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Hennie Williams Senior Lecturer in Sexual Health Sexual Health Physician Melbourne Sexual Health Centre School of Popula

Pelvic Inflammatory Disease. Hennie Williams Senior Lecturer in Sexual Health Sexual Health Physician Melbourne Sexual Health Centre School of Population Health University of Melbourne. Why is PID a heart sink?. No one can agree what it is how common it is what causes it

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Hennie Williams Senior Lecturer in Sexual Health Sexual Health Physician Melbourne Sexual Health Centre School of Popula

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  1. Pelvic Inflammatory Disease Hennie Williams Senior Lecturer in Sexual Health Sexual Health Physician Melbourne Sexual Health Centre School of Population Health University of Melbourne

  2. Why is PID a heart sink? • No one can agree • what it is • how common it is • what causes it • how to recognise if a patient has it • how to test for it • how to treat it • how commonly it causes complications But we are certain that it is important not to miss and that it is often sexually transmitted

  3. Definition Prevalence Cause Symptoms & signs Diagnosis Treatment Complications

  4. Definition Prevalence Cause Symptoms & signs Diagnosis Treatment Complications

  5. Definition and terminology Spectrum of disorders endometritis salpingitis tubo-ovarian abscess pelvic peritonitis Organisms from cervix or vagina to UGT Blood borne (eg TB) Post op Puerperal (delivery or abortion) Salpingitis: ‘laparoscopic diagnosis’ ~2/3 women with clinical PID have salpingitis remainder other conditions or normal pelvic laparoscopic examination Upper Genital Tract infection (UGTI) .

  6. Definition and terminology Endometritis Probably an early stage of PID May be patchy so can be missed on endometrial sampling Association with IMB acknowledged since 1985 Definition: > 5 polys /400x field with ≥1 plasma cell /120x field (Kiviat‘s) 40% of women with ‘cervicitis’ 66% with chlamydial cervicitis have endometritis 80-90% of women with salpingitits 30% of women with endometritis have salpingitis Unknown if endometritis alone causes long term sequelae Wolner-Hansen 1995, Paavonen 1985, Kiviat 1990, Paanoven 1985, Waaserheit 1986, Paavonen 1985 and 1987, Haggerty 2003, Wiesenfeld 2007)

  7. Definition Prevalence Cause Symptoms & signs Diagnosis Treatment Complications

  8. Prevalence Probably main cause of gynaecological pelvic pain Estimates 8-11% women of child bearing age in USA (Aral Jama 1991) 2% women < 25y in UK primary care (Simms 1999) 1.5% women attending Melbourne SHC (Doxanakis: 2008) Chlamydia prevalence often used as a surrogate marker decreased rates in Scandinavia paralleled by falls in PID (Australia mean community prevalence rates ~4%)

  9. Definition Prevalence Cause Symptoms & signs Diagnosis Treatment Complications

  10. Causative organisms Normal vaginal flora - mixed bacteria with lactobacilli predominating - some ‘normal’ vaginal bacteria are potentially pathogenic (eg E. coli, Klebsiella, Proteus, strep, staph, anaerobes) Endocervical canal - acts as a barrier protecting normally sterile UGT Disturbance of this barrier provides access for these bacteria to UGT - 75% of cases PID occur within 7d of menstruation (Eschenbach 1976) Gonorrhoea and Chlamydia are initiators of PID - ~15% of women with cervicitis develop PID ( Arya 1981, Forslin 1978)

  11. Causative organisms Most polymicrobial 1/3 Chlamydia trachomatis and/or Neisseria gonorrhoea >50% no proven microbiological causes With PID Mycoplasma organisms (eg Ureaplasma urealyticum) are more common in lower genital tract Other STIs in vagina (eg Trichomonas) are more common Role of normal vaginal flora (eg anaerobes, ecoli, proteus) unknown NB effect of sampling techniques

  12. Associations with PID • Association between BV and PID remains unclear • Do BV organisms cause PID? • or are they carried by Chlamydia and GC into UGT? • BV more common in women with PID (Soper 1994) • Prospective study (1179 women with BV over 3y) : no increase in PID • (Ness 2004) • PID risk increased 2 fold in women with highest counts of BV organisms in clusters (? STI cofactor for BV/PIG) (Ness 2005) • Douching: PID is more common in women who douche • but these women also have other risk factors for PID • (Wolner-Hanssen 1990, Rosenberg 1992)

