Pelvic inflammato-disease (PID) refers to a group of disorders caused by inflammation of the upper female reproductive tract, including endometritis, tubal inflammation, ovarian inflammation, pelvic peritonitis, and pelvic connective tissue inflammation.
Diagnostic points
1. Etiology of the pathogens causing pelvic inflammatory disease.
Sexually transmitted infection (Sn) pathogens such as Neisseria gonorrhoeae, Chlamydia trachomatis are the main causative agents, other infections may include aerobic bacteria, anaerobic bacteria, chlamydia and mycoplasma and viruses. Long Tengfei, Department of Gynecology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University
2, the route of infection vascular and lymphatic system spread, such as pelvic tuberculosis; through the genital erectile membrane or direct spread of dissemination, such as sexually transmitted diseases such as gonorrhea, chlamydia infection, etc.
3, clinical manifestations
(1) Acute pelvic inflammatory disease.
Increased leucorrhea, pain in the lower abdomen, purulent or pus-blood leucorrhea with foul odor; some patients have fever and rectal bladder irritation symptoms, irregular menstruation.
Physical examination: pressure pain in the uterine body and adnexal region, painful cervical lifting, palpable painful masses.
Blood count: elevated white blood cell count.
(2) Chronic pelvic inflammatory disease.
Increased leucorrhea and soreness in the lumbar region.
Physical examination: thickening of the adnexal region, pressure pain is not obvious.
Routine blood: white blood cell count is often not high.
4. Diagnostic criteria (Chinese Society of Obstetrics and Gynecology, Infectious Diseases Collaborative Group, 2008)
Minimum diagnostic criteria: uterine pressure pain, or; adnexal pressure pain, or; cervical lifting pain; the likelihood of diagnosis is greatly increased in patients with lower abdominal pressure pain accompanied by signs of infection in the lower genital tract.
Additional conditions supporting the diagnosis.
Oral temperature of 38.3 °C; purulent cervical or vaginal discharge; leukocytosis on microscopic examination of vaginal secretions; accelerated hematocrit; elevated C-reactive protein level; laboratory tests confirming cervical Neisseria gonorrhoeae or Chlamydia trachomatis infection.
Specific diagnostic criteria: endometrial biopsy showing pathological histological evidence of endometritis; transvaginal ultrasonography or MRI showing thickening of the tubal wall and fluid accumulation in the tubal lumen; may be accompanied by free fluid in the pelvis or tubo-ovarian mass; laparoscopic findings consistent with pelvic inflammatory manifestations.
5. Differential diagnosis should exclude appendicitis, ruptured ovarian endometriotic cyst, ectopic pregnancy, ruptured corpus luteum cyst, etc.
Treatment principles and protocols
(A) Treatment principles
1. Anti-infective treatment with antibiotics should be the main treatment, and surgical treatment should be performed if necessary.
2, drug treatment should be based on the pathogenic bacteria drug sensitivity test selection of antibiotics, patients need to be empirical treatment before obtaining drug sensitivity results, according to the severity of the disease to choose the possible ways and antibacterial drugs.
3. Broad-spectrum antibiotics are selected empirically to cover possible pathogens, including Neisseria gonorrhoeae, Chlamydia trachomatis, mycoplasma, anaerobes and aerobes.
(1) All treatment regimens must be effective against Chlamydia trachomatis of Neisseria gonorrhoeae.
(2) The antimicrobial spectrum should cover anaerobic bacteria in the currently recommended treatment regimens.
(3) Treatment should be initiated immediately upon diagnosis.
(4) The choice of treatment regimen should take into account factors such as effectiveness, cost, patient compliance and drug sensitivity.
(5) Appropriate Chinese medicine and herbal treatment can also play a certain effect.
(B) drug treatment
1, non-intravenous drug treatment (or outpatient treatment): patients in good general condition, mild symptoms, can tolerate oral antibiotics, with follow-up conditions, can be outpatient treatment.
(1) Preferred drug: Ofloxacin plus metronidazole orally, 2 times/day for 14 days; or levofloxacin plus metronidazole orally, 2 times/day for 14 days; or moxifloxacin 400mg orally, 1 time/day for 14 days.
(2) Secondary drugs: Ceftriaxone 250mg, intramuscular injection, single administration; or cefoxitin 2g, intramuscular injection, plus propofol 1g, oral, both single administration; or other three generations of cephalosporins, non-intravenous administration, plus doxycycline, oral, 1 time / 12 hours; or minocycline l00mg, oral, 1 time / 12 hours; or azithromycin 0 .5g, oral, 1 time / 12 hours for 14 days, and may be supplemented with metronidazole 50Omg, orally, 2 times/day for 14 days. Where cefoxitin provides better coverage of anaerobic bacteria, ceftriaxone provides better coverage of Neisseria gonorrhoeae.
Note: If oral medication continues for 72 hours without significant improvement in symptoms, the diagnosis should be reconfirmed and the treatment regimen adjusted.
