m.n., bacterialis vaginitis |
|
Sources |
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CANDIDA VULVOVAGINITIS
I. See also
A. Vaginitis
II. Epidemiology
. Candida Vulvovaginitis accounts for 45% of Vaginitis
A. Candida is cultured in 20-50% asymptomatic women
B. Vaginitis often self diagnosed incorrectly
III. Etiology
. Acute: Candida albicans (90%)
1. Normal commensal organism in vagina
2. Infection when Corynebacterium suppressed
A. Recurrent Vulvovaginal Candidiasis
1. Candida glabrata (increasing Incidence, now 15%)
2. Candida tropicalis
3. Candida parapsilosis
4. Saccharomyces cerevisiae
IV. Predisposing Factors
A. Medications
1. Corticosteroids
2. Immunosuppressant Medications
3. Broad spectrum antibiotics
a. Increases frequency of Candida carrier state
b. Does not increase symptomatic vulvovaginitis
B. Heat and moisture retaining clothing (e.g. nylon)
C. Pregnancy
D. Premenstrual phase of the Menstrual Cycle
E. Depressed cell mediated immunity (e.g. AIDS)
F. Obesity
V. Symptoms
. Asymptomatic in 20-50% of women
A. Intense vaginal or Vulvar Pruritus (50% of cases)
B. Vulvar Burning, soreness, or irritation
C. Thick white curd-like or “cottage cheese” discharge
D. No odor
E. Dyspareunia
F. Dysuria (33% of cases)
VI. Signs
. Adherent white cottage-cheese discharge in vagina
1. Sensitivity: 50%
2. Specificity: 90%
A. Vulvar erythema and edema (24% of cases)
VII. Labs
. KOH Preparation (10%)
1. Test Sensitivity: 50%
2. Pseudohyphae or budding yeast forms
3. 
A. Fungal Culture positive
1. Fungal Culture rarely performed
2. Fungal Culture may be very helpful in certain cases
. Confirm asymptomatic carrier of vaginal Candida
a. Identify cause of recurrent Vaginitis
B. Candida on Pap Smear
1. Specific but not sensitive
C. Vaginal pH <4.5 (Normal acidity)
D. Absent Amine odor
E. White Blood Cells not increased
F. Wet-Prep is not sensitive or specific for yeast
1. Bornstein (2001) Infect Dis Obstet Gynecol 9:105-11
VIII. Differential Diagnosis (Consider for refractory cases)
. Other Vaginitis cause
A. Infectious Cervicitis (Sexually Transmitted Disease)
B. Allergic Vaginitis or Vulvitis
C. Vulvodynia
IX. Management: Local First-Line Agents
1. Monistat 1200 mg vaginal tab PV qhs, 1 dose
2. Monistat 4% cream, 5 g PV qhs for 3 days
3. Monistat-3 200mg PV qhs for 3 days ($30)
4. Monistat-7 2% cream PV qhs for 7 days ($15)
5. Monistat Vag tabs 100mg PV qhs for 7 days ($15)
A. Clotrimazole (Gyn-Lotrimin, Mycelex G)
1. Clotrimazole 500 mg vaginal tab PV qhs, 1 dose ($19)
2. Clotrimazole 200 mg vaginal tab PV qhs for 3 days
3. Clotrimazole 2% cream qhs for 3 days ($14)
4. Clotrimazole 100 mg vaginal tab PV qhs for 7 days ($14)
5. Clotrimazole 1% cream qhs for 7 days ($14)
B. Butoconazole (Femstat)
1. Mycelex-3 5g of 2% Cream PV QHS for 3 days ($26)
2. Gynezole-1 (sustained release) 5 g of 2% cream once
C. Terconazole (Newer, binds better to Candida)
1. Vagistat-1 6.5% ointment, 5 g intravaginally once
2. Terazol 80 mg vaginal suppository PV for 3 days
3. Terazol-3 0.8%, 5 g vaginal cream for 3 days
4. Terazol-7 0.4%, 5 g vaginal cream qhs for 7 days ($25)
D. Nystatin
1. Vaginal tablet (100,000 unit) PV daily for 14 days
X. Management: Oral Agents
. Fluconazole 150 mg PO for 1 dose
1. As effective as Clotrimazole PV
A. References
1. (1994) Med Lett Drugs Ther 36(631): 1-2
XI. Management: Recurrent or resistant Treatment
. Any of above intravaginal meds for 14-21 days ($28-$54)
1. Consider maintenance after initial daily regimen
2. Maintenance: Repeat application once weekly
. Consider using monthly at time of Menses
3. Consider Terconazole (see above)
. More effective against other candida species
A. Fluconazole (Diflucan) ($16-$22 for two dose protocol)
1. See below for maintenance protocol
2. Less effective for non-albicans Candida
3. Dose 1: 150 mg PO
4. Dose 2: 150 mg PO at 72 hours after first dose
5. Consider a 3rd dose at 72 hours after second
6. Sobel (2001) Am J Obstet Gynecol 185:363-9
B. Other options
1. Ketoconazole (Nizoral) 200mg PO bid for 5-14 days
2. Itraconazole (Sporanox) 200 mg PO qd for 3 days ($40)
3. Gentian Violet vaginal staining 1-2x (Office charge)
4. Boric Acid 600 mg vaginal tab bid for 14 days ($14)
. Use is controversial
5. Flucytosine (Ancobon) cream applied to affected area
XII. Management: Prophylaxis (more recent protocol)
. Indication
1. Four or mor yeast infections per year
A. Initial treatment
1. Fluconazole (Diflucan) 150 mg PO q3 days for 3 doses
B. Maintenance
1. Fluconazole (Diflucan) 150 mg PO each week
2. Monitor liver enzymes (consider q1-2 months)
C. Efficacy
1. Suppression while on treatment: 90%
2. Following treatment: Infection recurs in 60%
D. References
1. Sobel (2004) N Engl J Med 351:876-83
XIII. Management: Prophylaxis (old protocol)
. Protocol for 6 month maintenance regimen
1. Start with 2 week recurrent treatment option above
2. Follow treatment with prophylaxis option below
3. Fungal Culture and exam timing
. Baseline
a. Two weeks (after treatment regimen above)
b. Three months
c. Six months (when stopping prophylaxis)
A. Medications
1. Clotrimazole 500 mg vaginal tab weekly to montly
2. Fluconazole 150 mg PO once weekly to monthly
3. Ketoconazole 200 mg PO bid five days monthly
4. Miconazole 100 mg vaginal tab qhs twice weekly
XIV. Prevention
