Pelvic inflammatory disease: clinical approach
文摘
科学
2024-07-23 19:14
澳大利亚
If you would like to view past exciting content, please click on the following link.Pelvic inflammatory disease (PID) is a condition characterized by inflammation that may involve the uterus, fallopian tubes, ovaries, and peritoneum. It is frequently caused by sexually transmitted pathogens such as gonorrhea and chlamydia, but can also arise from microorganisms typically found in the vaginal flora.Salpingitis, or inflammation of the fallopian tubes, significantly increases the risks of infertility and ectopic pregnancy, whereas peritonitis may result in pelvic adhesions and ongoing pelvic pain. Notably, even mild cases of PID can lead to these complications. The clinical presentation of PID varies greatly, from asymptomatic or mild symptoms to severe cases that include intense pelvic pain or sepsis.When evaluating a patient whose primary concern may indicate PID, begin with a CABCDE assessment to determine their stability. An unstable condition often points to sepsis.For unstable patients, prioritize securing their airway, breathing, and circulation immediately. This may involve intubation, establishing IV access, and continuous vital signs monitoring. Also, conduct an HCG pregnancy test without delay.Following initial stabilization, proceed with a thorough history and physical examination. Common symptoms reported include fever, nausea, vomiting, lower abdominal and pelvic pain, unusual vaginal discharge, and spotting between periods or after intercourse.It’s crucial to remember that upper abdominal pain may suggest perihepatitis, or Fitz-Hugh-Curtis syndrome, which occurs when pathogens from PID infect the area around the liver and diaphragm, causing inflammation of the liver capsule without affecting the liver tissue itself and forming "violin string" adhesions that can mimic gallbladder issues.During the physical examination, look for signs of sepsis such as increased temperature, low blood pressure, and rapid heart rate. Assess the abdomen for general tenderness, possibly with rebound pain or guarding. The pelvic exam is vital for identifying signs of cervicitis like swelling and inflammation, mucopurulent discharge from the cervix, and tenderness of the cervix, uterus, and adnexal areas. An adnexal mass may indicate a tubo-ovarian abscess.If PID with sepsis is suspected, initiate treatment with IV fluids and targeted antibiotics. Also, perform comprehensive lab tests including a complete blood count, chemistry panel, and lactate levels, as well as blood cultures and nucleic acid amplification testing (NAAT) to detect the responsible pathogens. Consider consulting gynecologic surgery if exploration is deemed necessary.For stable patients, start with a focused history, physical examination, and lab tests such as vaginal discharge microscopy, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and NAAT for gonorrhea and chlamydia.Remember, pathogens other than gonorrhea and chlamydia, including Trichomonas vaginalis, bacterial vaginosis, Mycoplasma genitalium, cytomegalovirus, and typical vaginal flora, can also cause PID. Thus, testing for these organisms may be beneficial.The history may reveal systemic symptoms such as fever, nausea, and vomiting. Additionally, patients might describe lower abdominal and pelvic pain, dysuria, dyspareunia, unusual vaginal discharge, and bleeding between periods or after intercourse.It's crucial to discuss sexual behaviors, especially any recent changes in sexual partners or practices, and habits like douching during the history taking. This discussion should be private and confidential, especially with adolescents, and may require asking caregivers to leave the room to ensure privacy.Always consider the possibility of sexual assault or abuse, particularly in young patients or children with a history of sexual activity. Follow-up actions regarding any allegations of abuse must adhere to state laws.Review the patient's contraceptive history as well, noting that non-barrier contraceptives like oral contraceptive pills do not protect against sexually transmitted infections such as gonorrhea or chlamydia.Here’s a high-yield fact: The risk of PID is not increased by the presence of an intrauterine device (IUD), except in the first three weeks after insertion. Furthermore, it is generally not necessary to remove the IUD when treating PID, unless the treatment fails after 48 to 72 hours.The minimum criteria for diagnosing PID on physical examination include cervical motion tenderness, uterine tenderness, and adnexal tenderness. Even the presence of just one of these can be clinically diagnostic in the context of PID. Other findings may include elevated body temperature, lower abdominal tenderness, signs of cervicitis like swelling and inflammation, a friable cervix, mucopurulent cervical discharge, and possibly an adnexal mass, which could suggest a tubo-ovarian abscess.While PID can often be diagnosed based on history and physical examination alone, laboratory tests can support the diagnosis. These include an elevated white blood cell count on saline microscopy, increased erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP), and