Pelvic inflammatory disease: Difference between revisions
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==Disposition== | ==Disposition== | ||
Admit: | Admit: | ||
*[[Tubo-ovarian abscess]] | |||
*[[Fitz-Hugh-Curtis]] | |||
*[[Pregnancy]] | |||
*[[Sepsis]]/[[peritonitis]] | |||
*Unable to tolerate PO | |||
*Failed outpt Rx | |||
*[[HIV]]+ | |||
Discharge: | Discharge: | ||
*72hr f/u | |||
*Instruct pt to abstain from sex or adhere strictly to condom use until sx have abated | |||
==Complications== | ==Complications== |
Revision as of 12:11, 4 February 2015
Background
- Pelvic Inflammatory Disease (PID) comprises spectrum of infections of the upper reproductive tract:
- Salpingitis, endometritis, myo/parametritis, oophoritis
- Perihepatitis (Fitz-Hugh-Curtis) is caused by lymphatic spread
- Tubo-ovarain abscess is caused by direct extension
- Salpingitis, endometritis, myo/parametritis, oophoritis
- Most common serious infection in women aged 16 to 25 years
- Most common cause of death is rupture of a tubo-ovarian abscess
- Begins as cervicitis w/ GC or chlamydia that may progress to polymicrobial infection
- Initial lower tract infection may be asymptomatic
Diagnosis
History
- Pelvic Pain (90%)
- Vaginal discharge (75%)
- Vaginal and postcoital bleeding (>33%)
- Dysuria, fever, malaise, N/V
Physical Exam
- CMT
- Adnexal tenderness
- Most sensitive finding (Sn ~95%)
- Mucopurulent cervicitis
- Absence should raise consideration of another dx
- RUQ Pain
- May indicate perihepatic inflammation (particularly w/ jaundice)
CDC Treatment Criteria
- Woman at risk for STIs
- Pelvic or lower abdominal pain
- No cause for the illness other than PID can be identified
- At least one of the following on pelvic exam:
- CMT
- Uterine tenderness
- Adnexal tenderness.
- Additional criteria that make the dx more likely:
Work-Up
- Urine pregnancy
- Wet mount
- Endocervical swab (for GC, Chlamydia)
- CBC
- ESR/CRP
- Urine culture, analysis (to excl UTI)
Imaging
- Pelvic U/S
- Ultrasound sensitivity may be as low as 56% and specificity of 85% [1]
- CT
Differential Diagnosis
Acute Pelvic Pain
Gynecologic/Obstetric
- Normal variants
- Nabothian cysts: Epithelial cells within mucous glans that appear as yellow inclusions on the cervix
- Cervial Ectropion: Edothelial cells on the exterior of the cervix
- Parous cervix: The is no longer round but may have multiple shapes after birth
- Pregnancy-related
- Ectopic Pregnancy
- Spontaneous abortion, threatened or incomplete
- Septic abortion
- Acute Infections
- Vulvovaginitis
- Adnexal Disorders
- Hemorrhage/rupture of ovarian cyst
- Ovarian torsion
- Twisted paraovarian cyst
- Other
- Myoma (degenerating)
- Genitourinary trauma
- Ovarian hyperstimulation syndrome
- Sexual assault
- Recurrent
- Mittelschmerz
- Primary/Secondary Dysmenorrhea
- Pelvic Congestion Syndrome
- Endometriosis
Genitourinary
Gastrointestinal
- Gastroenteritis
- Appendicitis
- Bowel obstruction
- Perirectal abscess
- Diverticulitis
- Inflammatory bowel disease
- Irritable bowel syndrome
- Mesenteric adenitis
Musculoskeletal
- Abdominal wall hematoma
- Psoas hematoma, psoas abscess
- Hernia
Vascular
- Pelvic thrombophlebitis
- Abdominal aortic aneurysm
- Ischemic bowel (Mesenteric Ischemia)
Treatment
- Tx all partners who had sex w/ pt during previous 60d prior to onset of sx
Outpatient Options
- Ceftriaxone 250mg IM x1 + doxycycline 100mg PO BID x14d +/- metronidazole 500mg PO BID x14d [3]
- Metronidazole based upon assessment of risk for anaerobes; consider in:
- Pelvic abscess
- Proven or suspected infection w/ Trichomonas or Bacterial Vaginosis
- History of gynecological instrumentation in the preceding 2-3wks
- Metronidazole based upon assessment of risk for anaerobes; consider in:
- Cefoxitin 2 g IM in a single dose and Probenecid, 1 g PO administered concurrently in a single dose[4] + Doxycycline 100 mg PO BID x 14 days +/- flagyl based on above criteria
Alternative Outpatient Options
- Ceftriaxone 250mg IM x1 + 1 g of Azithromycin per week, x 2 weeks[5] +/- flagyl based on above criteria
- Great cure rates in the Azithromycin group (98.2% vs 87.5%)[5]
Inpatient
- Cefoxitin 2gm IV q6hr OR cefotetan 2gm IV q12hr) + doxycycline PO or IV 100 mg q12hr OR
- Clindamycin 900mg IV q8h + gentamicin 2mg/kg QD OR
- Ampicillin/sulbactam 3gm IV q6hr + doxycycline 100mg IV/PO q12hr
Disposition
Admit:
- Tubo-ovarian abscess
- Fitz-Hugh-Curtis
- Pregnancy
- Sepsis/peritonitis
- Unable to tolerate PO
- Failed outpt Rx
- HIV+
Discharge:
- 72hr f/u
- Instruct pt to abstain from sex or adhere strictly to condom use until sx have abated
Complications
- Tubo-Ovarian Abscess
- Fitz-Hugh-Curtis
- Perihepatic inflammation seen only on CT, not US; LFTs are normal
- Responds to standard abx regimen
- Infertility
- Ectopic Pregnancy
- Chronic pelvic pain
See Also
Source
- ↑ Lee DC, Swaminathan AK. Sensitivity of ultrasound for the diagnosis of tubo-ovarian abscess: a case report and literature review. J Emerg Med. 2011 Feb;40(2):170-5. doi: 10.1016 PMID 20466506
- ↑ Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
- ↑ Ness RB et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol 2002;186:929–37
- ↑ CDC PID Treatment http://www.cdc.gov/std/treatment/2010/pid.htm
- ↑ 5.0 5.1 Savaris RF. et al. Comparing ceftriaxone plus azithromycin or doxycycline for pelvic inflammatory disease: a randomized controlled trial. Obstet Gynecol. 2007 Jul;110(1):53-60