. Control predisposing condition (e.g. Diabetes Mellitus)
A. Reduce predisposing medications (e.g. Corticosteroid)
B. Avoid moisture-retaining products near vagina
1. Nylon underwear
2. Panty-liners
3. Vaginal lubricants or Spermicides
C. Lactobacillus (probiotic) is not effective
1. Does not prevent post-antibiotic Vaginitis
2. Pirotta (2004) BMJ 329:548-51
XV. References
. Desai (1996) Am Fam Physician 54(4):1337-40
A. Hainer (2011) Am Fam Physician 83(7): 807-15
B. Nyirjesy (2001) Am Fam Physician 63(4):697-702
C. Sobel (1998) Am J Obstet Gynecol 178:203-11
D. Tobin (1995) Am Fam Physician 51(7):1715-20
TRICHOMONAL VULVOVAGINITIS
I. See also
A. Vaginitis
II. Epidemiology
. Accounts for 10% of Vaginitis
A. Prevalence
1. General gynecology clinics: 13-23%
2. Prostitutes: 75%
B. Transmission
1. Sexually Transmitted Disease
2. Men are asymptomatic in 90% of cases
3. Often transmitted with Gonorrhea and Chlamydia
4. Rarely transmitted by moist cloths
III. Etiology
. Protozoan infection
IV. Symptoms
. Asymptomatic in 25-44% of women
A. Copious, grayish-green Vaginal Discharge
1. Fishy odor to discharge
2. Frothy discharge (Carbon dioxide bubbles)
a. Sensitivity: 10%
b. Specificity: 70%
B. Vulvar and vaginal Pruritus with irritation and edema
C. Dysuria (20%)
V. Signs
. Vulvar edema and erythema
A. Strawberry Cervix (2-3% of cases)
1. Punctate Hemorrhages or Petechiae
2. Telangiectasia
VI. Lab
. Vaginal pH > 5.0
1. Sniff Test positive
. Fishy odor to discharge when KOH added
B. Wet preparation (from vaginal vault, not endocervix)
1. Motile pear shaped Trichomonads with flagella (70%)
. Twice the size of White Blood Cells (WBC)
a. 
2. Efficacy
. Test Sensitivity: 60-70%
C. Specific diagnostic tests (available as point-of-care clinic based tests)
1. Osom Trichomonas Rapid Test
2. BD Affirm VPIII Microbial Identification Test
3. Efficacy
. Test Sensitivity: 83%
a. Test Specificity: >97% (false positives are a concern in regions of low Prevalence)
D. Other testing
1. Gram Stain
. White Blood Cells over 10 per high powered field
2. Culture of Trichomonas vaginalis
. Grown on modified Diamond media
VII. Associated Conditions
A. Test for other Sexually Transmitted Disease
VIII. Management
. General
1. Treat Sexual Partner also
2. Avoid treatment in first trimester of pregnancy
3. Avoid intravaginal preparations of Metronidazole or Tinidazole due to low cure rates
A. Non-Pregnant, Non-Lactating Patient
1. Metronidazole (Flagyl) 2 g orally for 1 dose (preferred) or
2. Metronidazole (Flagyl) 250 mg PO three times daily for 7 days or
3. Metronidazole (Flagyl) 500 mg PO twice daily for 7 days or
4. Tinidazole (Tindamax) 2 grams orally for 1 dose
B. Pregnant (after first trimester, and preferred after 37 weeks)
1. Metronidazole (Flagyl) 2 g PO for 1 dose ($5) or
2. Metronidazole (Flagyl) 500 mg PO bid for 7 days
C. Lactation
1. Metronidazole (Flagyl) 2 grams PO for 1 dose
2. Discontinue Lactation for 24 hours after dose
D. Persistent or Recurrent Cases
1. Metronidazole 500 mg PO bid for 14 days
2. Metronidazole 2g PO qd for 3 days
3. Metronidazole gel 5g PV bid for 5 days ($30)
4. Povidone-Iodine Suppository PV bid for 14 days ($60)
5. Clotrimazole 100 mg vag tab PV qhs for 7 days ($14)
6. Tinidazole
7. Paromomycin (Humatin) 5g intravaginally qd x14 days
. Higher rate of Vulvitis and local Ulceration
IX. References
. Mandell (2000) Infectious Disease, Churchill, p. 2894-7
A. (1998) MMWR Morb Mortal Wkly Rep 47:1-115
B. Epling (2001) Am Fam Physician 64(7):1241-4
C. Workowski (2006) MMWR Recomm Rep 55:1-94
Trichomonas Vaginitis (C0040923) |
|
|
Definition (MSH) |
Inflammation of the vagina, marked by a purulent discharge. This disease is caused by the protozoan TRICHOMONAS VAGINALIS. |
|
Concepts |
Disease or Syndrome (T047) |
|
MSH |
D014247 |
|
SnomedCT |
500000, 276877003, 187202004, 187201006, 266165009 |
|
English |
Trichomoniasis, vaginal, Trichomonas Vaginitides, Vaginitides, Trichomonas, Vaginitis, Trichomonas, Trichomonal vulvovaginitis, TRICHOMONAS VAGINALIS INFECTION, FEMALE, Trichomonal Vaginitis, VAGINITIS TRICHOMONAL, trichomonas vaginitis, Leukorrhea – vag.-trichomonal, Leukorrhea vaginalis – trichomonal, Leukorrhoea vaginalis – trichomonal, Trichomonal leukorrhea, Trichomonal leukorrhoea, trichomonas vaginalis vaginitis, Trichomonal vaginitis (diagnosis), Vaginitis trichomonal, VAGINITIS TRICHOMONAS, Trichomonas Vaginitis [Disease/Finding], Trichomonas Vaginitis, trichomonas vaginities, trichomoniasis vaginal, vaginitis trichomonas, Vaginitis;trichomonal, vaginal trichomoniasis, Trichomonal fluor vaginalis, Trichomonal leukorrhea vaginalis, Trichomonal vaginitis, Vaginal trichomoniasis, Trichomonal leukorrhoea vaginalis, Trichomonal vaginitis (disorder), Vaginal trichomoniasis (disorder), trichomonal vaginitis |
|
French |
Vaginite trichomonale, Vaginite à Trichomonas |
|
German |
Vaginitis durch Trichomonen, Trichomonaden-Vaginitis, Trichomonadenvaginitis, Trichomonas-Vaginitis, Trichomonas-Kolpitis, Trichomonadenkolpitis, Trichomonaden-Kolpitis, Vaginitis, Trichomonas- |
|
Italian |
Vaginite da trichomonas, Vaginite da Trichomonas |
|
Portuguese |
Vaginite a tricomonas, Vaginite por Trichomonas |
|
Spanish |
