Tintinalli Tuesday: Pelvic Inflammatory Disease

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August 31, 2012 by EmerJencyWEBB

A little late (it’s been a busy work week), but still correctly named as I started this post on Tuesday…better late than never.  A less than sexy topic, but they will all get their moment in the limelight with Tintinalli Tuesday.

Spectrum of Ascending Gynecologic Infection

“salpingitis, endometritis, myometritis, parametritis, oophoritis, and tubo-ovarian abscess”

What organisms are involved?

Most common organisms include the sexually transmitted N. gonorrhea and C. trachomatis.

However, in up to a third of cases, this is a mixed flora with both aerobic and anaerobic organism, including normal vaginal flora such as G. vaginalis, as well as viruses such as HSV.

What percentage of untreated gonorrheal and chlamydial infections result in PID?

10-20%

What are the classic risk factors for PID?

Risky sexual behavior, History of STI or PID, Sexual Abuse, Frequent Douching, IUD within last month, Younger Age.

What are the complications of PID?

Tubo-ovarian abscess, Tubal Factor Infertility, Chronic Pelvic Pain, Peri-Hepatitis, Increased risk of ectopic pregnancy.

What are some symptoms associated with PID?

Lower abdominal/pelvic pain, vaginal discharge, pain with intercourse, dysuria, vague GI sx including nausea/vomiting, as well as fever

What are common physical findings?

Lower abdominal/pelvic tenderness to palpation, uterine/cervical/adnexal tenderness to palpation, CMT, mucopurulent cervicitis

What labs should be obtained?

Cervical swabs for wet prep analysis (clue cells, leukorrhea, yeast, trichomonad), GC/Chlamydia amplification testing, and Urine pregnancy testing as well as analysis are usually helpful.  Consider further ancillary testing such as RPR, HIV testing in populations at significant risk.

Who should we treat for PID?

Current guidelines suggest that empiric treatment should be initiated in those women at risk who exhibit lower abdominal pain, adnexal tenderness, and cervical motion tenderness.

This is, of course, after ruling out other potential pathology that may mimic this disease including appendicitis and ectopic pregnancy.

When should inpatient therapy be considered (from CDC guidelines)?

  • surgical emergencies (e.g., appendicitis) cannot be excluded;
  • the patient is pregnant;
  • the patient does not respond clinically to oral antimicrobial therapy;
  • the patient is unable to follow or tolerate an outpatient oral regimen;
  • the patient has severe illness, nausea and vomiting, or high fever; or
  • the patient has a tubo-ovarian abscess.

What antibiotics should you prescribe?

LINK TO CDC PID TREATMENT GUIDELINES 2010

Also, there has been a recent update published Aug. 12th, 2012 in response to growing numbers of antibiotic resistant gonorrheal infections, that no longer recommends oral cephalosporins for treatment.

LINK TO CDC UPDATE 2012

Is surgery the only proven therapy for TOA?

No.  Actually, most cases resolve with inpatient antibiotic therapy alone.  Those that are unresponsive or have complications (i.e. abscess rupture) will require surgery.

What are standard discharge instructions from the ED?

– 72 hr follow up with Gynecologist

– All sexual partners in preceding 60 days should undergo course of therapy

– No sexual activity until one full course of treatment performed and asymptomatic

– Initiate safe sex practices

(This outline is only a reference, and is not all-inclusive of ideas presented in the published chapter.  Nor should this be used to guide patient care. Please refer to the definitive text for details beyond the big ideas above.  All credit to the written material above goes to Tintinalli’s Emergency Medicine: A Comprehensive Study Guide 7th Edition)

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