It’s related problems

1. Pelvic Inflammatory Diseases It’s related problems Long Sui M.D., Ph.D. Obstetrics & Gynecology Hospital Fudan University E-mail: suilong@sh163.net 复旦大学附属妇产科医院

2. Contents： PID related Terms & Definition Diagnosis & Treat for PID New Guideline for Diagnosis & Treat of PID The implication of traditional Chinese medicine on the treatment of PID 复旦大学附属妇产科医院

3. Keystones • What is PID? • How common is PID? • How do women get PID? • What are the signs and symptoms of PID? • What are the complications of PID? • How is PID diagnosed? • What is the treatment for PID? • How can PID be prevented?

4. PID（2010 CDC） • Definition:PID is caused by micro-organisms colonizing the endocervix ascending to the endometrium and fallopian tubes. It is a clinical diagnosis implying that the patient has upper genital tract infection and inflammation. • The inflammation may be present at any point along a continuum that includes endometritis, salpingitis, and peritonitis. • Salpingal tubes is most common site. 输卵管炎 salpingitis 子宫内膜炎 endometritis PIDs • 盆腔腹膜炎 • peritonitis • 输卵管卵巢脓肿 • tubo-ovarian abscess,TOA

7. Inflammatory Sequelae(after effect)（2006 CDC） Ectopic Pregnancy Pelvic adhesion Chronic Pelvic Pain salpingo-oophoritis（subacute or atypical） Infertility chronic pelvic inflammatory disease: not anymore！！

8. Epidemiology

9. Epidemiology • In the United States, more than 750,000 women are affected by PID each year, and the rate is highest with teenagers and first time mothers. • PID causes over 100,000 women to become infertile in the US each year. • N. gonorrhoea is isolated in 40–60% of women with acute salpingitis. C. trachomatis is estimated to be the cause in about 60% of cases of salpingitis, which may lead to PID. • However, not all PID is caused solely by STIs; organisms that are considered normal vaginal flora can be involved, and individual cases of PID can be due to either a single organism or a co-infection of many different species. • 10% of women in one study had asymptomatic Chlamydia trachomatis infection and 65% had asymptomatic infection with Neisseriagonorrhoeae. • It was noted in one study that 10–40% of untreated women with N. gonorrhoea develop PID and 20–40% of women infected with C. trachomitis developed PID.

10. 2006 CDC Guidelines 重视 非典型 病原体 关注 新特征 诊断 新标准 治疗 新指南 New Diagnostic Criteria Atypical Pathogen New Guideline New Features

11. Atypical Pathogen • Two sources of pathogens of PID： • Exogenous/extrinsic source • Endogenous source • Co-exist of these two sources occur in >50% of PIDs Adherence of N. gonorrhoeae

12. Exogenous/extrinsic source • N. gonorrhoeae • C. trachomatis • BV • mycoplasma • Mycoplasmagenitalium生殖支原体 • Mycoplasmaurealytium解脲支原体 • Etiology: atypical pathogen • CT implicated in many cases All women diagnosed with acute PID should tested for CT

13. Endogenous Pathogen • Endogenous microorganisms found in the vagina, parasitic bacteria • Aerobic bacteria and Anaerobic bacteria • 可以仅为aerobic bacteria需氧菌感染 • 也可以仅为anaerobe 厌氧菌感染 • Mix infection or polyinfection are common in the new data.

14. Distribution of Pathogens inPID,US N. gonorrhoeae C. trachomatis Landers D V, et al. Am J Obstet Gynecol, 1991, I64(3); 849~59

15. Distribution of Pathogens inPID,China N. gonorrhoeae mycoplasmahominis mycoplasmahominis C. trachomatis C. trachomatis N. gonorrhoeae ZG ZhengTianjin Med2003，5；3（5） DYSun，孙道媛 1672-4488(2003)04-0471-0 （n=200）