Vaginitis por tricomonas, Trichomonal leukorrhea, Leukorrhoea vaginalis – trichomonal, Leukorrhea vaginalis – trichomonal, Trichomonal vaginitis, Trichomonal leukorrhoea, leucorrea vaginal por tricomonas, tricomoniasis vaginal (trastorno), tricomoniasis vaginal, vaginitis por tricomonas, vaginitis tricomoniásica (trastorno), vaginitis tricomoniásica, Tricomoniasis Vaginal, Vaginitis por Trichomonas |
|
Japanese |
トリコモナス性腟炎, ﾄﾘｺﾓﾅｽｾｲﾁﾂｴﾝ |
|
Swedish |
Trichomonas-vaginit |
|
Czech |
trichomonádová vaginitida, Trichomonádová vaginitida |
|
Finnish |
Trikomonasvaginiitti |
|
Russian |
TRIKHOMONADNYI VAGINIT, ТРИХОМОНАДНЫЙ ВАГИНИТ |
|
Polish |
Rzęsistkowica pochwy |
|
Hungarian |
Vaginitis, trichomonas okozta, Trichomonas vaginitis |
|
Dutch |
Trichomonas-vaginitis, Vaginitis, trichomonas- |
|
Sources |
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Trichomonas Infections (C0040921) |
|
|
Definition (MEDLINEPLUS) |
Trichomoniasis is a sexually transmitted disease caused by a parasite. It affects both women and men, but symptoms are more common in women. Symptoms in women include a green or yellow discharge from the vagina, itching in or near the vagina and discomfort with urination. Most men with trichomoniasis don’t have any symptoms, but it can cause irritation inside the penis. You can cure trichomoniasis with antibiotics. In men, the infection usually goes away on its own without causing symptoms. But an infected man can continue to infect or reinfect a woman until he gets treated. So it’s important that both partners get treated at the same time. Correct usage of latex condoms greatly reduces, but does not eliminate, the risk of catching or spreading trichomoniasis. Centers for Disease Control and Prevention |
|
Definition (MSH) |
Infections in birds and mammals produced by various species of Trichomonas. |
|
Concepts |
Disease or Syndrome (T047) |
|
MSH |
D014245 |
|
ICD9 |
131.9, 131 |
|
ICD10 |
A59, A59.9 |
|
SnomedCT |
187364002, 187206001, 56335008, 105648001 |
|
English |
Infections, Trichomonas, Infection, Trichomonas, TRICHOMONIASIS, DISEASES DUE TO TRICHOMONADIDAE, Infection by Trichomonas, NOS, TRICHOMONAL INFECTION, Trichomonas NOS, Trichomoniasis, unspecified, [X]Trichomoniasis, unspecified, INFECT TRICHOMONAS, TRICHOMONAS INFECT, Trichomonas Infections, trichomoniasis (diagnosis), E-531 DISEASES DUE TO TRICHOMONADIDAE, trichomoniasis, Trichomonas infections, [X]Trichomoniasis, unspecified (disorder), Trichomoniasis NOS, Trichomonas NOS (disorder), Trichomonas Infections [Disease/Finding], trichomonosis, trichomona, trichomonas infection, trichomoniasi, trichomonas, Trichomoniasis, Trichomonosis, Disease due to Trichomonadidae (disorder), Disease due to Trichomonadidae, Infection by Trichomonas (disorder), Infection by Trichomonas, Trichomonas; infection, infection; Trichomonas, Trichomonas Infection |
|
Italian |
Infezioni da trichomonas, Tricomoniasi, Tricomoniasi NAS, Infezioni da Trichomonas |
|
Dutch |
trichomoniasis, niet-gespecificeerd, Trichomonas; infectie, infectie; Trichomonas, Trichomoniasis, niet gespecificeerd, Trichomonasinfecties, trichomoniasis, Trichomoniasis |
|
French |
Trichomonase, non précisée, Infections à Trichomonas, Trichomonase, Trichomoniase |
|
German |
Trichomoniasis, unspezifisch, Trichomoniasis, nicht naeher bezeichnet, Trichomonen-Infektionen, Trichomonadeninfektionen, Trichomoniasis |
|
Portuguese |
Tricomoníase NE, Infecções por Tricomonas, Infecções a tricomonas, Tricomoníase |
|
Spanish |
Tricomoniasis no especificada, [X]tricomoniasis, no especificada (trastorno), [X]tricomoniasis, no especificada, Infecciones por Tricomonas, Trichomonas, SAI (trastorno), Trichomonas, SAI, enfermedad por Trichomonadidae (trastorno), enfermedad por Trichomonadidae, infección por Trichomonas (trastorno), infección por Trichomonas, tricomoniasis, tricomonosis, Infecciones por tricomonas, Tricomoniasis |
|
Japanese |
トリコモナス感染, トリコモナス症、詳細不明, ﾄﾘｺﾓﾅｽｶﾝｾﾝ, ﾄﾘｺﾓﾅｽｼｮｳ, ﾄﾘｺﾓﾅｽｼｮｳｼｮｳｻｲﾌﾒｲ, トリコモナス感染症, トリコモナス症 |
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Swedish |
Trichomonasinfektioner |
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Czech |
Trichomonas – infekce, Trichomonádové infekce, Trichomoniáza, Trichomoniáza, blíže neurčená |
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Finnish |
Trikomoniaasit |
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Russian |
TRIKHOMONADNYE INFEKTSII, ТРИХОМОНАДНЫЕ ИНФЕКЦИИ |
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Korean |
편모충증, 상세불명의 편모충증 |
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Polish |
Trichomoniaza, Rzęsistkowica, Trychomonadoza |
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Hungarian |
Trichomonas fertőzések, trichomoniasis, trichomoniasis, nem meghatározott |
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Sources |
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Bartholin’s Gland Abscess
I. Epidemiology
A. Bartholin’s Gland Duct Cysts and abscess Incidence: 2%
B. Most common in adult women under age 30 years
II. Pathophysiology
. Bartholin’s Gland
1. Vaginal vestibular glands provide moisture
2. Located at bilateral inferior labia minora
3. Drain via ducts at 4:00 and 8:00 positions of labia
4. Normal Bartholin’s Gland size <1 cm
A. Bartholin’s Gland Duct Cyst
1. Results from distal duct obstruction
B. Bartholin’s Gland Abscess (more common than cysts)