positive nucleic acid amplification testing (NAAT) for gonorrhea or chlamydia.Upon diagnosing pelvic inflammatory disease, check the pregnancy status using the previously obtained HCG test. If the patient is not pregnant, decide whether outpatient treatment is sufficient or if hospital admission is necessary. Start with a pelvic ultrasound to check for a tubo-ovarian abscess.If the ultrasound shows no abscess, the patient’s oral temperature is below 38.5 degrees Celsius, and there are no symptoms of nausea or vomiting, outpatient treatment with antibiotics like intramuscular ceftriaxone, oral doxycycline, and metronidazole for 14 days is advisable. Ensure a follow-up within 72 hours to assess clinical improvement.Here’s a clinical pearl: Advise all patients diagnosed with PID to abstain from sexual intercourse until the treatment is complete and symptoms have resolved. Additionally, test for HIV and syphilis. If the patient tests positive for gonorrhea or chlamydia, retest in 3 months. Treat and test all recent sexual partners for gonorrhea and chlamydia, regardless of the initial cause of PID.For the next group, if the ultrasound appears normal but the patient is severely ill, hospital admission may be necessary. Criteria for admission include a temperature above 38.5 degrees Celsius, persistent nausea and vomiting, or unsuccessful outpatient treatment. Begin treatment with intravenous (IV) fluids and IV antibiotics such as ceftriaxone, doxycycline, and metronidazole. Also, manage any additional symptoms with antiemetics and antipyretics as needed.Now, regarding abnormal ultrasound results: If the ultrasound reveals a multiloculated fluid collection with internal debris and enhanced surrounding vascularity, this indicates a tubo-ovarian abscess. These patients may exhibit symptoms like a high oral temperature, nausea, and vomiting, although not all may present with a fever. These findings warrant hospital admission.Treatment should include IV fluids, IV antibiotics, antiemetics, and antipyretics. Most patients will respond to IV antibiotics within 72 hours. If there is no response to antibiotic therapy after 72 hours, consultation with an experienced gynecologic surgeon for potential surgical exploration or definitive treatments like image-guided drainage or surgical intervention is advisable.Here's a vital clinical pearl: Postmenopausal patients presenting with a tubo-ovarian abscess should be considered at high risk for an underlying malignancy, necessitating surgical exploration by an experienced gynecologic surgeon.This concludes the management strategies for non-pregnant patients. Moving on to pregnant patients, PID during pregnancy is uncommon but can occur in the first trimester before the chorion and amnion fuse. The fusion of these membranes, alongside thickened cervical mucus, helps seal the uterine cavity to prevent the ascent of pathogens. The treatment approach is similar, involving hospital admission for administration of IV fluids, antibiotics, antiemetics, and antipyretics.However, there is a critical consideration: Before administering any antibiotics, consult with an obstetrician or infectious disease specialist to ensure the safety of the fetus. Avoid teratogenic antibiotics, such as doxycycline and fluoroquinolones. Surgical interventions should be approached with caution. Additionally, it's important to monitor pregnant patients with PID closely, as they are at increased risk for spontaneous abortion and subsequent preterm labor.- **Unstable Patients with PID**: These patients may have sepsis and require hospital admission. The initial steps include obtaining an HCG pregnancy test, starting IV fluids, administering IV antibiotics, and consulting for potential gynecologic surgical exploration if needed.- **Stable Patients**: First, confirm pregnancy status. Nonpregnant patients with a normal ultrasound and no signs of fever, nausea, or vomiting can be treated on an outpatient basis with antibiotics. However, those with a normal ultrasound but exhibiting a temperature above 38.5 degrees Celsius, nausea and vomiting, or failure of outpatient treatment should be admitted. This also applies to patients with ultrasound findings indicative of a tubo-ovarian abscess.- **Inpatient Management**: Treatment should include IV fluids, IV antibiotics, antipyretics, and antiemetics. If a tubo-ovarian abscess is detected, consultation with a gynecologic surgeon for possible surgical intervention or other definitive treatment should be considered.- **Pregnant Patients with PID**: All should be admitted to the hospital for management, which includes IV fluids, IV antibiotics, antiemetics, and antipyretics. It's crucial to consult with an obstetrician or infectious disease specialist before administering any antibiotics to ensure the safety of the fetus, especially avoiding teratogenic medications."Sexually transmitted infections treatment guidelines, 2021" MMWR Recomm Rep (2021)"Pelvic Inflammatory Disease" Obstet Gynecol (2010) - - - - - - - END - - - - - - -
作者：Joy，
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德国精英大学非精英医学博士，
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