2.Intravenous drug therapy (or hospitalization)
(1) Preferred drug: Cefotetan 2g, intravenous infusion, 1 time/12 hours; or Cefoxitin 2g , 1 time/6 hours. Add: Doxycycline l00mg, orally, 1 time/12 hours or Minocycline 100mg, orally, 1 time/l2 hours; or Azithromycin 0 .5g, intravenously or orally, 1 time/12 hours.
Caution.
① Other second- or third-generation cephalosporins may also be effective against PID and may replace cefotetan and cefoxitin, the latter two of which have a stronger anti-anaerobic
The latter two are more effective against anaerobic bacteria.
②In patients with tubal and ovarian abscesses, the addition of clindamycin or metronidazole to doxycycline (or minocycline or azithromycin) is usually more effective against anaerobic bacteria.
③In patients with tubal and ovarian abscesses, the application of doxycycline (or minocycline or azithromycin) plus metronidazole or doxycycline (or minocycline or azithromycin) plus clindamycin is more effective than doxycycline (or minocycline or azithromycin) alone in treating anaerobic bacterial infections.
(4) After clinical symptoms improve, continue intravenous administration for at least 24 hours, then switch to oral drug therapy for a total of 14 days.
(2) Secondary drug of choice: clindamycin, intravenous drip, 1 time/8 hours. Add a loading dose of gentamicin sulfate (2mg/kg) by intravenous drip or intramuscular injection; once-daily dosing is also possible.
Caution.
①Continue intravenous administration for at least 24 hours after clinical symptoms improve and continue oral clindamycin 450mg ,once a day for 14 days.
② Pay attention to the toxic side effects of gentamicin sulfate.
Preferred drug replacement regimen.
(1) Ofloxacin 400mg, IV, 1 time/12 hours, plus metronidazole 500mg, IV, or levofloxacin IV, 1 time/day, plus metronidazole, IV, 1 time/8 hours; or moxifloxacin 400mg, IV, 1 time/day.
(2) Aminoglin sulbactam sodium 3g, intravenous drip, plus: doxycycline 100mg ,oral, 1 time /l2 hours, or minocycline 100mg, oral, 1 time /12 hours; or azithromycin 0 .5g, intravenous drip or oral, 1 time / day.
[Aftereffective lesions]
1, improper diagnosis and treatment will increase the chance of sequelae of pelvic infection: up to 25% of patients relapse, pelvic
The incidence of infertility after pelvic inflammatory disease is 20% a 30%.
The incidence of ectopic pregnancy after pelvic inflammatory disease is 8 to 10 times higher than that of normal women.
3. About 20% of acute pelvic inflammatory episodes are followed by chronic pelvic pain.
4, due to the destruction of tubal tissue structure caused by PID, local defense function is reduced, can cause pelvic inflammatory re-infection resulting in recurrent episodes, with a history of PID, about 25% will have another episode.
5. pelvic abscess.
Diagnostic points] Acute pelvic inflammatory disease is treated with antibiotics for 3-5 days and the body temperature is still high, symptoms of peritonitis appear, pelvic examination, B ultrasound and mass aspiration can be clearly diagnosed.
Treatment principle】According to the severity of the disease, the size of the abscess, age, the requirements for fertility and whether there is a history of inflammation
The treatment is individualized according to the severity of the disease, the size of the abscess, the age, the requirement for fertility and the history of recurrent inflammation.
1.Unruptured abscess
(1) For the first time, apply intravenous antibiotics for 72 hours, and consider surgery if it is ineffective.
(2) If the signs of peritonitis are not serious, the abscess is
(3) Signs of peritonitis are heavy, the abscess is large and multifocal, and it is difficult to drain the abscess completely with a single puncture. or
When the abscess site is high and puncture is difficult, laparoscopic surgical treatment is appropriate.
2.Abscess rupture
(1) Those with total abdominal peritonitis and toxic symptoms should be treated with active supportive therapy.
(2) Use antibiotics and perform emergency dissection or laparoscopic surgical drainage at the same time.
3.Surgical indications
(1) Bilateral masses and masses >5-8cm in diameter.
(2) The intravenous application of antibiotics for 72 hours is ineffective.
(3) Persistence of masses despite good anti-inflammatory response.
(4) Abscess rupture.
4.Surgical methods
(1) Drainage: incision through the abdominal wall or posterior curvilinear ridge; puncture and drainage under ultrasound or CT guidance.
(2) Laparoscopy: separation of adhesions, aspiration of pus and necrotic tissue, and flushing of pelvic cavity.
(3) Conservative or radical surgery according to age and fertility requirements. For patients with small abscesses that may remain, or patients with recurrent episodes due to unresected chronic lesions and no fertility requirements, surgical removal of the adnexa is feasible, and if necessary, the uterus can be removed at the same time, with adequate postoperative drainage.