1. May occur spontaneously or as infection of duct cyst
III. Causes: Bacterial
. Sexually Transmitted Disease is a common cause in the United States
A. Other causes
2. Streptococcus faecalis
4. Pseudomonas aeruginosa
5. Bacteroides fragilis
IV. Symptoms
. Vulvar Pain worse with walking and intercourse
V. Signs
. Firm swelling at posterior vaginal introitus
1. Posterior labia minora affected
VI. Differential Diagnosis
. Epidermal Inclusion Cyst (at labia majora)
A. Skene’s Duct cyst (at Urethral meatus)
B. Other benign growth (mucous cyst, fibroma, Lipoma)
C. Squamous Cell Carcinoma (esp. postmenopausal woman)
VII. Management: Word Catheter Placement for cyst or abscess
. Betadine prep overlying abscess wall at labia
A. Administer Local Anesthesia with Lidocaine 1%
B. Make 5 mm stab incision over abscess with #11 blade
1. Incision should be oriented vertically
2. Incision should lie outside hymenal ring
C. Insert Word Catheter into incision
1. Inflate Word Catheter balloon with 2-3 c saline
D. Word Catheter remains in place for 4-6 weeks
VIII. Management: Other measures
. Marsupialization of Bartholin’s Gland Cysts
1. Only use for cysts (contraindicated for abscess)
2. Cyst wall excised
A. Excision of of Bartholin’s Gland Abscess
1. Indicated if refractory to other measures
2. Procedure timed wheo infection present
3. Refer to Gynecology or Surgery for procedure
IX. References
. Apgar in Pfenninger (1994) Procedures p. 596-600
A. Omole (2003) Am Fam Physician 68(1):135-40
Sexually Transmitted Diseases |
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Sexually transmitted diseases (STDs) are diseases acquired from having sexual contact (vaginal, oral, or anal) with someone who has an STD. Sexually transmitted diseases are among the most common infectious diseases in the United States. Currently there are more than 25 STDs that affect both men and women. |
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VaginitisVaginitis is inflammation of the vagina which is characterized by a vaginal discharge, itching, and/or irritation; a vaginal odor may be present. |
ChlamydiaChlamydia is a sexually transmitted disease that infects the urethra in men, and the urethra and cervix in women. This disease can spread to the reproductive organs and may lead to infertility. |
Condyloma / Genital Warts / Human Papilloma VirusCondyloma acuminata are genital warts caused by the human papilloma virus (HPV). HPV is one of the most common sexually transmitted diseases. The virus affects the skin on the outside of the body and the mucous membranes, it may cause cervical cancer if not treated. |
Genital HerpesGenital herpes is a sexually transmitted disease caused by the herpes simplex virus (HSV). The disease causes outbreaks of itchy and painful sores in the genital area. It may also affect the mouth and lips. |
GonorrheaGonorrhea is a sexually transmitted disease. It is a bacterial infection of the urethra in men, and the urethra and cervix in women. This disease can spread to the reproductive organs and may lead to infertility. |
HepatitisHepatitis is an inflammation of the liver caused by certain viruses. Viral hepatitis may include hepatitis A, hepatitis B, and hepatitis C. Hepatitis may be caused by other factors, such as use of drug and may be sexually transmitted. Treatments for hepatitis vary, depending on the type. |
HIVHuman immunodeficiency virus, or HIV, is the virus that may lead to acquired immune deficiency syndrome (AIDS) after many years. The virus weakens the immune system making it difficult to fight infections and cancer by attacking and destroying white blood cells. HIV and AIDS is an incurable disease, however, there are medications that strengthen the immune system, helping those infected to live a better quality of life. |
Pelvic Inflammatory DiseasePelvic inflammatory disease, commonly called PID, is a sexually transmitted disease (STD) that affects the female reproductive organs. Pelvic inflammatory disease is one of the most serious complications of a sexually transmitted disease in women. Pelvic inflammatory disease can cause irreversible damage to the uterus, ovaries, fallopian tubes, or other parts of the female reproductive system, and may cause infertility. |
SyphilisSyphilis, a sexually transmitted disease caused by the bacteria Treponema pallidum and can be effectively treated with antibiotic therapy. Primary syphilis initially resembles chancre sores. The sores are like large round bug bites that are hard and painless and occur on the genitals or in or around the mouth. |
TrichomoniasisTrichomoniasis is a sexually transmitted disease (STD) caused by an organism called Trichomonas vaginalis. Women are most often affected by this disease with symptoms of vaginal discharge or vulvar itching and irritation; a vaginal odor may be present. Men are often asymptomatic and usually do not know they are infected until their partners need treatment. |
Sexually Transmitted Diseases
Sexually transmitted diseases (STDs) are infectious diseases transmitted through sexual contact. The Center for Disease Control and Prevention (CDC) estimates that 19 millioew cases occur annually in the US. Fifty percent of the new infections occur in people between the ages of 15 to 24 years.
