Infection of the female genital tract; pelvic inflammatory disease[md]PID

PID will probably be the commonest gynaecological disease you will see, and may account for a third your admissions. If it is common in your area, half the women of childbearing age who present with acute abdominal pain may have it. You may admit two or three of them every week, and treat ten times as many as outpatients. The numbers of these patients, their frequent long stay in hospital, their mortality, the surgery they need, and the complications that follow make PID a major public health problem.

Infection elsewhere in the abdominal cavity usually originates in the gut, but infection in a woman's pelvic cavity usually starts in her genital tract. With the rare exception of tuberculosis, it always ascends from her vagina and cervix. PID is thus only a disease of women.

Infection follows two routes:

(A) Infection may spread through her tubes to cause: (1) In her cervix, cervicitis. (2) In her endometrium, endometritis. (3) In her fallopian tubes, salpingitis or pyo- or hydro-salpinx. (4) In her tubes and ovaries, salpingo-oophoritis (acute, subacute, or chronic) or a tubo-ovarian abscess. (4) In her pelvic cavity, pelvic peritonitis or a pelvic abscess. (5) In the rest of her peritoneal cavity, generalized peritonitis or peritoneal abscesses.

(B) Infection may also spread through her uterine wall into her broad ligaments to cause cause pelvic cellulitis (parametritis), a broad ligament abscess, or septic thrombophlebitis of her ovarian or her uterine veins. This is serious and causes septicaemia with few local signs.

Both subacute and chronic PID may cause an inflammatory mass containing her inflamed tubes, her ovaries, her uterus, her omentum, and loops of her gut. Between all these there are collections of pus, and in chronic cases fluid-filled pseudocysts. PID is always bilateral, although it may be dominant on one side.

Although they are similar, it is convenient to discuss: (1) PID unrelated to pregnancy, that is PID which does not obviously follow abortion or delivery. Because this kind of PID typically follows a period, it is sometimes called ''postmenstrual PID'. For want of a better name, this is what we will call it here. It is one of the most serious effects of the three sexually transmitted organisms discussed below (gonococci, chlamydia, and mycoplasma). When ''PID' is referred to it is usually this kind of PID that the speaker has in mind. (2) Post abortal PID (septic abortion, 6.6a). (3) Infected obstructed labour (18.4). (4) Puerperal sepsis (''puerperal PID', 6.7). (5) Sepsis after Caesarean section (''postcaesarean PID', 6.8).

A patient with ''postmenstrual PID' is not pregnant, she has suffered no birth trauma and there are no infected products of conception. She may however have an IUD in her uterus, which increases the risk of serious infection and may delay recovery. This kind of PID is seldom fatal, and never causes septic thrombophlebitis. All the others are dangerous, and commonly kill her. Postabortal peritonitis is particularly deadly and has a mortality of 50%. A girl of 17 may waste away with a bowel fistula like ]]a terminal cancer patient, as did the patient, ''Grace', described below.

Fig. 6-9 PELVIC SEPSIS. A, infection spreading from the uterus to cause peritonitis. Infection can also spread as an infected thrombus (thrombophlebitis). B, infection of the connective tissue beside the uterus (parametritis). Infection may spread into the broad ligament, round the vagina or uterus, or up into the loin. C, a collection of pelvic pus. D, salpingitis. After Garry MM et al. ''Obstetrics Illustrated', pp. 319[nd]320. E and S Livingstone. with kind permission. The organisms responsible for PID may be: (1) Sexually transmitted[md]gonococci (either penicillin-sensitive, or ''PPNG', penicillinase-producing Neisseria gonorrhoeae), mycoplasma, or chlamydia (both less common). (2) The normal flora of her gut and vagina[md]coliforms, various anaerobes, and rarely actinomyces. The latter organisms (and sometimes even the former) live harmlessly in the vagina and cervix, and only cause disease when the barriers to spread are removed by: (a) Abortion or delivery (very common). (b) Menstruation. Or, (c) some medical intervention, such as a ''D and C' (not uncommon), the insertion of an IUD (common but usually mild), or a hysterosalpingogram (rare).

