Pelvic inflammatory disease (PID) is a group of diseases caused by infections in the upper female reproductive tract, including endometritis, tubal inflammation, tubo-ovarian abscesses and pelvic peritonitis. Pathogens of sexually transmitted infections such as Neisseria gonorrhoeae and Chlamydia trachomatis are the main causative organisms of PID. Some aerobic and anaerobic bacteria, viruses and mycoplasma are also involved in the development of PID.
Most of the causative microorganisms causing PID come from the vagina upstream and are mostly mixed infections. Delay in the diagnosis and effective treatment of PID may lead to sequelae of PID such as tubal infertility and ectopic pregnancy.
1. Diagnosis of PID
The clinical manifestations of PID vary, so the diagnosis is usually based on a combination of clinical symptoms, signs and laboratory tests.
Minimum criteria for the diagnosis of PID: In sexually active women and others at risk for STI, PID should be diagnosed and empirical treatment for PID should be given if other etiologies are excluded and one of the following conditions is met: the likelihood of diagnosis of PID increases when lower abdominal pain is accompanied by signs of infection in the lower genital tract.
Uterine pressure pain;
Adnexal pressure pain;
painful cervical lifting.
Additional criteria for the diagnosis of PID.
Oral temperature ≥ 38.3°C;
Purulent discharge from the cervix or vagina;
Microscopic examination of vaginal discharge with leukocytosis;
Elevated erythrocyte sedimentation rate;
Elevated C-reactive protein level;
Laboratory tests confirm the presence of cervical Neisseria gonorrhoeae or Chlamydia trachomatis infection. Most patients with PID have purulent cervical discharge or leukocytosis on microscopic examination of vaginal secretions.
If the cervical discharge is normal in appearance and there are no leukocytes on microscopic examination of vaginal secretions, the diagnosis of PID is unlikely and other possible causes of lower abdominal pain need to be considered. If available, the pathogenic microorganisms, especially those associated with STI, should be actively sought.
Specific criteria for the diagnosis of PID.
Endometrial biopsy showing histopathological evidence of endometritis ;
Transvaginal ultrasonography or MRI showing thickening of the tubal wall and fluid accumulation in the lumen, which may be accompanied by free pelvic fluid or tubo-ovarian masses;
Laparoscopy shows obvious congestion on the surface of the fallopian tubes, tubal edema, and purulent exudate at the umbilical end of the fallopian tubes or in the plasma membrane layer.
2.Treatment of PID
2.1 Treatment principles
Antibacterial drug therapy is the main treatment, and surgical treatment is performed if necessary. Broad-spectrum antimicrobial drugs are selected based on experience to cover possible pathogens, including Neisseria gonorrhoeae, Chlamydia trachomatis, mycoplasma, anaerobes and aerobes.
All treatment regimens must be effective against Neisseria gonorrhoeae and Chlamydia trachomatis, and the absence of positive microbiological findings in the endometrium and cervix does not exclude upper genital tract infections due to Neisseria gonorrhoeae and Chlamydia trachomatis.
The recommended treatment regimen antimicrobial spectrum should cover anaerobic bacteria.
Treatment should be started immediately after diagnosis, and timely and rational application of antimicrobial drugs is directly related to long-term prognosis.
Safety, efficacy, economy, and patient compliance should be taken into account when choosing a treatment regimen.
The method of administration: intravenous or non-intravenous administration and the need for hospitalization should be decided according to the severity of the disease.
2.2 Antimicrobial drug therapy
2.2.1 Intravenous drug therapy
Intravenous dosing regimen A.
Monotherapy: second-generation cephalosporins or third-generation cephalosporins antibacterial drugs are administered intravenously, and the dosing interval is decided according to the half-life of the specific drug, such as cefotetan 2g/12h, intravenously; or cefoxitin 2g/6h, intravenously; or ceftriaxone lg/24h, intravenously.
Combination of drugs: If the selected drugs do not cover anaerobic bacteria, additional nitroimidazoles, such as metronidazole 0.5g/12h, intravenous drip, are required. To cover atypical pathogenic microorganisms, doxycycline 0.1g/12h, orally, ×l4d; or minocycline 0.1g/12h, orally, ×l4d; or azithromycin 0.5g/d, intravenously or orally, and after 1~2d change to oral 0.25g/d, 5~7d.
Intravenous administration of regimen B.
Ofloxacin 0.4g/12h, IV drip; or Levofloxacin 0.5g/d, IV drip. To cover anaerobic infections, nitroimidazoles, such as metronidazole 0.5g/12h, intravenously, can be added.
Intravenous administration of regimen C.
Ampicillin sodium sulbactam 3g/6h, intravenously; or amoxicillin potassium clavulanate 1.2g/(6~8)h, intravenously. To cover anaerobic bacteria, nitroimidazoles, such as metronidazole 0.5g/12h, intravenously, can be added.
To cover atypical pathogenic microorganisms, doxycycline 0.1g/12h, orally, ×14d; or minocycline 0.1g/12h, orally, ×14d; or azithromycin 0.5g/d, intravenously or orally, and after 1~2d, change to oral 0.25g/d, 5~7d.
Intravenous dosing regimen D.
Lincomycin dose 0.9g/8h, intravenous drip; add gentamicin sulfate, the first loading dose of 2mg・kg-1・8h-1 intravenous drip or intramuscular injection, maintenance dose 1.5mg.kg-1・8h-1; both drugs can be administered once a day.
2.2.2 Non-intravenous drug therapy
Non-intravenous drug administration regimen A.