Common types of STDs include the following.
Acquired Immune Deficiency Syndrome (AIDS)
AIDS is caused by the human immunodeficiency virus (HIV), a virus that destroys the body’s ability to fight off infection. People who have AIDS are very susceptible to many life-threatening diseases and to certain forms of cancer.
Transmission of the virus most often occurs during sexual activity or by the sharing of needles used to inject intravenous drugs.
Human Papillomavirus (HPV)
HPV is a common sexually transmitted disease that can cause genital warts called condylomas, which can occur on the inside or outside areas of the genitals and may spread to the surrounding skin or to a sexual partner. Because HPV infection does not always cause warts, the infection may go undetected.
Women with an HPV infection have an increased risk of developing cervical cancer.Regular Pap tests can detect HPV infection, as well as abnormal cervical cells. An HPV vaccine is available to help prevent cervical cancer.
Although there is treatment for the genital warts (which sometimes go away on their own), the virus remains and warts can reappear. Certain types of HPV can also cause warts on other body parts such as the hands, called common warts; however, these do not generally cause health problems.
Chlamydial Infections
Chlamydial infections, the most common of all STDs, can affect both men and women. They may cause an abnormal genital discharge and burning with urination. In women, untreated chlamydial infection may lead to pelvic inflammatory disease (PID) . Chlamydial infections can be treated with antibiotic therapy. Unfortunately, many people with chlamydial infection have few or no symptoms of infection. The most common and serious complications occur in women and include pelvic inflammatory disease, ectopic (tubal) pregnancy, and infertility.
Gonorrhea
Gonorrhea causes a discharge from the vagina and painful or difficult urination. The most common and serious complications occur in women, and include pelvic inflammatory disease , ectopic (tubal) pregnancy, and infertility. Gonorrhea infections can be treated with antibiotic therapy.
Genital Herpes
Genital herpes infections are caused by the herpes simplex virus (HSV).
Symptoms may include painful blisters or open sores in the genital area, which may be preceded by a tingling or burning sensation in the legs, buttocks, or genital region. The herpes sores usually disappear within a few weeks, but the virus remains in the body and the lesions may recur from time to time.
There is no cure for HSV but there are anti-viral agents to take that can shorten an outbreak and reduce symptoms.
Syphilis
The initial symptom of syphilis is a painless open sore that usually appears in or around the vagina. Untreated syphilis may go on to more advanced stages, including a transient rash and, eventually, serious involvement of the heart and central nervous system. Syphilis infections can be treated with antibiotic therapy.
Other diseases that may be sexually transmitted include:
· Bacterial vaginosis
· Chancroid
· Cytomegalovirus infections
· Granuloma inguinale (donovanosis)
· Lymphogranuloma venereum
· Molluscum contagiosum
· Pubic lice
· Scabies
· Trichomoniasis
· Vaginal yeast infections
Women suffer more frequent and severe symptoms from STDs. Some STDs can spread into the uterus (womb) and fallopian tubes and cause pelvic inflammatory disease , which can lead to both infertility and ectopic (tubal) pregnancy.
STDs in women also may be associated with cervical cancer .
STDs can be passed from a mother to her baby before or during birth. Some infections of the newborn may be successfully treated, but others may cause a baby to be permanently disabled or even die.
When diagnosed early, many STDs can be successfully treated.
To choose a North Shore-LIJ Women’s Health gynecologist, schedule testing for sexually transmitted diseases, or discuss how to prevent STDs, visit Our Physicians or Make an Appointment
Pelvic Inflammatory Disease
Radiology > Pelvic Inflammatory Disease
Summary
Description
· Pelvic inflammatory disease (PID) is a clinical syndrome arising from infection that may involve any or all of the following: uterus, fallopian tubes, ovaries, peritoneal surfaces, and contiguous structures
· Most cases are due to ascending spread of microorganisms from the vagina and endocervix to the upper genital tract
· Neisseria gonorrhoeae and Chlamydia trachomatis are usually implicated as the inciting pathogens
· The resulting spectrum of inflammatory disorders includes endometritis, parametritis, salpingitis, oophoritis, and peritonitis
Synonyms
Immediate action
PID is not typically a medical emergency, except when the patient is septic or has a ruptured tubo-ovarian abscess. These complications may occur in up to 10% of women and should be considered during the initial evaluation.
