Diagnosis Of Pelvic Inflammatory Disease Research Articles

Laparoscopic management of suspected acute pelvic inflammatory disease

Study Objective. To evaluate the efficacy of acute-phase operative laparoscopy in women with suspected pelvic inflammatory disease (PID). Design. Open series (Canadian Task Force classification II-3). Setting. University hospital. Patients. Thirty-three patients with clinically suspected PID. Intervention. Acute-phase operative laparoscopy. Measurements and Main Results. Laparoscopy confirmed the diagnosis of PID in 20 (61%) patients; 11 (33%) women had other disease and 2 (6%) had no evidence of disease. Laparoscopic procedures in women with PID were pelvic irrigation (all patients), lysis of adhesions (most cases), drainage and irrigation of unilateral or bilateral pyosalpinx (7), drainage and irrigation of tubo-ovarian abscess (3), and extirpation of disease (2). Laparoscopic intervention was also performed in 11 (85%) of 13 women without PID. No major complications occurred. Conclusion. Acute-phase operative laparoscopy provided a final diagnosis in all but, three patients (91%).

Acute pelvic inflammatory disease in a gynecological casualty setting

This paper presents a prospective study on the validity of clinical diagnostic criteria of acute pelvic inflammatory disease (PID) in Sri Lanka over a period of 15 months. The study assessed 1817 consecutive gynecological admissions and acute PID was diagnosed according to the established clinical criteria. Clinical signs and symptoms of PID among women aged 18-22 years include abdominal pain abnormal vaginal discharge urinary symptoms irregular bleeding vomiting rectal symptoms fever an erythrocyte sedimentation rate of 15 mm/hour or higher abnormal adnexal tenderness and a palpable adnexal mass. The gynecological casualty admissions categorized into one of the following clinical groups are outlined. The study identified 29 visually confirmed acute PID cases with 41 patients with acute PID in the series. This indicates that there is a 2.26% acute PID incidence in the casualty gynecological setting (95% confidence interval 1.91-2.61). When the clinical diagnosis was equivocal the positive value for acute PID diagnosis was 76%. This indicates that if laparoscopy had not been used to confirm acute PID 24 patients with equivocal PID would have been overtreated with expensive broad-spectrum antibiotics. This article emphasizes that in the absence of contraindications and availability of facilities laparoscopy is very useful; and at the same time treatment of clinically equivocal cases must not be delayed as this may lead to serious consequences.

Pelvic Inflammatory Disease — an Evidence-based Approach to Diagnosis

Pelvic inflammatory disease (PID) is inflammation of the upper female genital tract and related structures. It may arise from blood borne infection, such as tuberculosis, or from spread from an area of intra-abdominal sepsis, but in practice these are rare sources and most cases result from ascending infection from the lower genital tract. PID may arise de novo or may be secondary to a breach of the cervical mucous barrier, in particular by surgical instrumentation and the events of pregnancy. There is a wide range of pathology from mild endometritis to generalized peritonitis. PID is important economically and socially because of its sequelae, tubal infertility, ectopic pregnancy and chronic pelvic pain.1 It is thus a major cause of short-term and long-term morbidity and the cost of assisted reproduction techniques to overcome tubal infertility is high. Infertile women and those with chronic pelvic pain may suffer considerable psychological distress. In addition, ectopic pregnancy still results in a number of maternal deaths every year. Traditionally, the diagnosis of PID has been based on the finding of bilateral tenderness of the uterine appendages in women complaining of lower abdominal or pelvic pain. Associated symptoms include deep dyspareunia, menstrual disturbances, vaginal discharge, urinary and bowel symptoms and features suggestive of a systemic illness, such as fevers and malaise. Associated physical signs include abdominal tenderness, pain on moving the cervix (excitation pain) and the presence of palpable adnexal masses. There may be objective signs of fever and tachycardia.