Ceftriaxone 250mg, intramuscular injection, single dose; or cefoxitin 2g, intramuscular injection, single dose. After single intramuscular administration, change to other second- or third-generation cephalosporins, such as ceftizoxime and cefotaxime, for oral administration for a total of 14 d.
If the selected drug does not cover anaerobic bacteria, additional nitroimidazoles are required, such as metronidazole 0.4g/12h, orally; for the treatment of atypical pathogenic microorganisms, doxycycline 0.1g/12h, orally (or minocycline 0.1g/12h, orally); or azithromycin 0.5g/d, orally, and after 1~2d change to 0.25g/d, 5~7
Non-IV administration of regimen B.
Ofloxacin 0.4g/12h, orally; or levofloxacin 0.5g/d, orally; to cover anaerobic bacteria can add metronidazole 0.4g/12h, orally, for 14d.
2.2.3 Precautions for drug administration
Those administered intravenously should continue intravenous treatment for at least 24h after clinical symptoms improve, and then switch to oral drug therapy for a total of 14d.
If the diagnosis of Neisseria gonorrhoeae infection is confirmed, intravenous regimen A or non-intravenous regimen A is preferred, and drugs targeting Neisseria gonorrhoeae should be added for those who choose non-triple cephalosporins. Close attention should be paid to the ear and renal toxicities of the drug if intravenous regimen D is chosen.
In addition, occasional serious neurological adverse events have been reported with the combination of lincomycin and gentamicin. Those whose symptoms do not improve significantly after 72 h of drug treatment should reconfirm the diagnosis and adjust the treatment regimen.
2.3 Surgical treatment
Indications for surgery.
Drug therapy is ineffective. Tubal or ovarian abscess or pelvic abscess should be operated promptly if the temperature does not decrease continuously, the symptoms of infection poisoning do not improve or the mass increases after 48~72h of drug treatment.
Persistence of mass. If the mass persists or increases in size after more than 2 weeks of drug treatment, surgery should be performed.
Rupture of abscess. Abdominal pain suddenly increases, chills, high fever, nausea, vomiting, abdominal distension, examination of abdomen refusing to press or manifestation of infectious toxic shock, abscess rupture should be suspected. If abscess rupture is not treated in time, the mortality rate of patients is high. Therefore, once an abscess rupture is suspected, surgical exploration needs to be performed immediately along with antibacterial drug treatment.
Surgical approach: Surgery can be either transabdominal or laparoscopic depending on the situation. The scope of surgery should be considered comprehensively according to the extent of the lesion, the patient’s age, and general condition. The principle should be to remove the lesion. In young women, the ovaries should be preserved as much as possible.
In older women with bilateral adnexal involvement or repeated adnexal abscesses, total hysterectomy + bilateral adnexal resection is feasible; in extremely debilitated or critically ill patients, the scope of surgery must be decided on a case-by-case basis. If the pelvic abscess is low and protrudes toward the posterior vaginal vault, transvaginal incision and drainage can be performed.
2.4 Traditional Chinese medicine, Chinese herbal medicine and physiotherapy
Traditional Chinese medicine, herbal medicine and physical therapy have a role in the treatment of PID. On the basis of antibacterial drug treatment, supplemented with Chinese herbal medicine treatment such as Kangmu anti-inflammatory suppository, Gui Zhi Fu Ling capsule and Safflower Ruyi pill can reduce the occurrence of chronic pelvic pain sequelae.
2.5 Treatment of PID in pregnancy
Because PID during pregnancy increases the risk of maternal death, stillbirth, and preterm delivery, pregnant women with suspected PID are recommended to be hospitalized for intravenous antimicrobial drug treatment. Tetracyclines and quinolones are contraindicated in women during pregnancy and lactation.
2.6 Treatment of sexual partners
Sexual partners who have been in contact with a patient with PID within 60 d prior to the onset of symptoms are likely to be infected with Neisseria gonorrhoeae and Chlamydia trachomatis and should be tested and treated accordingly. If STI-associated pathogenic organisms are detected in patients with PID, sexual partners need to be treated at the same time.
During the treatment period of female PID patients, unprotected sexual intercourse must be avoided.
3.Follow-up after PID treatment
Patients with drug-treated PID should be followed up within 72h to clarify whether there is any improvement in clinical conditions, such as reduction of fever, abdominal pressure pain or rebound pain, reduction of uterine and adnexal pressure pain, and reduction of cervical lifting pain. If no improvement is seen then further investigations and adjustment of the treatment plan are recommended.
For PID patients with Chlamydia trachomatis and Neisseria gonorrhoeae infections, the above pathogens should also be re-examined 4-6 weeks after the end of treatment.
4. Prevention of PID
Screening of cervical secretions of high-risk women for Chlamydia trachomatis infection is quite common to Ы file the incidence of PID.
5.Diagnosis and management of lower abdominal pain
Lower abdominal pain is the main symptom of PID, but at present, the medical resources in China are unbalanced, and many primary hospitals are unable to make etiological diagnosis and necessary laboratory tests for acute PID, so that PID cannot be diagnosed and treated in a timely manner.
In order to better diagnose and treat PID, avoid the formation of sequelae of upper reproductive tract infection (tubal factor infertility and ectopic pregnancy), and ensure women’s health, the management of lower abdominal pain for women has practical value. However, when applied clinically, especially in the face of patients with acute lower abdominal pain, care should be taken to exclude other surgical or obstetrical and gynecological emergencies before administering antimicrobial drugs.