· Check vital signs immediately; if there is evidence of hemodynamic instability, prepare the patient for transport to a tertiary care facility
· Obtain adequate intravenous access
· Watch urine output closely; placement of a Foley catheter may be required
· Begin treatment with broad-spectrum antibiotics immediately
Consultation with gynecology, surgery, or critical care specialists is warranted.
Urgent action
· Early diagnosis and treatment will help to minimize the risk of short- and long-term complications
· Evaluate the patient’s pregnancy and HIV status
Key points
· PID is an infection of the female pelvic organs, typically caused by ascending polymicrobial infection with an inciting sexually transmitted pathogen, such as gonorrhea or chlamydia
· Diagnosis is difficult because of the variable presentation of PID and potentially mild symptoms. Providers must have a high suspicion for this diagnosis in young, sexually active women and a low threshold for treatment, given the long-term consequences of untreated disease: infertility, ectopic pregnancy, and chronic pelvic pain
· Symptoms and findings often include pelvic pain, adnexal/uterine tenderness to palpation, and cervical motion tenderness
· PID is treated with broad-spectrum antibiotics and can be managed on an outpatient basis with close follow-up. Specific criteria can be used to determine the need for inpatient treatment
Background
Cardinal features
· A disease of sexually active women
· Ascending infection from the lower genital tract spreads to the uterine and fallopian tube mucosa
· Infection may extend to the ovaries, pelvic peritoneum, and beyond, resulting in pelvic abscesses and perihepatitis
· PID compromises tubal patency and is implicated in most cases of ectopic pregnancy
· Silent cases of chlamydial salpingitis occur, also leading to tubal factor infertility and ectopic pregnancy
· PID also results in chronic pelvic pain and recurrent disease
Causes
Common causes
· Usually due to ascending polymicrobial infection from the lower genital tract
· The most common primary infecting organisms are C trachomatis and N gonorrhoeae
· After lower genital tract infection with these organisms, normal vaginal bacterial lactobacilli are supplanted by facultative organisms, such as Escherichia coli, Bacteroides (Prevotella) spp, anaerobic cocci,Haemophilus influenzae, group A streptococci, Mycoplasma hominis, and Ureaplasma urealyticum
· Treatment must therefore include broad-spectrum antibiotic coverage
· In addition, all transcervical gynecologic procedures (eg, dilation and curettage, endometrial biopsy, tubal lavage, and hysterosalpingography) are associated with a risk of upper genital tract infection
· Infrequently, PID may occur via direct spread from intraperitoneal/abdominal infections (appendicitis or diverticulitis), and hematogenous spread has been reported
Rare causes
Two recognized rare causes of PID are:
· Genital tract tuberculosis
· Caused by Actinomyces israelii, a Gram-positive and non-acid-fast organism
· May be associated with intrauterine device (IUD) use
· Infections are typically indolent and are characterized by mild pelvic discomfort and irregular vaginal bleeding
· Infection invades across tissue planes, causing fibrosis, induration, and destruction of normal tissue architecture
· Treatment with prolonged high-dose antibiotics, initially parenteral, is given, often followed by surgery
Genital tract tuberculosis:
· Infection of the genital tract by Mycobacterium tuberculosis is usually secondary to hematogenous spread from non-genital tract foci and is uncommon in developed countries
· Infection is extremely indolent
· Characterized by mild pelvic discomfort and menstrual irregularities
· The only symptom may be infertility
· Diagnosed by endometrial biopsy or culture of menstrual fluid
· Treatment with antituberculous drugs for 18 to 24 months
Contributory or predisposing factors
· Age: peak incidence between 15 and 24 years
· Young age at first intercourse
· Single state
· New sexual partner
· Multiple sexual partners in the preceding 3 months
· Vaginal douching has been identified by some authorities as a risk factor; however, this association has not been definitively proven
· IUD use slightly increases the risk of PID for a few months after insertion
· Recent transcervical instrumentation
· History of PID: 20% of patients or more will have a recurrence
· Chlamydial or gonococcal cervicitis: 8% to 10% will develop PID
· Bilateral tubal ligation may decrease the risk of bacterial ascension and PID
Epidemiology
Incidence and prevalence
The exact incidence and prevalence in the United States is unknown, given the frequency of asymptomatic or subclinical infections.
Incidence
· Said to affect approximately 1 million US women annually
· May be decreasing in frequency, a change attributed to programs that screen for Chlamydia
Prevalence
· Self-report surveys performed by the Centers for Disease Control and Prevention (CDC) in 1995 report ‘percent ever treated for PID’ as high as 10.6% among non-Hispanic black women and 7.6% among all women
Frequency
· Results in approximately 250,000 hospital admissions yearly
· 20% to 30% of cases are sexually active adolescents
· Most common cause of female infertility and ectopic pregnancy
Demographics
Age
Peak incidence is between 15 and 24 years of age.
Socioeconomic status
Some evidence that low income, poor education, and unemployment are relevant factors.
Codes
ICD-9 code
· 614.0 Acute salpingitis and oophoritis
· 614.1 Chronic salpingitis and oophoritis
· 614.2 Salpingitis and oophoritis not specified as acute, subacute, or chronic
· 614.3 Acute parametritis and pelvic cellulitis
· 614.4 Chronic or unspecified parametritis and pelvic cellulitis
· 614.5 Acute or unspecified pelvic peritonitis, female
· 614.7 Other chronic pelvic peritonitis, female
· 614.8 Other specified inflammatory disease of female pelvic organs and tissues
· 614.9 Unspecified inflammatory disease of female pelvic organs and tissues
Read more about Pelvic inflammatory disease from this First Consult monograph:
Diagnosis Differential diagnosis Treatment Summary of evidence Outcomes Prevention Resources
More Key Resources
Overview
Pelvic Inflammatory Disease
Lentz: Comprehensive Gynecology, 6th ed.