The association of interleukin 6 with clinical and laboratory parameters of acute pelvic inflammatory disease

Objective: We sought (1) to determine whether interleukin 6 levels are increased in plasma and cervical secretions and endometrial tissue obtained from women with a clinical diagnosis of pelvic inflammatory disease, (2) to determine whether interleukin 6 levels in these sample sites reflected the clinical severity of acute infection, and (3) to determine whether interleukin 6 levels in endometrial tissue obtained from these women were higher in the presence of histologic endometritis. Study Design: We performed a prospective pilot study on 20 women with a clinical diagnosis of pelvic inflammatory disease (patients) and then compared them with 20 women presenting to the gynecology clinic without pelvic complaints (control subjects). Interleukin 6 levels were measured by enzyme-linked immunologic testing in plasma, cervical secretions, and endometrial biopsy specimens. Results: Cervical interleukin 6 levels were higher in patients than control subjects (median, 317 vs 111 pg/mL; P = .003). Among women with pelvic inflammatory disease, statistically significant positive correlations were noted between the clinical severity score and the erythrocyte sedimentation rate ( r = 0.45; P = .04), the clinical severity score and the white blood cell count ( r = 0.49; P = .03), the plasma interleukin 6 levels and the erythrocyte sedimentation rate ( r = 0.55; P = .02), and the plasma interleukin 6 levels and the white blood cell count ( r = 0.54, P = .01). Endometrial tissue interleukin 6 levels were also higher in patients with versus those without histologic endometritis (median, 427 vs 17 pg/mL; P = .004). Conclusion: In this pilot study interleukin 6 levels in cervical secretions were significantly higher in women with pelvic inflammatory disease versus those without pelvic inflammatory disease. In women with pelvic inflammatory disease, endometrial tissue samples with histologic evidence of endometritis were observed to have higher levels of interleukin 6. Interleukin 6 may be a useful adjunct to the clinical diagnosis of pelvic inflammatory disease. (Am J Obstet Gynecol 1999;181:940-4.)

Peripheral blood T cell proliferative response to chlamydial organisms in gonococcal and non-gonococcal urethritis and presumed pelvic inflammatory disease.

OBJECTIVE: To study peripheral blood mononuclear cell (PBMC) proliferative response to Chlamydia trachomatis elementary bodies in (a) controls, (b) various stages of gonococcal (c) and non-gonococcal urethritis, and (d) women...

The rate of diagnosis and demography of pelvic inflammatory disease in general practice: England and Wales.

Knowledge of pelvic inflammatory disease (PID) epidemiology is essential to the understanding of reproductive morbidity in women. This paper estimates the rate of PID diagnosis in general practice (GP) and the level of association between PID diagnosis and demographic factors. Diagnoses of PID were made at 1.7% of attendances amongst women aged 16 to 46. Increased risk of PID was associated with smoking (P<0.0001), younger age groups (P<0.0001) and lower socioeconomic groups (P<0.0001). Compared to patients who were married, increased risk was also associated with those patients who were widowed, separated or divorced and not cohabiting (adjusted rate ratio (RR)=1.62; confidence limits (CL) 1.35 to 1.97), and with those who were unmarried but cohabiting (adjusted RR=1.32; 95% CL 1.11 to 1.56). General practice is an important focus for the diagnosis and treatment of PID. If intervention and surveillance are to be undertaken effectively, more has to be known about the epidemiology of this important public health problem.

Diagnosing Pelvic Inflammatory Disease with Limited Diagnostic Tools in a Region of Ghana

The objective of this study was to describe how pelvic inflammatory disease (PID) is diagnosed in a region with limited technological diagnostic tools. Subsequently, we retrospectively reviewed 208 PID case notes and interviewed 25 clinicians in two regional level and four district hospitals of the Central Region of Ghana We found out that the clinical diagnosis of PID was frequently based on the features of lower abdominal pain, vaginal discharge, fever, lower abdominal tenderness, cervical motion, and adnexal tenderness. Sexual histories of suspected cases were rarely obtained while menstrual and contraceptive histories were scanty. Fifty-one per cent and two per cent of patients received bimanual and vaginal speculum examinations respectively. Predisposing factors were observed in 23 per cent of patients. There was a notion that poor genital hygiene was a cause of PID. We conclude that the periodic audit of clinical management of PID even in the absence of objective diagnostic tools is essential in identifying issues that could improve case prevention, recognition, and management. (Afr J Reprod Health 1999; 3 [1]: 88 - 97) Key Words : Pelvic inflammatory disease, diagnosis, Ghana

Response of gonococcal clinical isolates to acidic conditions.

