Atlas of pathophysiology, 2 Edition

Part II - Disorders

Genital Diseases

Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) is infection of the uterus, fallopian tubes, or ovaries. About 1 million women are treated for PID each year in the United States and about 1 in 7 women are treated for the disease at some point in their lives. Early diagnosis and treatment prevent damage to the reproductive system. Untreated PID may cause infertility and may lead to potentially fatal septicemia and shock. PID may also lead to complications that include chronic pelvic pain and formation of scar tissue (adhesions).

Causes

·   Infection with aerobic or anaerobic organisms, such as:

§  Neisseria gonorrhoeae and Chlamydia trachomatis (most common)

§  staphylococci, streptococci, diphtheroids, PseudomonasEscherichia coli

Predisposing conditions

·   Conization or cauterization of the cervix

·   Insertion of an intrauterine device

·   Use of a biopsy curette or an irrigation catheter

·   Tubal insufflation

·   Abortion, pelvic surgery, infection during or after pregnancy

Pathophysiology

Normally, cervical secretions have a protective and defensive function. Conditions or procedures that alter or destroy cervical mucus impair this bacteriostatic mechanism and allow bacteria present in the cervix or vagina to ascend into the uterine cavity. Uterine infection can also follow the transfer of contaminated cervical mucus into the endometrial cavity by instrumentation. Bacteria may also enter the uterine cavity through the bloodstream or from drainage from a chronically infected fallopian tube, a pelvic abscess, a ruptured appendix, diverticulitis of the sigmoid colon, or other infectious focus.

Uterine infection can result from contamination by one or several common pathogens or may follow the multiplication of normally nonpathogenic bacteria in an altered endometrial environment. Bacterial multiplication is most common during parturition because the endometrium is atrophic, quiescent, and not stimulated by estrogen.

Signs and symptoms

·   Profuse, purulent vaginal discharge

·   Low-grade fever, malaise

·   Lower abdominal pain

·   Severe pain on movement of cervix or palpation of adnexa

·   Vaginal bleeding

·   Chills

·   Nausea and vomiting

·   Dysuria

Diagnostic test results

·   Culture and sensitivity and Gram stain testing of endocervix or cul-de-sac secretions show the causative agent.

·   Urethral and rectal secretions reveal the causative agent.

·   Blood test reveals elevated C-reactive protein level.

·   Transvaginal ultrasonography shows the presence of thickened, fluid-filled fallopian tubes.

·   Computed tomography scan shows complex tubo-ovarian abscesses.

·   Magnetic resonance imaging provides images of soft tissue; useful not only for establishing the diagnosis of PID, but also for detecting other processes responsible for symptoms.

·   Culdocentesis obtains peritoneal fluid or pus for culture and sensitivity testing.

·   Diagnostic laparoscopy identifies cul de-sac fluid, tubal distention, and masses in pelvic abscess.

Treatment

·   Antibiotic therapy beginning immediately after culture specimens are obtained and reevaluated as soon as laboratory results are available (usually after 24 to 48 hours); infection may become chronic if treated inadequately; PID therapy regimens should provide broad-spectrum coverage of likely etiologic pathogens: C. trachomatis, N. gonorrhoeae, anaerobes, gram-negative rods, and streptococci

·   Analgesics

·   I.V. fluids

·   Adequate drainage if pelvic abscess forms

·   Ruptured abscess (life-threatening complication):

§  total abdominal hysterectomy with bilateral salpingo-oophorectomy

§  laparoscopic drainage with preservation of the ovaries and uterus appears to hold promise

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DISTRIBUTION OF ADHESIONS IN PELVIC INFLAMMATORY DISEASE

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