Many gonococci, and typically all chlamydia and mycoplasma are sensitive to tetracycline. But when PID follows pregnancy or an abortion, it is caused by a mixture of organisms, including anaerobes, for which she needs metronidazole with chloramphenicol. By the time you see her, secondary invaders are likely to be present, whatever the primary cause of her infection.

HIV makes a mild genital infection more likely to progress to PID, so if yours is a high AIDS area, test for her HIV if you can.

The clinical manifestations of pelvic sepsis are wide. They range from an otherwise symptomless infertility caused by blocked tubes, to generalized peritonitis, septicaemia and septic shock, with everything between these two extremes. Like a fire, PID can be of any degree of severity, from smouldering to fulminating. Also, like a fire, it can die down, only to light up again later. So you will see: (1) Early acute cases who may not become infertile, if you treat them early and energetically. (2) An occasional fulminating case with peritonitis and shock. This can be an early acute case which is particularly severe, or it can be due to a tubo-ovarian abscess, which has previously caused only minor symptoms, bursting into the peritoneal cavity. (3) Chronic cases. (4) Chronic cases with a flare-up.

The typical acute case of postmenstrual PID has fever, bilateral lower abdominal pain, and tenderness, but seldom any rigidity. She usually also suffers from frequency of urine, dyspareunia, heavy or prolonged periods, and usually also has a vaginal discharge (see below). She may not admit to all these symptoms, especially if she is a young unmarried girl. On pelvic examination, she is usually equally and acutely tender in both her vaginal fornices (unlike an ectopic pregnancy, in which she is usually only tender in one of them). Her pain may be so intense that you have to repeat the examination after you have given her an analgesic. She may also have a lower abdominal mass, vomiting, fever and a raised ESR.

Her symptoms are usually mild, but can be severe with signs of peritonitis and occasionally septic shock. Acute cases are often atypical, either because the disease is mild, or because it has been modified by previous treatment.

The typical chronic case complains of infertility, and pelvic pain, often with dyspareunia, poor general health, and much misery. The diagnosis may be difficult, and the differential diagnoses include psychosomatic pain.

You can usually treat a patient non-operatively. Occasionally, you will need to drain pus. Unfortunately, once PID has become chronic, she may have recurrent pain, and if she is educated her threshold to it is likely to be lower. Don't operate on chronic PID unless you have to, because once it has been present for more than a few weeks, her pelvic organs will be so densely stuck to one another that freeing them will be difficult and dangerous[md]you can easily injure her gut. If you have to operate, do so on the indications given below, and be conservative. Leave her pelvic organs intact unless she has a tubo-ovarian abscess. Removing this can be difficult, so open it and drain it. If necessary, and you are sufficiently skilled, return later to remove her tubes in the chronic phase, or (better) persuade someone else to. If she can be left with her uterus and some ovarian tissue, she will continue to menstruate.

GRACE NYRIENDA (17) was admitted with vaginal bleeding and fever, having attempted to procure an abortion on herself at 16 weeks. Her cervix was wide open, the products of conception were visible, and there was a foul discharge. She was treated with antibiotics and her uterus was evacuated. A few days later she was very ill with a distended abdomen. Three litres of thin pus were washed out of her peritoneal cavity and tetracycline was instilled. There was no perforation in her uterus. She was treated with more antibiotics, intravenous fluids, and nasogastric suction. Two weeks later she was still febrile and very ill. A second laparatomy was done to drain residual abscesses. Chronic sores developed at the sites of the drainage tubes, which continued to discharge pus. She did not eat well, and vomited from episodes of subacute obstruction, but was not well enough for a third laparotomy. Three months after admission she died extremely wasted. LESSONS (1) This is a typical history; there were no obvious mistakes in her treatment. Often, there is nothing you can do. (2) Any abortion, particularly a procured one, is dangerous at 16 weeks. Fig. 6-10 A PLAN FOR MANAGING PID. Stage One: the patient has no peritoneal irritation, and no pelvic mass. Stage Two: she has peritonitis as shown by bilateral lower quadrant rebound tenderness. Stage Three: she has a mass in her adnexa (tubo- ovarian abscess) or pouch of Douglas. Stage Four: she is very ill indeed, as after the rupture of a tubo-ovarian abscess. This regime differs slightly from that in the text. After De Mulder X, ''Pelvic inflammatory disease in Zimbabwe', Tropical Doctor 1988;2:85.