This study examined the response to acidic conditions of four gonococcal isolates -NRL38874 (Proto/IB-2), NRL38884 (Pro/IA-2), NRL38953 (Proto/IB-3) and NRL39029 (Pro/IA-3) - obtained from various sites in patients in whom a diagnosis of pelvic inflammatory disease had been made by laparoscopic examination. Acid tolerance of the clinical isolates was strain and growth phase dependent. Growth of the four strains on solid media was undetectable below pH 5.8. In liquid culture, strain NRL38884 did not survive below pH 5.2; strains NRL38874, NRL38953 and NRL39029 survived to pH 4.5. Between pH 4.2 and pH 5.1, the latter three strains exhibited a peak in survival at pH 4.6-4.7 during log phase, suggesting that there may be a distinct acid tolerance system operating at this pH. SDS-PAGE of whole-cell, total membrane and outer-membrane fractions of the four strains prepared from pH 7.2 and pH 6.1 plate cultures revealed numerous differences in protein composition. Acidic conditions reduced the expression of the reduction modifiable outer-membrane protein Rmp, and induced the expression of many membrane proteins, including gonococcal hsp63. Immunoblotting studies with matched serum samples and strains from patients with pelvic inflammatory disease indicated that IgG recognition of outer-membrane components from strains cultured in acidic and neutral conditions was quite different. The results suggest that the immune system interacts with unique outer-membrane constituents on gonococci colonising sites at different pH.

Risk factors for laparoscopically confirmed pelvic inflammatory disease: findings from Mumbai (Bombay), India.

OBJECTIVES: Sexually transmitted diseases (STDs) are an important cause of pelvic inflammatory disease (PID) but have often not been detected in microbiological studies of Indian women admitted to hospital gynaecology...

PELVIC INFLAMMATORY DISEASE: From Diagnosis to Prevention

Pelvic inflammatory disease (PID) refers to infection of the uterus, fallopian tubes, and adjacent pelvic structures that is not associated with surgery or pregnancy. PID causes major medical, social, and economic problems worldwide. Long-term sequelae, most notably tubal factor infertility and ectopic pregnancy, are common and extremely costly to the healthcare system. The most important causative micro-organisms are Chlamydia trachomatis, Neisseria gonorrhoeae, and micro-organisms associated with bacterial vaginosis. The clinical spectrum of PID ranges from subclinical endometritis to severe salpingitis, pyosalpinx, tubo-ovarian abscess, pelvic peritonitis, and perihepatitis. Clinical diagnosis of PID has limitations. The clinical diagnostic criteria are insensitive and nonspecific, and false-positive and false-negative diagnosis is common; however, direct visual diagnosis is not always feasible, requires general anesthesia, and is costly. More research is needed of noninvasive diagnosis of PID. Current treatment guidelines call for broad-spectrum antimicrobial coverage. Screening for asymptomatic chlamydial infection is the mainstay of prevention of PID. Emerging evidence from randomized controlled trials provides strong evidence that intervention with selective screening for chlamydial infection effectively reduces the incidence of PID.

Transvaginal sonographic markers of tubal inflammatory disease.

Since the introduction of transvaginal sonography (TVS), clear pictures of the female reproductive tract have been obtained. These images enable the accurate description of Fallopian tube pathology. However, the current literature on the ultrasound diagnosis of pelvic inflammatory disease (PID) is confusing and contradictory. The goal of our study was to identify sonographic markers of inflammatory disease of the pelvis and to place these in a clinical context. Seventy-seven patients were scanned by TVS. They were divided into two groups, according to their clinical picture, the first group with acute PID and the second with a history of chronic PID or no history at all. The sonographic markers studied were shape, wall structure and wall thickness of the Fallopian tube. Ovarian involvement and the presence of pelvic fluid were also evaluated. The best marker of tubal inflammatory disease, either acute or chronic, was the presence of an incomplete septum of the tubal wall, which was present in 92% of the total cases. A thick wall and the 'cogwheel' sign were sensitive markers of acute disease, whereas a thin wall and 'beads-on-a-string' sign were indicators of chronic disease. Palpable findings and surgical history were not discriminatory, but were present in three-quarters and one-third of the study population, respectively. Three false-positive cases are presented: an ovarian cystadenoma, an appendiceal mucocele and one case with periovarian fluid accumulation. The tubo-ovarian complex and the tubo-ovarian abscess should be considered separate entities that differ in their clinical implications. TVS allows one to distinguish between them. Distinguishing characteristics of acute and chronic salpingitis are presented.

Pelvic inflammatory disease: the importance of aggressive treatment in adolescents.

