We’re gonna move on and talk about pelvic inflammatory disease.
This is an ascending tract infection.
When I was a student,
I was oftentimes very confused
about the difference between cervicitis and PID.
Essentially what it means is that the infection
ascends from the cervix into the uterus,
the fallopian tubes, and possibly the ovaries,
and potentially even into the abdominal cavity.
So patients can get endometritis which is inflammation
and infection of the uterus.
Salpingitis, which is inflammation
and infection of the fallopian tubes.
A tubo-ovarian abscess that is abscess on the ovary,
and then potentially even peritonitis
which is when the infection leaves the fallopian tubes
and goes into the intra-abdominal cavity.
Now, the causative organisms here most commonly
are gonorrhea and chlamydia,
but it can also be associated with anaerobes
or possibly enteric organisms.
We wanna make sure that we’re thinking about PID
'cause there are a lot of implications
and complications that can happen down the line
if a patient isn't treated.
So if we see a patient in the Emergency Department
with lower abdominal pain,
burning when they urinate,
some other kinds of you know,
symptoms related to the GU tract,
we wanna make sure that we’re thinking about this diagnosis,
because if you missed it
the patient can then go on to develop infertility,
chronic pelvic pain, and possibly
related to ectopic pregnancy development in the future.
So for all patients who come to the Emergency Department
with lower abdominal pain
and any kind of GU symptoms that are female,
you wanna make sure that you’re doing that pelvic exam.
You’re thinking about whether or not
it could be pelvic inflammatory disease,
and then you're asking about the sexual history.
So what kind of history is the patient gonna tell you?
What kinds of things are they gonna be experiencing?
Now patients may be reasonably asymptomatic.
They might have a little bit of lower abdominal pains,
some burning when they urinate
to very severe illness.
Patients can have lower abdominal pain most commonly,
they can have fever and systemic symptoms,
they can have nausea and vomiting,
they can have a lot of discharge,
burning when they urinate, dyspareunia.
So patients can range from really not that symptomatic
to being very, very sick.
And I've taken care of patients on all kind of ranges
within this spectrum.
Patients who you know,
look very well
to patients who are very ill and need to be admitted
to the hospital for PID.
So it’s really a wide range.
On the physical exam,
you may have a patient who have some lower abdominal tenderness,
cervical motion tenderness.
So when you do the cervical exam and you go
and you move their cervix,
they may experience pain.
Sometimes, we call that the chandelier’s sign.
So a patient, when you move their cervix
and the pain is so severe that they can almost jump off the bed,
and kind of hold on to the chandelier,
we call it the chandelier sign.
And you may also see discharge on exam.
It might be white,
it might be yellow in color.
You can always ask a patient
if they normally have vaginal discharge
and if they feel like this looks different.
On by manual exam,
the patient may have adnexal tenderness.
You may feel a mass if they have a large TOA,
And then the cervix may be friable.
So it might bleeding, or appear irritated,
or kind of reddish in color.
PID is a clinical diagnosis.
Again, I wanna make sure that I'm stressing that
for women who are presenting to the Emergency Department
with symptoms of lower abdominal pain and GU symptoms,
go ahead and think about this.
Make sure you’re doing that pelvic exam.
Again, the main test we send off here
is the Nucleic Acid Amplification Test
for gonorrhea and chlamydia.
And for a majority of patients we will stop there.
Now, if your patient appears very ill
or is having a lot of adnexal tenderness on one side or the other,
you wanna move on and get some additional imaging.
For the most part we get an ultrasound,
is really the best test to look at those GU structures,
it’s the best test to look at the uterus,
and the ovaries,
and the fallopian tubes.
But if you don’t have ultrasound available,
you can also potentially get a CAT scan
to take a look for these things.
On an ultrasound or a CT scan,
what you’re looking for is you're looking for is salpingitis.
You're looking for inflammation around the fallopian tubes,
or also passively a tubo-ovarian abscess.
You're looking to see if the ovary has an abscess,
or is very swollen, or inflamed in that area.
And for PID,
due to significance of sequelae of untreated infection
have a very low threshold to treat presumptively
based on your patient’s symptoms and history.
Again, remember that that Nucleic Acid Amplification Test
isn’t gonna come back right away.
It’s going to be delayed for a period of time,
so make sure that you're treating
and thinking about this if you think that it’s present.
Now, uterine or adnexal tenderness
or that cervical motion tenderness support the diagnosis.
So what shall we do for patients who have PID?
We wanna make sure that we treat them
and we have to sort of figure out
if our patient can have outpatient treatment
or in-patient treatment.
The outpatient treatment for PID
is ceftriaxone intramuscularly again.
So similar to what we do for cervicitis.
And then doxycycline twice a day for 14 days.
Now, it’s not important that you memorize these doses
but it’s important that you remember
that you wanna treat for a long period of time.
You wanna treat your patient for 14 days.
If you are all concerned for anaerobic cause
such as trichomoniasis or another anaerobe,
consider adding on metronidazole as well
to treat that additionally.
For in-patient treatment,
so some patients need to be admitted
and we’ll get to who needs to be admitted in a moment,
you can choose with cefotetan plus doxycycline
or cefoxitin plus doxycycline.
So doxycycline is always included in those regimens.
Now, for the most part many of these patients can go home.
Who needs to be admitted to the hospital?
This is a really key thing.
So the people who need to be admitted are pregnancy and PID.
PID and pregnancy is relatively rare
and that’s due to the fact that the mucus plug forms
very early on in pregnancy.
So the mucus plug basically blocks the cervix
and blocks an infection from getting up into that area.
But definitely in very early pregnancy,
patient’s can develop PID.
Keep it in mind if you're concerned
that a pregnant patient has PID,
always involve your OB-GYN consults
and more than likely that patient’s gonna need to be admitted
for IV antibiotics.
Patients who have a tubo-ovarian abscess
always need to be admitted.
Sometimes, they need to go to the operating room
to get treatment for that
and then anyone who has intractable vomiting,
so if you're unable to tolerate your oral medications,
you're unable to take the doxycycline,
you need to be admitted to the hospital.
And also if a patient has been on oral medications for a few days,
so let’s say, you discharge them,
they go home,
they’ve been talking their medication,
they return and they’re still having pain
they're still having discharge,
they may still be having a fever.
Those patients also need to be admitted to the hospital.
A little clinical pearl here is
a condition known as Fitz-Hugh-Curtis syndrome,
and what this is it’s a peri-hepatitis associated with PID.
So it’s patients who come in
with right upper quadrant abdominal pain
and symptoms of PID.
You wanna think about this diagnosis.
Patients may have elevated liver function test,
they might have pain and tenderness in the right upper quadrant,
and this is a hepatitis that's associated with PID.
So a liver infection associated with PID.