16. Distribution of Pathogens inPID,Guangzhou With different objects,research item and methods，non-RCT data！

17. Diagnosis

18. Diagnosis • Traditionally, the diagnosis of PID has been based on a triad of symptoms and signs, including pelvic pain, cervical motion and adnexal tenderness, and the presence of fever. • It is now recognized that there is wide variation in many symptoms and signs among women with this condition, which makes the diagnosis of acute PID difficult. • The clinical diagnosis is roughly incorrect due to the inactive or concealed symptoms and signs • PPV for symptomatic PID was only about 65～90% • With high PPV in some special group（active sexual intercourse and STD clinic）

19. Concern for New Characteristics • It is now recognized that there is wide variation in many symptoms and signs among women with this condition, which makes the diagnosis of acute PID difficult. • Some women may develop PID without having any symptoms. • The diagnosis of PID should be considered in women with any genitourinary symptoms, including, but not limited to, lower abdominal pain, excessive vaginal discharge, menorrhagia, metrorrhagia, fever, chills, and urinary symptoms . A triad of PID cervical motion and adnexal tenderness Fever Pelvic Pain

20. New Criteria for PID minimum criteria (最低诊断标准) Uterine tenderness Adnexal tenderness Cervical motion tenderness 2006 CDC Guidelines 《Chineses Guideline Protocol for PID》 Sensitivity will become lowered if a triad was necessary simultaneously

22. Differential diagnosis

23. Differential diagnosis • Appendicitis, ectopic pregnancy, septic abortion, hemorrhagic or ruptured ovarian cysts or tumors, twisted ovarian cyst, degeneration of a myoma, and acute enteritis must be considered. • A sensitive serum pregnancy test should be obtained to rule out ectopic pregnancy. Culdocentesis will differentiate hemoperitoneum (ruptured ectopic pregnancy or hemorrhagic cyst) from pelvic sepsis (salpingitis, ruptured pelvic abscess, or ruptured appendix). • No single test has adequate sensitivityand specificity to diagnose pelvic inflammatory disease.

24. Pelvic and vaginal ultrasounds are helpful in the differential diagnosis of ectopic pregnancy of over six weeks. • Laparoscopy is often utilized to diagnose pelvic inflammatory disease, and it is imperative if the diagnosis is not certain or if the patient has not responded to antibiotic therapy after 48 hours.

25. Advantages & Disadvantages on Laparoscopy Advantages Disadvantages • Unacceptable • Unable to diagnose on mild salpingitis • Cannot observe the endometrium • Direct visual monitoring and diagnosis • Pathogen analysis through sampling • Integration of Diagnosis & Treat No single case history ,positive sign or symptom or lab test could be sensitive and specific at the same time

26. Prognosis

27. Prognosis • This makes early identification by someone who can prescribe appropriate curative treatment very important in the prevention of damage to the reproductive system. • Since early gonococcal infection may be asymptomatic, regular screening of individuals at risk for common agents (history of multiple partners, history of any unprotected sex, or people with symptoms) or because of certain procedures (post pelvic operation, postpartum, miscarriage or abortion). • If the initial infection is mostly in the lower tract, after treatment the person may have few difficulties. If the infection is in the fallopian tubes or ovaries, more serious complications are more likely to occur.

28. Complications Complications Delayed Even subtle or mild PID Ectopic Pregnancy Recurrent PID Chronic Pelvic Pain What does “delayed” mean？ Infertility

29. Treatment

30. Basic Rules for Treatment of PID • Therapy regimens for PID must provide empirical, broad-spectrum coverage of likely pathogens, including N. gonorrhoeae, C. trachomatis, gram-negative facultative bacteria, anaerobes, and streptococci.

31. Principle of Treatment on PID • Antibiotics which must be empirical, broad-spectrum coverage of likely pathogens,surgical treatment will be carried out if necessary. • Majority of PID could be cured through proper application of antibiotics • Full dose and in time administration was important for treatment of PID,otherwise some complication will be arised.

