A5. Adnexal inflammatory diseases; diagnosis, differential diagnosis, and therapy

Definition and epidemiology

I’m pretty sure they mean pelvic inflammatory disease.

Pelvic inflammatory disease (PID) is an infection of the upper genital tract and neighbouring pelvic organs. It causes colpitis, endocervitis, endometritis, salpingitis, oophoritis, peritonitis, perihepatitis, and/or tubo-ovarian abscess.

It affects approx. 4% of women of reproductive age and is a common cause of infertility.

Etiology

The majority of PID cases are caused by sexually transmitted pathogens, like Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma hominis.

It may also be caused by non-specific bacteria like staphylococci, E. coli, streptococci, etc.

Most cases are polymicrobial. These pathogens ascend from the vagina to the uterus, fallopian tubes, ovaries, and adnexa.

Around 85% of cases occur spontaneously in sexually active females of reproductive age, especially women < 25 years. The remaining 15% follow invasive procedures like endometrial biopsy, curettage, insertion of IUD, etc.

Classification

We can distinguish acute (symptoms last < 30 days) and chronic (symptoms last > 30 days or reappear after treatment) PID.

We can also distinguish PID according to the history of recent delivery, as either puerperal or nonpuerperal.

Clinical features

The majority of cases are subclinical without any symptoms or signs. 1/3 of cases are moderate, causing discomfort for the patient, and only 4% are so severe that medical care is necessary.

When it causes pain, lower abdominal pain is the most common symptom. Other symptoms can be dyspareunia, metrorrhagia, fever, abnormal vaginal discharge, dysmenorrhoea, etc.

Diagnosis and evaluation

Bimanual examination is important, as tenderness of the adnexa, cervix, and uterus are so characteristic that they’re virtually diagnostic. Culture and PCR of cervical and vaginal swab can tell us the pathogen.

To further specify the diagnosis, we can use transvaginal ultrasound or endometrial biopsy. Ultrasound cannot diagnose PID, but it can rule out other conditions like free pelvic fluid, hydrosalpinx, etc. Exploratory laparoscopy may be used in difficult cases.

It’s important to exclude several conditions, like:

  • Ectopic pregnancy with a pregnancy test
  • Urinary tract infection with urine culture
  • Appendicitis with McBurney tenderness and vomiting

Treatment

If the symptoms are not so severe the patient can be treated outpatient on broad-spectrum antibiotics, like fluoroquinolone ± metronidazole.

If the outpatient treatment does not help, if the patient has a tubo-ovarian abscess, if the patient has severe illness, or if a surgical emergency cannot be excluded, the patient should be hospitalised and treated with IV antibiotics.

The male partner should be treated as well.

Complications

  • Tubo-ovarian abscess
  • Adhesions
  • Infertility – due to adhesion and scarring

A tubo-ovarian abscess is a complication of pelvic inflammatory disease (PID). It usually presents with acute lower abdominal pain, fever, chills, vaginal discharge, and an adnexal mass. We can treat it with antibiotics with or without ultrasound-guided drainage or surgery.


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