PID [s7](''postmenstrual PID') This is the patient with PID who has not recently aborted (6.6a), or delivered (6.7), or had a Caesarean section (6.8), and who typically has ''postmenstrual PID', commonly either gonococcal, chlamydial, or mycoplasmic. For the drainage of a pelvic abscess, see Section 6.5. For the management of adhesions see also Section 10.7.

[+20]ACUTE PID DIFFERENTIAL DIAGNOSIS. Acute ''postmenstrual PID' has mostly to be distinguished from other causes of acute lower abdominal pain, including appendicitis (12.1) and a urinary infection (10.2). The main gynaecological differential diagnosis is a ruptured ectopic pregnancy (16.6). Fixity of her pelvic organs on vaginal examination is no help in distinguishing between PID (common), tuberculosis (uncommon), and endometriosis (rare), because they all do this.

Suggesting a ruptured ectopic pregnancy[md]a ''Yes' answer to the following questions: (1) Is she more than slightly anaemic? (2) Has she missed one or more periods by more than a few days? This is often followed by a small loss of dark or brownish blood vaginally. (3) When you examine her vaginally, is she more tender on one side than on the other? (4) Has she a mass on one side? In a subacute ectopic pregnancy the Fallopian tube mass is unilateral, but the pelvic haematocele of a chronic ectopic pregnancy usually feels as if it is in the midline. (5) Is she afebrile? An ectopic pregnancy does not usually cause fever, whereas acute or subacute PID usually does.

Suggesting a twisted ovarian cyst: a mass, no fever, and colicky lower abdominal pain, sometimes with vomiting.

If you are not sure of the diagnosis, and have a laparoscope (15.4), look for red, sticky, and oedematous tubes.

CAUTION ! (1) Her vaginal discharge is not proportional to the severity of her PID. Candida and Trichomonas cause a profuse discharge, but do not usually cause PID. Gonococci and Chlamydia cause a less obvious mucopurulent discharge. (2) Expect your diagnosis to be wrong in about 20% of patients.

MANAGEMENT. You can usually treat her as an outpatient. Admit her if: (1) She is too ill to go home, especially if she has: (a) bilateral lower quadrant rebound tenderness (indicating peritonitis), (b) a mass or (c) shock. (2) You cannot exclude an acute surgical condition, especially an ectopic pregnancy. (3) Outpatient treatment has failed. (5) She is unlikely to take her drugs or return for follow up.

ANTIBIOTICS. Cervical smears and cultures are of little help in choosing an antibiotic, because the organisms in her cervix may not be those which are causing the infection elsewhere. The absence of gonococci in a cervical smear does not exclude gonococcal infection. Usually, you will need to treat her blindly with a broad-spectrum antibiotic. If possible follow up and treat her partners.

Give her tetracycline 500 mg and metronidazole 400 mg, both 4 times daily for 7 to 10 days (2.9). Doxycycline 100 mg twice daily is better than tetracycline but is more expensive. Encourage her to complete the course. She is likely to stop if she feels better. Also, give her an analgesic.

If she is very ill with signs of spread outside her uterus, she needs parenteral antibiotics (2.9) in high dose against a wide range of organisms. Give her: (1) Benzyl penicillin 1.2 g 6-hourly. And, (2) give her chloramphenicol 1 g intravenously immediately followed by 500 mg intravenously 6- hourly. And, (3) give her gentamicin 80 mg intravenously 8- hourly. Or, give her intravenous chloramphenicol and metronidazole.

IF SHE FAILS TO RESPOND TO NON-OPERATIVE TREATMENT, as shown by feeling better, a falling temperature, less pain, and a reduction in the size of the mass; and particularly if she gets worse: (1) Have you made the right diagnosis? (2) Is there a collection of pus somewhere which needs draining? (3) Is she on the right antibiotic in the right dose? If you do decide that this is the problem, make sure you have excluded a wrong diagnosis or collections of pus.