Pelvic Inflammatory Disease (Quick Reference)
Ferri: Ferri’s Clinical Advisor 2013, 1st ed.
Pelvic inflammatory disease and tubo-ovarian abscess
Lareau SM – Infect Dis Clin North Am – 01-DEC-2008; 22(4): 693-708, vii
Sexually transmitted infections and pelvic inflammatory disease in women (includes Table)
Trigg BG – Med Clin North Am – 01-SEP-2008; 92(5): 1083-113, x
Genitourinary emergencies in the nonpregnant woman
Schmitz G – Emerg Med Clin North Am – August, 2011; 29(3); 621-635
Epidemiology
Epidemiology of Pelvic Inflammatory Disease
Lentz: Comprehensive Gynecology, 6th ed.
Pelvic inflammatory disease and tubo-ovarian abscess
Lareau SM – Infect Dis Clin North Am – 01-DEC-2008; 22(4): 693-708, vii
Epidemiology of Pelvic Inflammatory Disease
Ferri: Ferri’s Clinical Advisor 2013, 1st ed.
Epidemiology of infections in women
Risser JM – Infect Dis Clin North Am – 01-DEC-2008; 22(4): 581-99, v
Signs & Symptoms
Symptoms and Signs of Pelvic Inflammatory Disease
Lentz: Comprehensive Gynecology, 6th ed.
Clinical Manifestations of Pelvic Inflammatory Disease (includes Table)
Long: Principles & Practice of Pediatric Infectious Diseases, 3rd ed., Revised Reprint
Etiology
Etiology of Pelvic Inflammatory Disease
Lentz: Comprehensive Gynecology, 6th ed.
Etiologic Agents of Pelvic Inflammatory Disease
Long: Principles & Practice of Pediatric Infectious Diseases, 3rd ed., Revised Reprint
Diagnosis
Diagnosis of Pelvic Inflammatory Disease
Lentz: Comprehensive Gynecology, 6th ed.
Evaluation of acute pelvic pain in women
Kruszka PS – Am Fam Physician – 15-JUL-2010; 82(2): 141-147
Acute pelvic pain in women: Ultrasonography still reigns (includes Images)
Sheth S – Ultrasound Clin – April, 2011; 6(2); 163-176
Treatment & Management
Management of Pelvic Inflammatory Disease
Lentz: Comprehensive Gynecology, 6th ed.
Management of Pelvic Inflammatory Disease
Long: Principles & Practice of Pediatric Infectious Diseases, 3rd ed., Revised Reprint
Treatment of Pelvic Inflammatory Disease
Bope and Kellerman: Conn’s Current Therapy 2012, 1st ed.
Prognosis
Sequelae of Pelvic Inflammatory Disease (includes Table)
Lentz: Comprehensive Gynecology, 6th ed.
Complications and Sequelae of Pelvic Inflammatory Disease
Long: Principles & Practice of Pediatric Infectious Diseases, 3rd ed., Revised Reprint
Screening & Prevention
Methods of Preventing STDs (includes Table)
Lentz: Comprehensive Gynecology, 6th ed.
Prevention of Pelvic Inflammatory Disease
Long: Principles & Practice of Pediatric Infectious Diseases, 3rd ed., Revised Reprint
Patient Education
· Managing Your Pelvic Inflammatory Disease
Practice Guidelines
Sexually Transmitted Diseases Treatment Guidelines (2010)
Source: US Centers for Disease Control and Prevention
Management of Pelvic Inflammatory Disease (2008)
Source: International Union Against Sexually Transmitted Infections
Management of Acute Pelvic Inflammatory Disease (2008)
Source: Royal College of Obstetricians and Gynaecologists (UK)
Drugs
Pelvic inflammatory disease
The pelvic inflammatory disease (PID) is a generic term for the inflammation of the female genitals located in the pelvis (uterus, Fallopian tubes, ovaries, ligaments of uterus). Since the simultaneous inflammation of all these organs together occurs only in very severe cases, it is advisable to identify them separately as accepted in medical terminology: inflammation of the cervix (cervicitis), the endometrium (endometritis), the Fallopian tubes (salpingitis), the ovarium (oophoritis), and separately the Fallopian tubes and the ovarium (adnexitis). Ovarian inflammation and catching a chill are accepted in everyday language.
Etiology of pelvic inflammatory disease
The primary cause is always a bacterial infection. While the normal flora of the vagina consists of mainly bacteria and some fungi, a couple of centimeters away, the healthy inner genitals are usually sterile. The thick cervical mucus has antibacterial activity under physiological circumstances that prevent bacteria from penetrating into the sterile uterine cavity. Only the pathogens of certain sexually transmitted diseases, mainlygonorrhoea and Chlamydia bacteria may penetrate through the cervix and cause an ascending infection.
The bacterial members of the normal vaginal flora can reach the pelvic organs with the instruments used for abortion, curettage, by the insertion or removal of an intrauterine device, or during miscarriage and delivery, or incidentally through the thread of an intrauterine device.
While in case of sexually transmitted diseases the canalicular spread is typical, the infections caused by delivery and instruments or in certain cases those occurring near the intrauterine devices spread typically by lymphogenous and canalicular route.