  13. Associations with PID • age < 25 yrs • sexual intercourse < 20 yrs • self reported history of STI • non white-ethnicity • not having had children • exposure to Chlamydia Case control study 140/381 patients with PID in GUM clinic 105 controls from general practice 136 controls from PID free tubal ligation group

  14. Definition Prevalence Cause Symptoms & signs Diagnosis Treatment Complications

  15. Symptoms & Signs Lower abdominal/pelvic pain Dyspareunia Irregular vaginal bleeding (PCB or IMB) Abnormal vaginal discharge Lower abdominal and pelvic tenderness Adenexal tenderness Cervical motion tenderness Muco-purulent cervicitis Abnormal vaginal discharge Fever May be asymptomatic

  16. Symptoms & Signs Asymptomatic PID is still associated with reproductive morbidity 112 women with infertility 36 had adhesions and laparoscopic evidence of PID only 11 had a history of clinical PID (Obstets Gynecol 1995 86 321 Wolner Hanssen) Women with tubal factor infertility 1/3 still have Chlamydia in UGT without a history of PID (Keilani 1989, Separd 1989)

  17. Diagnostic investigations No ideal diagnostic test Many investigations that help but as specificity increases, sensitivity decreases …. sensitivity more important than specificity? - avoid missed diagnosis and prevent complications

  18. Diagnostic investigations Laparoscopy “gold standard”: tubal oedema, erythema or purulent exudate not very sensitive in early diagnosis invasive (Jacobson 1969, Method 1988) variable sensitivity (as low as 50%) and specificity (as low as 85%) compared to fimbrial biopsy (Sellors Am J Obstet Gynecol1991) Clinical diagnosis and laparoscopy triad: low sensitivity(65%, 60%) (Peipert 1997) Endometrial biopsy histopathologic evidence of endometritis Transvaginal sonography, Magnetic resonance imaging and Doppler techniques

  19. Clinical diagnosis • In day to day practice • 1. LAP or pelvic pain (with no other cause) and • 2. At risk of STI and • 3. One or more of • cervical motion tenderness • uterine tenderness • adnexal tenderness • Specificity increased by presence of inflammation in LGT • Exclude • ectopic • appendicitis • endometriosis • ovarian cyst complication. • CDC Guidelines 2006:http://www.cdc.gov/std/treatment/2006/toc.htm

  20. Clinical diagnosis Additional helpful indicators Temp > 38.3C Abnormal cervical or vaginal mucopurulent discharge Presence of abundant WBCs on saline microscopy of vaginal secretions, Increased ESR, Increased CRP Lab documentation of cervical infection with Gonorrhoeae or Chlamydia (but absence of these 2 infections does not exclude a diagnosis of PID)

  21. Cervicitis

  22. Clinical diagnosis Value of microscopy of vaginal secretions high number of WBCs (> epithelial cells) abnormal vaginal flora may not help in confirming the diagnosis but low number of WBCs normal flora (lactobacilli ++) may help in rejecting it (NPV 95%)

  23. Clinical diagnosis Other investigations Endo cervical swab for Chlamydia, Gonorrhoea, MG Vaginal swab for Trichomonas Vaginal and cervical slides for micro (?polymorphs) Pregnancy test US scan

  24. How good are we at diagnosing PID? • Retrospective review • 325 cases with PID at MSHC 2002-06 • 21,785 unselected walk in female controls • Significant differences between doctors • in the proportion of women diagnosed with PID • 4 times greater variation in diagnosis of PID than genital warts • Characteristics of women with PID similar between high diagnosing and low diagnosing doctors

  25. Definition Prevalence Cause Symptoms & signs Diagnosis Treatment Complications

  26. Treatment Australian National Management Guidelines for STIs (SHSOV) 2008 Azithromycin 1 g stat + Doxycycline 100 mg bd 14d + Metronidazole 400 mg bd 14d + if gonorrhoea suspected: Ceftriaxone 500 mg stat [USA /UK /Europe: Cephalosporin (+/- Metronidazole)] Partner notification CDC - all partners; treat if sexual contact within 60 days UK - contact tracing for 6 months prior to onset of symptoms and treat

  27. 831 patients with mild to moderate PID • - randomised to outpatient or inpatient treatment • with im cefoxitin and oral doxycycline. • - follow up 35 months • - no difference in pregnancy rates, frequency of recurrence of PID, chronic pelvic pain or ectopic pregnancy