Many patients with acute PID have a mass of matted viscera (as distinct from an abscess which needs drainage). This may take 6 weeks to resolve, but there is no point in continuing antibiotics for more than 2 weeks. If she is not well and has a spiking temperature after 6 weeks, she probably has an abscess which needs draining vaginally or suprapubically.

CAUTION ! Don't change antibiotics unless: (1) You have given them for at least 3 days. (2) You have carefully reviewed her. (3) You are sure that your original diagnosis of PID is correct. (4) You are reasonably sure she does not have a collection of pus anywhere.

LAPAROTOMY [s7]FOR ACUTE PID INDICATIONS. Refer her if you can, this is not an easy operation. She has a significant chance of dying. There are three indications for a laparotomy:

(1) The diagnosis is in doubt, and there is a possibility that she might have an ectopic pregnancy or appendicitis, for example.

(2) After 48 hours of antibiotic treatment for PID (particularly after a septic abortion, 6.6a), she is not improving. Instead, her pulse continues to rise, her temperature is maintained, and there are signs that peritonitis is spreading.

(3) She has sudden generalized peritonitis with shock due to rupture of a tubo-ovarian abscess. This may be spontaneous or it may follow a vaginal or rectal examination. If her history is suggestive, resuscitate her and operate immediately. She is in grave danger.

RESUSCITATION. Give her intravenous fluids (A 15.3). She may need 3 or 4 litres of glucose saline during the first 24 hours. She may bleed considerably from the raw surfaces that will form when you free the adhesions between the loops of her gut, so have two units of blood cross-matched. If she is seriously ill, she is in danger of renal failure, so insert an indwelling catheter and monitor her urine output. Pass a nasogastric tube.

PERIOPERATIVE ANTIBIOTICS. If she is not already on tetracycline and metronidazole, start these before the operation. Or, give her chloramphenicol and metronidazole (2.9).

ANAESTHESIA. (1) General anaesthesia with intubation (A 10.1). (2) If she is very sick, you can if necessary operate under local infiltration anaesthesia (A 6.9) and heavy premedication with pethidine and diazepam (A 5.2), but this will be unpleasant for you and for her. Also, local anaesthetics do not work well in the presence of infection. (3) Ketamine (A 8.1) with local infiltration anaesthesia of her abdominal wall.

INCISION. Make a lower midline incision (9.2) and extend it above her umbilicus if necessary. Here are some of the things you may find. Also be prepared on occasion to find some quite unexpected condition such as a perforated typhoid ulcer (31.8).

If the infection is limited to her pelvis, examine her upper abdominal cavity before you explore her pelvis and disturb the adhesions, which are limiting the spread of infection. Examine her subphrenic and subhepatic spaces, and her paracolic gutters; look for abscesses between the loops of her small gut as far as you can reach them. If you find pus, deal with it as in Sections 6.2, 6.3 and 6.4. If you find dense adhesions, see also Section 10.7.

If you don't find pus in her upper abdomen, carefully protect the upper uninfected part of her abdominal cavity with large abdominal packs. Slowly and methodically divide the adhesions between her gut and her uterus, and look for pus. Divide the adhesions round her tubes and ovaries, and release the pus you find there. Try to get right down into her pouch of Douglas. There is usually no need to remove her tubes or ovaries, however diseased they may look. The tubes have a double blood supply which prevents them becoming gangrenous, and they are not connected to a contaminated viscus like the appendix.

When you find her fundus push your fingers down behind it, between her tubes, which will almost meet in the middle. You need not fear perforating her gut here. Gradually work your fingers down below her tubes. Free them from her gut from below upwards.

Remember her anatomy: it is always the same. Both tubes will be stuck down behind her uterus, over the top of each ovary. Her rectum and colon will be adherent from below upwards to the back of her uterus, and then to both her tubes. Loops of small gut and omentum will have stuck to them on top. If you can find her fundus you will know where you are.

Don't panic when you find a mass of adherent gut and omentum. It will always come clear in the end. First get down to her fundus by lifting off her gut and omentum. Divide all adhesions and release all pockets of pus.