Pelvic inflammatory disease (PID), an infection of the female genital tract, presents a number of difficult challenges in diagnosis and management. Adolescents in particular require aggressive care of PID to prevent the long-term sequelae of chronic pelvic pain and infertility. This article reviews the etiology, microbiology, diagnosis, and management of PID, with an emphasis on treating adolescents with PID.

Doppler flow characteristics in patients with pelvic inflammatory disease: responders versus nonresponders to therapy.

The objective of this retrospective study was to evaluate the role of Doppler flow studies in predicting the response to antibiotic treatment in patients with pelvic inflammatory disease (PID). The resistance indices in pelvic masses of 24 patients with clinical diagnoses of PID were analyzed. Twelve patients responded favorably to antibiotic treatment (the conservative treatment group), while the other patients showed no clinical improvement and underwent surgery (surgical treatment group). The mean resistance index in the conservative treatment group was significantly higher (0.60 +/- 0.15) than that in the surgical treatment group (0.52 +/- 0.08; p < 0.05). In keeping with hyperemia of inflammation, fallopian arterial resistance seems to decrease with the severity of PID.

Pelvic inflammatory disease in the adolescent population.

Statistics suggest that the adolescents have a higher rate of diagnosis of pelvic inflammatory disease than any other age group. Early recognition improves the chances of preventing the long-term consequences of ectopic pregnancy and tubal infertility. For a significant number of teens, the symptoms are mild or vague, requiring a high index of suspicion by the physician to initiate treatment. The purpose of this article is to review the currently accepted guidelines for diagnosis and management of pelvic inflammatory disease in the adolescent patient.

Clinical utility of CA125 levels in predicting laparoscopically confirmed salpingitis in patients with clinically diagnosed pelvic inflammatory disease.

OBJECTIVE: The purpose of this study was to determine the utility of serum CA125 determinations in diagnosing acute salpingitis. METHODS: CA125 levels were determined for 34 women with the clinical diagnosis of pelvic inflammatory disease (PID). Acute salpingitis was confirmed laparoscopically in 28 women (82.3%). RESULTS: Twenty patients (71.4%) with laparoscopically confirmed acute salpingitis had CA125 levels greater than 7.5 units, compared with no patients (0/6) with laparoscopically normal tubes (P = 0.002). The degree of elevation of CA125 levels correlated with the severity of tubal inflammation noted at laparoscopy. All patients with levels above 16 units had laparoscopically severe salpingitis. CONCLUSIONS: We conclude that while CA125 levels above 7.5 units may modestly improve the ability of the clinical diagnosis of PID to accurately reflect visually confirmed acute salpingitis, limitations of the test make its clinical utility questionable.

Clinical Utility of CA125 Levels in PredictingLaparoscopically Confirmed Salpingitis in PatientsWith Clinically Diagnosed PelvicInflammatory Disease

Objective: The purpose of this study was to determine the utility of serum CA125 determinations in diagnosing acute salpingitis.Methods: CA125 levels were determined for 34 women with the clinical diagnosis of pelvic inflammatory disease (PID). Acute salpingitis was confirmed laparoscopically in 28 women (82.3%).Results: Twenty patients (71.4%) with laparoscopically confirmed acute salpingitis had CA125 levels greater than 7.5 units, compared with no patients (0/6) with laparoscopically normal tubes (P = 0.002). The degree of elevation of CA125 levels correlated with the severity of tubal inflammation noted at laparoscopy. All patients with levels above 16 units had laparoscopically severe salpingitis.Conclusions: We conclude that while CA125 levels above 7.5 units may modestly improve the ability of the clinical diagnosis of PID to accurately reflect visually confirmed acute salpingitis, limitations of the test make its clinical utility questionable.

PELVIC ULTRASONOGRAPHY

Pelvic ultrasonography is a valuable tool for the emergency physician in the evaluation of the wide spectrum of pelvic complaints presenting to the emergency department. The goal of this article is to outline pelvic problems that can be readily identified by the emergency physician using pelvic sonography early in the patient's evaluation. A special emphasis is placed on the sonographic diagnosis of ectopic pregnancy.

A profile of inpatient STD-related pelvic inflammatory disease in the Top End of the Northern Territory of Australia.