  28. RCT of 106 women outpatient treated PID Ceftriaxone 250 mg then either Azithromycin 1 g weekly for 2 weeks or Doxycycline 100 mg bd for 2 weeks Clinical cure rate at 14 days 98.2% (CI =0.9-0.99) 85.7% (CI = 0.72-0.93)

  29. Retrospective review of case notes Clinical cure rates: Doxycycline and Metronidazole 55% (18% non responders) Doxycycline and Metronidazole 72% (8% non responders) plus Ceftriaxone stat im dose

  30. Relationships between CCR and reproductive morbidity? Treatment regimens all look at short term clinical cure rates, very little on long term reproductive morbidity. PEACH Study: endometritis not associated with reproductive morbidity (Haggerty 2003) FUP (despite eradication of UGT Chlamydia and GC) rates of infertility, pelvic pain and recurrent PID were still elevated (Ness 2002) Need to eliminate maybe other PID pathogens? Reproductive morbidity worse withnon gonococcal infection Overall PEACH study demonstrates that although current treatment eradicates UGT GC and Chlamydia these are still at risk of long term morbidity greater than if they hadn’t had PID

  31. Treatment for Anaerobes Is anaerobic cover necessary to prevent sequelae? Compliance with metronidazole poor Relevance of anaerobes unclear: ? contamination from sampling ? responsible for sequelae Fluoroquinolones no anaerobic cover Azithromycin some anaerobic cover but not ideal for GC Moxifloxacin some anaerobic cover (poor Gram+) but covers Chlamydia, MG and GC. Clinical cure rates of anaerobic PID Azithromycin (97%) vs Azithromycin and Metronidazole (96%) Azithrom not ideal for GC with resistance patterns ( Bevan 2003) Animal models: ? Repeat doses Azithromycin shows possibility

  32. Definition Prevalence Cause Symptoms & signs Diagnosis Treatment Complications

  33. Complications Infertility, pelvic pain and ectopic pregnancy What is the excess risk of infertility in women after genital chlamydial infection? A systematic review of the evidence

  34. Complications Infertility proportional to severity of laparoscopic findings but not clinical symptoms (Jacobson 1969 and Bernstein 1987) Tubal Infertility after mild, moderate and severe PID is 10, 25 and 50% respectively (Jacobson 1969) Ectopics: 10-15% of conceptions will be ectopic after mild PID and 50% after severe PID(Bernstein 1987) Delay in treatment > 48 hours increases risk of infertility and ectopic pregnancy by 3 fold (Hillis 1993 Am J obstet Gynecol) 1/3-1/2 women will develop pelvic pain (Bernstein 1987 and Stacey 1992)

  35. Complications Is serology helpful in identifying those at risk of complications? Generally believed that ChHSP60 Abs were predictive of complications PEACH study contradicts this mild to moderate PID risk of complications related to Chlamydia EB Abs (not Chsp60 Abs) (Ness 2008 STD)

  36. Complications MG associated with PID but does it cause infertility? PEACH study - positive MG PCR not predictive of complications - but MG Abs more common in women with TFI Evidence still conflicting! (Haggerty 2007)

  37. Take Home Messages Mild to moderate PID is a clinical diagnosis but may be asymptomatic! 1/3 cases are caused by Chlamydia or Gonorrhoea Partners need testing and treatment Even mild PID may cause significant long-term morbidity Severity of symptoms is not related to the risk of complications Maintain a low threshold for diagnosis in young sexually active women Delaying treatment increases the risk of reproductive morbidity Diagnosis remains unsatisfactory - no perfect diagnostic test and the outcome in individual patients is uncertain Condoms to prevent STIs are important

  38. Sexual Health Education • 1. PG Certificate in Sexual Health • 4 post graduate subjects by distance or in classroom at MSHC • 2. Masters of Public Health (with a specialised Sexual Health Stream) • 3. Nurses Pap Smear Accredited course • Clinical Sexual and Reproductive Health for Nurses (incl HIV counselling) • 4. Short Courses on STIs • 5. Pre and Post test HIV counselling courses • MSHC and Melbourne School of Population Health, University of Melbourne • http://www.sph.unimelb.edu.au http://www.mshc.org.au • Contact: Hennie Williams 03 9341 6249 hwilliams@mshc.org.au

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