CAUTION ! Don't tear her gut. Avoid doing so by going slowly, and squeezing and pinching the plane of cleavage between your fingers (10.7). Cut dense adhesions with scissors.

If she has generalized peritonitis, suck away as much pus as you can, then suck out her paracolic gutters. Make sure you release any collections of pus under her abdominal wall, between her large gut and her abdominal wall, and under her diaphragm and her liver (subphrenic and subhepatic spaces). Bring out her whole small gut over its full length in stages. Break down adhesions between loops of gut, by careful blunt dissection, to release the many collections of pus between them. Then go to her pelvis, and proceed as above for a localized pelvic infection.

If you find she has a septic abortion, you will have to make the difficult decision as to whether or not to do a hysterectomy. Assess the state of her uterus and adnexa. By the time she has generalized peritonitis, hysterectomy is probably best: (1) The main indication for it is a perforated septic abortion. (2) How many children has she? If she is young and has no children, losing her uterus will be a major disaster. Even if you leave it, she will probably be infertile. (3) How skilled are you? If you are skilled this favours hysterectomy. A subtotal operation will be enough, but it will be dangerous. Occasionally, you may be able to avoid hysterectomy and do a salpingo-oophorectomy if generalized peritonitis seems to originate in an abscess in one of the adnexa (uncommon). Usually, all you need do when this happens is to drain pus and leave a tube in the abscess.

If you find that there is acute inflammation in her pelvis, and perhaps elsewhere without much pus, the infection is very early and she is lucky. Wash out what pus there is. Close her abdomen and continue chemotherapy.

If she has a ruptured tubo-ovarian abscess, leave the tube in and insert a drain.

LAVAGE AND DRAINS depend on the extent of the sepsis you found:

If the pus was localized to her pelvis, wash it out of her pelvis only (6.2), before you remove the packs protecting the rest of her peritoneal cavity. Place two tube drains in her pouch of Douglas, and bring them out through stab incisions, lateral to her rectus muscles.

If she had generalized peritonitis, drains do not work well, so wash out her whole peritoneal cavity as in Section 6.2.

CLOSURE. Close her abdomen as a single layer and leave her skin open for secondary closure (9.8). This is better than inserting tension sutures.

DIFFICULTIES [s7]WITH ACUTE PID Be prepared for small gut fistulae (9.14), and a burst abdomen (9.13), especially if abdominal distension persists for some time postoperatively.

If she has a mass and you are not sure if she has a RUPTURED ECTOPIC OR A PELVIC ABSCESS, do a culdocentesis (16- 6) under general anaesthesia. If you find pus, drain it through her vagina. If you find blood which fails to clot, do a laparotomy (16.7).

If she HAS AN IUD IN AND PRESENTS WITH WITH PAIN, you will not find it easy to decide if her IUD is causing her pain, or if PID is causing it. If her symptoms are not too severe, and her cervix is merely a little tender, see if she will settle quickly with antibiotics and an analgesic. If she settles, leave her IUD. If you always remove an IUD because it causes a little pain and tenderness, you will remove too many. If she is febrile and very tender, give her antibiotics for 24 hours and then remove her IUD.

CAUTION ! Don't remove her IUD immediately. Removing it from her acutely infected cervix will be very painful.

If you find ACUTELY INFLAMED TUBES (SALPINGITIS), when you expect to find something else, leave them, her infection will settle if you give her an appropriate antibiotic. Do a peritoneal toilet and close her abdomen. Unlike an appendix, which you must remove (12.1), her tubes will not become gangrenous, or form a faecal fistula, or leak faeces into her peritoneal cavity.

If you enter her abdomen, expecting to find pus, but FIND LITTLE PUS OR NONE, and few signs of inflammation, examine her pelvic organs and particularly her infundibulopelvic ligaments (20-17). One or both may be thickened and oedematous, and the thickening may extend under her ovaries to her uterus. If so she has SEPTIC THROMBOPHLEBITIS of her ovarian veins (not uncommon). If you find nothing, the thrombophlebitis is probably in a uterine vein which is not so easily seen. If you don't find anything else, particularly any pus, close her abdomen. Continue with antibiotics in high doses. If possible, 24 hours after the operation start her on intravenous ]]heparin 5000 to 10,000 units by bolus intravenous injection 6-hourly, controlled by estimating her clotting time and lengthening it to about 15 minutes. Continue this for at least 2 weeks. Watch carefully for abnormal bleeding, particularly from the abdominal incision, or her urinary or intestinal tracts. She should improve quite quickly.