Course of the disease
Based on the course of the disease the classic pelvic inflammatory disease can be differentiated: there is an acute inflammation accompanied by severe lower abdominal pain, excessive vaginal discharge, feeling of fullness or bloating, bladder spasm during urination, or in some cases accompanied by pain radiating to the limbs and waist and high fever. This acute infection develops as a superinfection of a previously damaged Fallopian tubes; it is always a polymicrobial disease i.e. the infection is caused by different bacteria. The treatment consists of a high-dose combination of antibiotics applied for a prolonged time (at least for 14 days). Hospitalization and intravenous antibiotics may be required for the treatment of severe cases or in less severe cases wher the patient is nulliparous.
When the inflammation is caused by a sexually transmitted Chlamydia trachomatis bacterium, the symptoms are much less severe and the patient has no fever. The lack of symptoms is the consequence of Chlamydia bacteria multiplying in columnar epithelial cells and their life cycle is longer than average bacteria’s. Therefore the infection spreads slowly along the epithelial layer ascending through the epithelial layer of the cervix, the uterus, and then the Fallopian tube. In case of an extended Chlamydia infection the inflammation and as a consequence, scarring may spread in the whole abdominal cavity, including the surface of the liver. Since Chlamydia bacterium infects only the columnar cells and the transitional cells of the urethra, the first station of the infection is not the vagina, since it is covered with non-keratinized stratified squamous epithelium, but the canal of the cervix. First localized inflammation develops, followed by an excessive, purulent cervical-os discharge that is usually accompanied by a vaginal infection called bacterial vaginosis with bad-smelling, watery vaginal discharge. If the infection is diagnosed in time, Chlamydia infection can be cured with appropriate antibiotic treatment without severe residual symptoms. In case of a prolonged or repeated inflammation the cervical epithelium is thickened and its discharge production is increased. This discharge appears as complaints of viscid vaginal discharge. If the infection is not diagnosed in time it starts to ascend slowly towards the Fallopian tubes. When the infection reaches the uterine cavity or the developed infection spreads to the connective tissues and ligaments around the uterus cervical motion tenderness develops. Lower abdominal pain occurs during sexual intercourse or gynaecological exam. The infection often takes a latent form; the greatest danger is that it can go unnoticed and severely damage the Fallopian tubes; its late complications may be infertility, ectopic pregnancy, or chronic pelvic pain, or during a gynecology intervention it may furnish a perfect basis for acute pelvic inflammatory disease, or abscess formation in severe cases. Its typical example is when Fallopian tube permeability is checked during an infertility test. A contrast dye is injected through the cervix and the uterine cavity into the Fallopian tubes in this case. When the Fallopian tubes are permeable, the contrast dye gets into the abdominal cavity that can be observed easily on an X-ray. Should bacteria be driftet from the vagina or the inflamed cervix with the injected solution during the intervention, they may infect the previously damaged Fallopian tube that can even lead to a severe inflammation.
Late complications of pelvic inflammatory disease
A very nasty characteristic of pelvic inflammatory diseases is that they don’t disappear without traces. The changes, that later cause the complications usually develop during several previous (even asymptomatic) inflammations. The wall of the Fallopian tube is thickened; the movement of the Fallopian tube that is similar to the bowel peristaltic movement is weakened or stopped, the tiny cilia of the ciliated columnar epithelium lining the canal of the Fallopian tube are damaged, therefore the stream induced by their wavelike movement towards the uterine cavity is stopped. Should the wall of the Fallopian tube be severely scarred or the adhesions formed around the Fallopian tubes strike the Fallopian tube- the canal gets blocked. The blocked Fallopian tube leads to infertility. If only the function of the Fallopian tube is damaged or the canal is not blocked totally it may lead toectopic pregnancy. The thickened mucous membranes due to the repeated inflammation produce an excessive amount of discharge that may cause chronic discharge. Its interesting form is when discharge cumulates in the dilated Fallopian tube that is blocked towards the abdominal cavity, then from time-to-time it is emptied causing a sudden, excessive mucous vaginal discharge.
The scarring around the Fallopian tubes or along the ligaments of the uterus may be the source of a chronic pelvic pain. It blocks the function of the surrounding organs – the bowel peristaltic movement, the release of mature eggs in the ovarium –, as well as the uterus and its adnexa loose their mobility, and become fixed as a consequence of scarring.
Abscess
In most of the cases abscess develops as a superinfection of the previously damaged Fallopian tube. Abscess is a collection of pus demarked from its environment by a wall. Should the abscess contain the Fallopian tube only, we speak about pyosalpinx (purulent salpingitis), should the process affect the whole wall of the Fallopian tube and should it spread to the surrounding organs, therefore to the ovarium and the bowels, a tubo-ovarian abscess is developing. The combination of antibiotic treatment and surgery gives a chance for recovery in case an abscess is formed. The affected fallopian tube and even the ovarium (in case of a tubo-ovarian abscess) should be removed during surgery! Important! Should the inflammation affect the uterus, like in case of an inflammatioear a carelessly used intrauterine device, or after delivery, a febrile miscarriage, the removal of the uterus may be required!
According to these it is clearly understandable that pelvic inflammatory disease can be cured effectively, without any residual symptoms in its early stage only. Should the disease progress, the treatment requires a strict and prolonged medication with the combination –in many cases- of surgery and the risk of late complications and the incidental loss of certain organs is significantly increased at the same time. Infections may be prevented more easily than diagnosed and cured!
The most important risk factor in the development of pelvic inflammatory diseases is the number of sexual partners during the life, the gynecological surgeries (abortion) or the improper use of intrauterine devices. So the prevention of unintended pregnancies and therefore abortions is highly recommendable, for instance by contraceptive pills, and so the prevention of sexually transmitted diseases, simply by the use of condoms. During the use of intrauterine devices it is very important to maintain the normal vaginal flora, to treat vaginal infections in time and the change of the intrauterine devices in time according to the instructions./strong
