ch 4. Pelvic Inflammatory Diseases (PID)

Posted: May 13, 2012 in Gynocology

Classifications :

  1.  Lower female reproductive tract Infections, including the vagina and cervix.
  2. Upper female reproductive tract Infections, including the uterus and fallopian tubes.
  3. Inflammations to the adjacent pelvic structures in the pelvis and abdomen, including perihepatic structures (Fitz-Hugh Curtis syndrome).

Etiology :

Normal flora has a significant role in defense against infection by genital pathogens. The female genital tract, especially the vaginal secretions, contain from 108 to 109 bacteria per gram of fluid examined.

Lactobacilli produce lactic acid from glucose keeping the vagina at an acidic pH (3,8-4,2). Glycogen is metabolized by vaginal epithelial cells to glucose, which then serves as a substrate for Lactobacillus.Vaginal acidity depends on adequate levels of estrogens as well as the presence of lactic acid-producing bacteria such as Lactobacilli. Concentrations of lactobacilli are probably important determinants of vaginal pH as well. The increased concentration of lactic acid producing bacteria in the vaginal fluid may result in a lower pH which determines decreased susceptibility to infection. Estrogens have a direct effect on the number of organisms and composition of the bacterial flora

Lactobacillus (70-90%), Staphylococcus epidermalis (30-60%), diphteroids (30-60%), Hemolytic Streptococci (10-20%), nonhaemolytic streptococci (5-30%), Escherichia coli (20-25%), Bacte-roides (5-15%), Peptococcus (10-60%), Peptostreptococcus (10-40%), Clostridium (5-15%).

Risk Factors :

  • Age less than 25 years
  • Intrauterine device
  • Multiple sex partners
  • Previous history of pelvic inflammatory disease or sexually transmitted disease
  • Regular vaginal douching
  • Sexual intercourse with a male infected with Chlamydia or gonorrhea
  • Unprotected sexual intercourse

Bartholinitis :

Bartholinitis is an inflammation of Bartholin’s gland (large gland of vaginal vestibule). It may be caused by Staphylococcus, E.coli and N. gonorrhea. Any type of the pathogen initiates ductal inflammation and obstruction that can lead to Bartholin’s abscess. There can be serous, serous-purulent, or purulent inflammation.Infection of Bartholin’s glands can lead to secondary infections, abscess or cyst formation.

If the infection of gland is caused by N.gonorrhea specific antibacterial treatment is prescribed.

Vulvitis :

Vulvitis is a vulvar inflammation. It may be primary and secondary.

  1. Primary vulvitis is caused by local irritants (including feminine hygiene sprays, deodorants, tight-fitting synthetic undergarments in women with obesity or diabetes mellitus.
  2. Secondary vulvitis are caused by accompanying discharge from vagina.Long-term dermatitis, seborrhea or eczema.Infections such as fungal and bacterial infections, pediculosis, or scabies.

To relieve inflammation and itching the main suspected cause must be removed The therapy includes local application of (cortisone ointment two or three times a day) boric acid solution or KMn04 solution Candidasis is treated with Gyno-pavenl 150mg in suppositories — 3 days, or Orungal lOOmg twice a day during 6-7 days orally, and then one capsule per day every first day of menstrual cycle during 3-6 cycles. Treatment with local antibiotics and steroids is successful

Anatomy of Vulva

Vulvitis after Herpes Virus Infection

Bacterial Vaginosis :

BV  is caused by an imbalance of naturally occurring bacterial flora and is often confused with yeast infection (candidiasis), or infection with Trichomonas vaginalis (trichomoniasis), which are not caused by bacteria.The microorganisms involved in BV are very diverse, but include Gardnerella vaginalis, Mobiluncus, Bacteroides, and Mycoplasma. A change in normal bacterial flora including the reduction of Lactobacilli, which may be due to the use of antibiotics or pH imbalance, allows more resistant bacteria to gain a foothold and multiply.

Non-bacterial Vaginitis

Cervicitis :

Endocervicitis is the inflammation of mucosa layer of the endocervix. Bacteria cause infection of the columnar epithelium. Chlamydia trachomatis, Mycoplasma, Trichomonas vaginalis, N. Gonorrhoeae, Herpes Simplex, viruses, Candida, E.coli, and Staphylococci cause Cervicitis.

Acute endometritis :

Acute endometritis is an inflammation of endometrium (mucus layer of uterine). It may occur in such cases as: endometritis after uterine curettage or suction and puerperal endometritis. Endometritis is caused by bacteria, viruses, mycoplasma.

There are nonspecific and specific endometritis. Specific endometritis is caused by M. Tuberculosis, N. Gonorrhea, Chlamidia trachomatis, Actinomyces.

Curettage

Chronic endometritis :

Chronic endometritis is a sequale of untreated acute endometritis or nona-dequate treatment of postabortion or purperal endometritis. The chronic endometritis sometimes is associated with the use of intrauterine device (IUD). In some cases it may occur without acute stage.The chronic endometritis results from organisms that are normally in lower genital tract (Protei, E. Coli, Staphylococcus, Mycoplasma).

Intra-Uterine Device

Parametritis :

Parametritis is an inflammation of parametrium (Connective Tissue adjacent to the Uterus). Inflammation of the whole pelvic cellular is called pelviocellulitis. According to international statistics these diseases are classified as acute parametritis or pelvic phlegmona.

Infection agents may be staphyloccocus, streptoccocus, E.coli, etc. It can be caused by one microbic agent or microbe association.

Salpingo oophoritis :

Salpingo oophoritis is the inflammation of the uterus lining, fallopian tubes, or ovaries. Salpingo oophoritis is the most frequent among all pelvic inflammatory diseases. Most cases of oophoritis are secondary to salpingitis. The ovaries become infected by the purulent material that escapes from fallopian tube. If the tubal fimbriae are adherent to the ovary, the tube and ovary together may form a large retort-shaped tubo-ovarian abscess.

Most patients with salpingoophoritis have lower abdominal, adnexal tenderness (unilateral or bilateral) purulent cervical exudate or purulent vaginal discharge

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