If you find DISSEMINATED YELLOWISH-WHITE NODULES throughout her pelvic cavity, or a localized infection in her pelvis with nodules on her tubes and perhaps a CASEOUS ABSCESS, suspect that she has TUBERCULOSIS. Take a biopsy and send this for histology.

If you ACCIDENTALLY TEAR HER PELVIC COLON, what you should do depends on the size of the tear and where it is. If it is small, oversew it. If it is large, either close it and make a defunctioning colostomy (9.5) higher up, or divide her colon, close the distal end, and bring the proximal end out as a terminal colostomy (Hartmann's procedure, 9.5).

If there is PERSISTENT SEPSIS in her peritoneal cavity, in spite of repeated attempts at drainage, she is likely to go steadily down hill and die, after several months of great suffering (see the story of Grace above).

[+20]CHRONIC PID DIAGNOSIS. Feel for tenderness of her uterine adnexa on bimanual examination, and for tender masses.

THE DIFFERENTIAL DIAGNOSIS includes urinary tract infection, endometriosis (rare in the developing world), and pelvic tuberculosis (uncommon).

ANTIBIOTICS. Give these as for acute PID for 10 to 14 days. If she has a recurrent infection, consider giving her three courses starting on the first days of successive menstrual periods.

If she improves, she feels better, her pain is less, and her mass disappears over 1 to 3 months.

If she does not improve, either your diagnosis is wrong, or she has a collection of pus, perhaps a chronic tubo- ovarian abscess or a pyosalpinx. Treatment is difficult. Refer her.

DIFFICULTIES [s7]WITH CHRONIC PID If, on laparoscopy or laparotomy, you see BLUISH OR BROWN NODULES on the surface of her peritoneum and particularly on her uterosacral ligaments, surrounded by puckering, suspect ENDOMETRIOSIS. You are most likely to see such nodules on her uterosacral ligaments, in her pouch of Douglas, on her ovaries, on the posterior surface of her broad ligament, or on the fimbrial ends of her tubes. Refer her. Or, if she has pain give her a non-cyclical progestogen to suppress menstruation, such as norethisterone 10 mg daily starting on the 5th day of the cycle (increased if spotting occurs to 25 mg daily in divided doses to prevent break-through bleeding) for at least 6 months. Or, give her Depo-Provera 50 mg weekly or 100 mg every 2 weeks for 3 months.

If she is a YOUNG WOMAN WHO COMPLAINS OF INFERTILITY, menstrual irregularity, and chronic pelvic discomfort, TUBERCULOSIS (29.5) is a possibility.

If she has an IUD in and presents with UNILATERAL SIGNS and perhaps a HARD TUBO-OVARIAN MASS, suspect ACTINOMYCOSIS (rare) as the result of the introduction of the IUD. Confirm the diagnosis by biopsy at laparotomy. She will recover on treatment, and may possibly become fertile. Give her 2 megaunits of benzyl penicillin 6-hourly for 2 weeks, and then oral penicillin V 250 mg 6-hourly for 8 weeks.

If she has chronic PID and is worried about INFERTILITY, you can assure her that removing masses will not make her fertility better or worse, because she is probably incurably infertile already.

If she has chronic PID and is worried about PAIN but is not worried about having any more children, unilateral or bilateral salpingectomy without hysterectomy is usually possible. This is difficult, so don't attempt it yourself unless referral is impossible and you have considerable operative experience.

Fig. 6-11 PID AND PELVIC TUBERCULOSIS. A, acute salpingitis with swollen congested tubes and pus leaking from the ostium. B, chronic salpingo-oophoritis with the tubes and ovaries densely bound by adhesions. C, a tubo-ovarian cyst. D, a tuberculous pyosalpinx. E, a hydrosalpinx. From Young, James, ''A Textbook of Gynaecology' (5th edn, 1939). A and C Black.