Pelvic Inflammatory Disease

PID Basics - The Pelvic Peril

• Ascending infection of upper female genital tract: endometritis, salpingitis, oophoritis, tubo-ovarian abscess, pelvic peritonitis.
• Causative Agents:
  • Neisseria gonorrhoeae (most common in India)
  • Chlamydia trachomatis (most common worldwide)
  • Polymicrobial: Anaerobes, Mycoplasma genitalium, GBS, E. coli.
• Risk Factors:
  • Multiple sexual partners, young age at first intercourse.
  • Previous PID, STIs.
  • IUCD insertion (first 3 weeks).
  • Douching, instrumentation.

⭐ Chlamydia trachomatis is the most common cause of silent PID, leading to infertility and ectopic pregnancy due to tubal damage (Fitz-Hugh-Curtis syndrome: perihepatitis).

Symptoms & Signs - Sounding the Alarm

• Cardinal Symptoms:
  • Lower abdominal pain: Bilateral, dull/crampy; often worse with menses/coitus.
  • Abnormal vaginal discharge: Typically mucopurulent ± odor.
  • Abnormal uterine bleeding: E.g., intermenstrual/postcoital.
• Other Common Features:
  • Dyspareunia (deep).
  • Fever (>38.3°C/101°F), chills.
  • Nausea/vomiting (severe cases).
• Key Examination Findings:
  • Cervical Motion Tenderness (CMT) - "Chandelier sign".
  • Adnexal tenderness (uni/bilateral).
  • Uterine tenderness.
  • Visible mucopurulent cervicitis.
  • ± Adnexal mass (suggests Tubo-Ovarian Abscess/TOA).
  • ± RUQ pain (Fitz-Hugh-Curtis syndrome).

⭐ Cervical Motion Tenderness (CMT), the "Chandelier Sign," is a classic and highly suggestive sign of PID on bimanual examination.

Diagnosis Decoded - Cracking the Case

• Clinical Suspicion: Sexually active woman, lower abdominal pain.
• Minimum CDC Criteria (≥1 required for empirical treatment):
  • Cervical Motion Tenderness (CMT) 📌 "Chandelier Sign"
  • Uterine tenderness
  • Adnexal tenderness
• Additional Criteria (support diagnosis):
  • Oral temperature > 38.3°C
  • Abnormal mucopurulent cervical/vaginal discharge
  • ↑ WBCs on saline microscopy of vaginal secretions
  • Elevated ESR/CRP
  • Lab evidence of N. gonorrhoeae or C. trachomatis infection (NAAT)
• Definitive/Specific Criteria (most conclusive):

  • Endometrial biopsy: Histopathologic evidence of endometritis

  • Transvaginal Sonography (TVS) or MRI: Thickened, fluid-filled tubes, tubo-ovarian abscess (TOA), hydrosalpinx.

  • Laparoscopy: Direct visualization (erythema, edema, adhesions, pus from fimbriae).

⭐ Laparoscopy remains the gold standard for PID diagnosis, particularly if the diagnosis is uncertain or symptoms persist despite initial therapy, allowing direct visualization of pelvic organs.

Treatment & Trouble - Taming the Flame

• Goals: Relieve symptoms, cure infection, prevent sequelae (infertility, ectopic, chronic pain).
• Hospitalize if: Surgical emergency unclear, TOA, pregnant, severe illness (high fever, N/V), no response/tolerance to oral.
• Outpatient (Mild-Moderate PID):
  • Ceftriaxone 250mg IM (1 dose) + Doxycycline 100mg PO BID x 14d.
  • Add Metronidazole 500mg PO BID x 14d (if anaerobes/BV/trichomoniasis suspected).
• Inpatient (Severe PID/TOA):
  • IV: Cefoxitin 2g q6h / Cefotetan 2g q12h + Doxycycline 100mg IV/PO q12h.
  • Alt: IV Clindamycin 900mg q8h + Gentamicin (LD 2mg/kg, MD 1.5mg/kg q8h or 3-5mg/kg qd).
  • Transition to PO for total 14d course.
• Partner Management: Treat all sexual partners from preceding 60 days.
• Follow-up: Re-evaluate in 48-72h. No improvement? Re-assess diagnosis/Admit.
• Complications (Trouble): TOA, hydrosalpinx. 📌 PIPE: Pelvic pain (chronic), Infertility, Perihepatitis (Fitz-Hugh-Curtis), Ectopic pregnancy.

⭐ Fitz-Hugh-Curtis syndrome: perihepatitis (RUQ pain) with "violin-string" adhesions (liver capsule-peritoneum). Caused by C. trachomatis / N. gonorrhoeae.

High‑Yield Points - ⚡ Biggest Takeaways

• PID is an ascending infection, primarily by N. gonorrhoeae & C. trachomatis.
• Key symptoms: Lower abdominal pain; Key signs: Cervical motion tenderness (CMT), adnexal/uterine tenderness.
• Laparoscopy is gold standard for diagnosis, but usually clinical diagnosis based on criteria.
• Major complications: Infertility, ectopic pregnancy, chronic pelvic pain, tubo-ovarian abscess (TOA).
• Fitz-Hugh-Curtis syndrome: Perihepatitis with RUQ pain and "violin-string" adhesions.
• Treat with broad-spectrum antibiotics (e.g., ceftriaxone + doxycycline +/- metronidazole); treat partners_._