Pelvic inflammatory disease
Pelvic inflammatory disease: Excerpt from Handbook of Diseases
Pelvic inflammatory disease (PID) is any acute, subacute, recurrent, or chronic infection of the oviducts and ovaries, with adjacent tissue involvement. It includes inflammation of the cervix (cervicitis), uterus (endometritis), fallopian tubes (salpingitis), and ovaries (oophoritis), which can extend to the connective tissue lying between the broad ligaments (parametritis).
Early diagnosis and treatment prevents damage to the reproductive system. Untreated PID may cause infertility and may lead to potentially fatal septicemia, pulmonary emboli, and shock.
Causes
PID can result from infection with aerobic or anaerobic organisms. The aerobic organism Neisseria gonorrhoeae is its most common cause because it readily penetrates the bacteriostatic barrier of cervical mucus.
Normally, cervical secretions have a protective and defensive function. Therefore, conditions or procedures that alter or destroy cervical mucus (including conization or cauterization of the cervix) impair this bacteriostatic mechanism and allow bacteria present in the cervix or vagina to ascend into the uterine cavity.
Uterine infection can also follow the transfer of contaminated cervical mucus into the endometrial cavity by instrumentation. Consequently, PID can follow insertion of an intrauterine device (IUD), use of a biopsy curet or an irrigation catheter, or tubal insufflation. Other predisposing factors include abortion, pelvic surgery, and infection during or after pregnancy.
Bacteria may also enter the uterine cavity through the bloodstream or in drainage from a chronically infected fallopian tube, pelvic abscess, ruptured appendix, diverticulitis of the sigmoid colon, or other infectious foci.
The most common bacteria found in cervical mucus are staphylococci, streptococci, diphtheroids, chlamydiae, and coliforms, including Pseudomonas and Escherichia coli.
Uterine infection can result from one or several of these organisms or it may follow the multiplication of normally nonpathogenic bacteria in an altered endometrial environment. Bacterial multiplication is most common during parturition, because the endometrium is atrophic, quiescent, and not stimulated by estrogen.
Signs and symptoms
Clinical features of PID vary with the affected area but commonly include a profuse, purulent vaginal discharge, which is sometimes accompanied by low-grade fever and malaise (particularly if gonorrhea is the cause). The patient experiences lower abdomenal pain; movement of the cervix or palpation of the adnexa may be extremely painful. (See Forms of pelvic inflammatory disease, page 612.)
Diagnosis
Tests commonly used to diagnosis PID include:
❑ Gram stain of secretions from the endocervix or cul-de-sac; culture and sensitivity testing aids selection of the appropriate antibiotic. Urethral and rectal secretions may also be cultured.
❑ ultrasonography or computed tomography scanning to identify an adnexal or uterine mass. (X-rays seldom identify pelvic masses.)
❑ culdocentesis to obtain peritoneal fluid or pus for culture and sensitivity testing.
The patient’s history is also significant because PID is commonly associated with recent sexual intercourse, IUD insertion, childbirth, or abortion.
Treatment
To prevent the progression of PID, antibiotic therapy begins immediately after culture specimens are obtained. Such therapy can be reevaluated when laboratory test results are available (usually after 24 to 48 hours); infection may become chronic if treated inadequately.
The guidelines of the Centers for Disease Control and Prevention (CDC) for outpatient treatment include a single dose of cefoxitin plus probenecid given concurrently or a single dose of ceftriaxone. Each of these regimens is given with doxycycline for 14 days.
The CDC guidelines for inpatient treatment recommend doxycycline alone or a combination of clindamycin and gentamicin.
Development of a pelvic abscess necessitates adequate drainage. A ruptured abscess is life threatening. If this complication develops, the patient may need a total abdominal hysterectomy with bilateral salpingo-oophorectomy.
Special considerations
❑ After establishing that the patient doesn’t have drug allergies, administer antibiotics and analgesics as necessary.
❑ Check for fever. If it persists, carefully monitor fluid intake and output, watching the patient for signs of dehydration.
❑ Watch for abdominal rigidity and distention, possible signs of developing peritonitis.
❑ Provide frequent perineal care if vaginal drainage occurs.
❑ To prevent a recurrence, explain the nature and seriousness of PID, and encourage the patient to comply with the treatment regimen.
❑ Stress the need for the patient’s sexual partner to be examined and, if necessary, treated for infection.
❑ Because PID may cause painful intercourse, advise the patient to consult with her physician about sexual activity.
CLINICAL TIP: To prevent infection after minor gynecologic procedures, such as dilatation and curettage, tell the patient to immediately report any fever, increased vaginal discharge, or pain. After such procedures, instruct her to avoid douching and intercourse for at least 7 days.
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Book Source Details
- Book Title: Handbook of Diseases
- Author(s): Springhouse
- Year of Publication: 2003
- Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Handbook of Diseases
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2003
ISBN: 1-58255-266-5
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