To obtain a profile of inpatient STD-related pelvic inflammatory disease (PID) in the Top End of the Northern Territory. Review of case records. The Royal Darwin Hospital, the tertiary referral centre for the Top End, during the three years from June 1991 to May 1994. All admissions with a diagnosis of STD-related PID. The presentation and incidence of STD-related PID in Aboriginal and non-Aboriginal women. PID was the reason for 14% of admissions of Aboriginal women and 2% of non-Aboriginal women. Of 175 episodes of PID in 169 patients admitted over the three years of the study, 41 (23%) had gonorrhoea, 64 (37%) had chlamydia and 7 (4%) had both organisms isolated on genital swab. Aboriginal women were more than twice as likely to have gonorrhoea (38% versus 18%; risk ratio, 2.12; 95% confidence interval, 1.27-3.53) as non-Aboriginal women. Median time from first symptoms to presentation was six days. All gonococcal isolates were penicillin susceptible. STD-related pelvic inflammatory disease is an important problem among women in the Top End of the Northern Territory. As PID is a preventable illness, further measures aimed at prevention and earlier, more effective treatment of STDs that cause PID are urgently required.

Antibodies to the chlamydial 60 kd heat-shock protein are associated with laparoscopically confirmed perihepatitis

OBJECTIVE: Our purpose was to examine clinical, microbiologic, serologic, and laparoscopic findings associated with perihepatitis. STUDY DESIGN: In a prospective study of 157 women with a clinical diagnosis of pelvic inflammatory disease, 27 women with laparoscopically confirmed perihepatitis and salpingitis were compared with 46 patients with salpingitis alone. RESULTS: Both current use or a history of ever using oral contraceptives was negatively associated with perihepatitis ( p = 0.05 and p = 0.008, respectively). Moderate-to-severe pelvic adhesions were present at laparoscopy significantly more often in the perihepatitis-salpingitis group (70%) than in the salpingitis alone group (35%, p = 0.003). Antibody to the chlamydial 60 kd heat-shock protein at ≥0.5 optical density was detected in 67% of the perihepatitis-salpingitis group and in 28% of the salpingitis alone group ( p = 0.005), and the median titer was significantly higher in the former group ( p = 0.02). CONCLUSION: Compared with women with salpingitis alone, patients with perihepatitis-salpingitis do not have distinctive clinical or microbiologic findings but do manifest a higher prevalence of moderate-to-severe pelvic adhesions and both a higher prevalence and higher titers of antibody to the chlamydial heat-shock protein-60. (Am J Obstet Gynecol 1997;176:870-7.)

Ampicillin/sulbactam vs. cefoxitin for the treatment of pelvic inflammatory disease

Objective The safety and efficacy of ampicillin plus sulbactam were compared with those of cefoxitin in the treatment of women with pelvic inflammatory disease (PID). Methods This single-site, randomized, prospective, third-party-blinded, comparative, parallel-treatment study enrolled 93 women with a diagnosis of PID. Patients were treated with either ampicillin/sulbactam (2 g/1 g, administered intravenously [IV], every 6 h) or cefoxitin (2 g, administered IV, every 6 h) for a minimum of 12 doses. Patients with cultures positive for Chlamydia trachomatis also received concurrent oral or IV doxycycline (100 mg twice daily). Patients with cultures negative for C. trachomatis received prophylactic oral doxycycline (100 mg twice daily) for 10–14 days after treatment with either ampicillin/sulbactam or cefoxitin was completed. Results Ninety-three patients were entered in the study: 47 in the ampicillin/sulbactam arm and 46 in the cefoxitin arm. All 93 patients were evaluable for safety; 61 (66%) were evaluable for efficacy. Demographic characteristics were similar for the groups. Of the 27 evaluable ampicillin/sulbactam-treated patients, 67% experienced clinical cure, 30% improved, and 4% failed treatment. Respective values for the 34 cefoxitin-treated patients were 68%, 24%, and 9% (P = 0.67). Pathogens were eradicated in 70% of the women given ampicillin/sulbactam vs. 56% of those who received cefoxitin (P = 0.64). Conclusions Overall, ampicillin/sulbactam demonstrated clinical and bacteriologic efficacy at least equivalent to that of cefoxitin in the treatment of women with acute PID. The use of ampicillin/sulbactam for this indication may avoid the complex dosing regimens associated with other treatments. Infect. Dis. Obstet. Gynecol. 5:319–325, 1997. © 1998 Wiley-Liss, Inc.