32. Antibiotics Empirical Administration of Antibiotics Broad-spectrum coverage prompt individual Antibiotics should be administered before the result of drug sensitive test comes out

33. Treat Promptly • Timely（24～48hrs）and proper therapy with antibiotics • Eliminate pathogen • Meliorate symptom and sign • Decrease complication

34. Indication for Surgery Tube-Ovarian abscess or pelvic abscess after 48-72hrs of therapy Persistent symptom and sign of PID Laparotomy must be carried out once ruptured abscess with antibiotics administration simultaniously Rupture of Abscess No respond to antibiotics Lasting abscess

35. Outpatients • Regimen A Cefoxitin, 2 g intramuscularly, plus probenecid, 1 g orally concurrently, or Ceftriaxone, 250 mg intramuscularly, or Equivalent cephalosporin Plus: Doxycycline, 100 mg orally 2 times daily for 14 days With or without: Metronidazole, 500 mg orally 2 times daily for 14 daysa • Regimen B Ofloxacin, 400 mg orally 2 times daily for 14 days, or Levofloxacin, 500 mg orally once daily for 14 days With or without: Metronidazole, 500 mg orally 2 times daily for 14 daysa

36. Inpatients • Regimen A Cefoxitin, 2 g intravenously every 6 hours, or Cefotetan, 2 g intravenously every 12 hours, Plus: Doxycycline, 100 mg orally or intravenously every 12 hours • Regimen B Clindamycin, 900 mg intravenously every 8 hours Plus: Gentamicin, loading dose intravenously or intramuscularly (2 mg/kg of body weight) followed by a maintenance dose (1.5 mg/kg) every 8 hours • aUse of metronidazolerecommended in those cases in which bacterial vaginosis is diagnosed concurrently with PID. • Adapted from Centers for Disease Control and Prevention.The sexually transmitted diseases treatment guidelines. Centers for Disease Control and Prevention, 2002; MMWR 2002; 51: RR-6. with permission.

37. Criteria for hospitalization clinical disease is severe,withnausea,vomiting or high fever the diagnosis is uncertain,surgical emergency could not be excluded(appendicitis) compliance with an outpatient regimen is in question Pregnant women with PID pelvic abscess is suspected No effect to orally antibiotics

38. Criteria for discharge • Hospitalized patients can be considered for discharge when 1.their fever has lysed (99.5°F for more than 24 hours) 2.the white blood cell count has become normal 3.rebound tenderness is absent 4.repeat examination shows marked amelioration of pelvic organ tenderness

39. For sexual partners Sexual partners of women with PID should be evaluated and treated for urethral infection with chlamydia or gonorrhea. One of these STDs usually is found in the male sexual partners of women with PID not associated with chlamydia or gonorrhea.

40. Tubo-ovarian Abscess

41. Tubo-ovarian Abscess • An end-stage process of acute PID, tubo-ovarian abscess is diagnosed when a patient with PID has a pelvic mass that is palpable during bimanual examination. The condition usually reflects an agglutination of pelvic organs (tube, ovary, bowel) forming a palpable complex. • Tubo-ovarian abscess is treated with an antibiotic regimen administered in a hospital . About 75% of women with tubo-ovarian abscess respond to antimicrobial therapy alone. • Failure of medical therapy suggests the need for drainage of the abscess . Although drainage may require surgical exploration, percutaneous drainage guided by imaging studies (ultrasound or computed tomography) should be used as an initial option if possible. Trocar drainage, with or without placement of a drain, is successful in up to 90% of cases in which the patient failed to respond to antimicrobial therapy after 72 hours.

42. Prevention

43. Prevention • Risk reduction against sexually transmitted infections through barrier methods such as condoms. • Going to the doctor immediately if symptoms of PID, sexually transmitted infections appear, or after learning that a current or former sex partner has, or might have had a sexually transmitted infection. • Getting regular gynecological (pelvic) exams with STI testing to screen for symptomless PID. • Discussing sexual history with a trusted physician in order to get properly screened for sexually transmitted diseases. • Getting a STI history from your current partner and insisting they be tested and treated before intercourse. • Treating partners to prevent reinfection or spreading the infection to other people. • Diligence in avoiding vaginal activity, particularly intercourse, after the end of a pregnancy (delivery, miscarriage, or abortion) or certain gynecological procedures, to ensure that the cervix closes.

44. Q & A • What is PID? • How common is PID? • How do women get PID? • What are the signs and symptoms of PID? • What are the complications of PID? • How is PID diagnosed? • What is the treatment for PID? • How can PID be prevented?

45. THANKS FOR YOUR ATTENTION