Pelvic Inflammatory Disease and Tubo-Ovarian Abscess

PID/TOA

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1.     Definition

a.     Acute or subclinical infection of the upper genital tract in women often accompanied by involvement of neighboring organs

2.     Risk Factors

a.     Sexually active, multiple partners, h/o STI (or partner w/ STI), h/o PID, age<25

b.     Condoms are protective

c.      Rare in pregnancy after first trimester as the decidua and mucus plug prevent ascending infection

3.     Microbiology

a.     Clinically considered a mixed, polymicrobial infection, including facultative anaerobes and anaerobes

b.     NG/CT are the most commonly identified pathogens, but are found in <50% of infections

4.     Spectrum of Disease

a.     Acute PID

                                               i.     Acute in onset low abdominal pain, usually bilateral and rarely lasts longer than 2 weeks

1.     Vaginal discharge, dysuria, AUB

2.     Severe cases may include the abdomen and present with ileus, hydronephrosis, or perihepatitis [(Fitz-Hugh Curtis Syndrome) and present w/ RUQ pain, pleuritis, referred right shoulder pain, and may confuse the clinical picture with cholecystitis]

                                              ii.     PE: Acute cervical motion/uterine/adnexal tenderness; purulent endocervical discharge

                                            iii.     Minority of patients present with leukocytosis

b.     Tubo-Ovarian Abscess

                                               i.     Serious, potentially life-threatening, as rupture may result in sepsis; historically (prior to modern abx and surgery), mortality could reach 50%

1.     Ruptured abscesses may still result in sepsis

c.      Subclinical PID

                                               i.     Often suspected in cases of tubal factor infertility and tubal occlusion in patients who did not otherwise present w/ sxs

d.     Chronic PID

                                               i.     Indolent presentation with low-grade fevers, weight loss, abdominal pain

                                              ii.     Reported with atypical bacteria, including actinomyces and tuberculosis

1.     Actinomyces israelii often found in s/o IUD; it is normally found in the genital tract. If found on cervical cytology exam, recs are to first assess for sxs. If asxs, no further action. If sxs, treat with antibiotics and remove the IUD to send it for anaerobic culture

a.     Severe Actinomyces infections (TOA, disseminated) require IV abx for weeks-months, and require ID consults – in these cases IUD should be removed

b.     PCN or tetracyclines for tx

5.     Imaging

a.     Ultrasound images

                                               i.     Normal images do not rule out PID

                                              ii.     Acute Salpingitis

1.     Tubular structure, solid, not attached to ovaries, not fluid filled

a.     Image from Romosan et al.

                                              ii.     Hydrosalpinx/Pyosalpinx

1.     “Incomplete Septum Sign:” Tube distends and folds upon itself

a.     Image from Sayasneh et al.

2.     “Beads on a string:” Tube distends and viewed in cross-section

a.     Image from Abdel-Gadir

3.      “Cogwheel Sign:” Thick-walled tube is also distended by pus

a.     Image from Sayasneh et al.

                                              ii.     TOA

1.     Complex, thick-walled, multilocular cysts, often with internal echoes or multiple fluid levels. Cannot differentiate between tube and ovary.

a.     Image from Vendhan et al.

a.     CT/MRI are useful in excluding alternative diagnoses

2.     Diagnosis

a.     Clinical exam – often presumptively made in young women at risk who present with pain and have cervical motion, uterine, or adnexal tenderness. Have a low threshold for diagnosis and treatment – due to consequences to reproduction or pain, patients with minimal or subtle findings should be treated.

b.     Diagnosis may be supported by fever, leukocytosis, purulent discharge/WBCs in vaginal fluid/friable cervix, documentation of NG/CT infection, elevated ESR or CRP

c.      Laparoscopy may be used for diagnosis, as well as endometrial biopsy

3.     PID Treatment

a.     Treatment should include coverage of NG/CT

b.     Inpatient management

                                               i.     Suggested if: surgical emergency cannot be ruled out, TOA, pregnancy, severe illness/high fever, n/v or inability to tolerate PO or outpatient regimen, no response to oral abx

c.      While anaerobes are often isolated, anaerobic coverage with flagyl hasn’t been shown to increase cure rates

d.     IV

                                               i.     Cefoxitin (2g q6h) or Cefotetan (2g q12h) plus Doxycycline (100mg q12h)

                                              ii.     Clindamycin (900mg q8hr) plus Gentamicin (2mg/kg loading dose f/b maintenance dose 1.5mg/kg q8h)

1.     +/- Ampicillin (2g q6h)

                                            iii.     Then transition to PO regimen to complete 14d course

e.     PO

                                               i.     Ceftriaxone (250mg IM once) plus Doxy 100mg q12h)

1.     Third generation cephalosporins have less anaerobe coverage than cefoxitin/cefotetan, and therefore would err towards rx’ing metronidazole with these regimens

                                              ii.     Cefoxitin (1g IM once) plus probenecid (1g PO once) plus Doxy (100mg q12hr)

                                            iii.     Any of those regimens +/- metronidazole 500mg q12hr

                                            iv.     Duration of treatment for 14d

f.      Severe PCN allergy

                                               i.     IV regimen of gent/clinda as above, then transition after 24hrs of improvement to PO doxy at discharge

                                              ii.     PO regimens available include levofloxacin (500mg PO QD) and azithromycin (2g PO once)

g.     Follow-up

                                               i.     If no improvement in 72hrs, would consider failure of outpatient therapy and hospitalize for IV abx and consider additional diagnostic evaluation (i.e. laparoscopy for alternative diagnoses)

4.     TOA Treatment

a.     Surgery

                                               i.     Suspected intraabdominal rupture is a life-threatening emergency similar to ruptured ectopic pregnancy. Patient may show signs of hemoperitoneum or unstable vitals

                                              ii.     Indications include: evidence of intra-abdominal rupture, sepsis, large abscesses (>9cm)

                                            iii.     Procedure

1.     If concern for rupture, laparotomy approach is preferred, particularly if patient is unstable

2.     Confirm diagnosis of TOA by visualizing adnexa; send cultures for both aerobic and anaerobic culture

3.     Remove as much of the abscess cavity and infectious/inflammatory fluid as possible

a.     USO is preferred, but traditional approach was for TAH-BSO; therefore discussion with patient regarding future fertility may be required preoperatively if this may be required

4.     Copiously irrigate the peritoneal cavity

5.     Upon closure, the wound class is ‘Dirty’, so some advocate leaving a closed suction drain (JP drain) or leaving the subcutaneous/skin layers open with delayed closure vs closure by secondary intention

                                            iv.     Postmenopausal women – increased rates of malignancy in a TOA, therefore management may be surgical staging

1.     Counsel patients on risk of malignancy, and involve gynecologic oncology for full cancer staging surgery with intraop frozen pathology of adnexal masses to assess for malignancy

b.     Antibiotic Therapy

                                               i.     Recommended inpatient with IV antibiotics, and full course of abx for minimum of 2 weeks

                                              ii.     Candidates for Abx alone: Hemodynamically stable, premenopausal, small abscess (<9cm; otherwise at increased risk of failure of abx), hasn’t failed abx alone

                                            iii.     Treatment Failure

1.     After 48-72hr of antibiotics, treatment failure is:

a.     New/persistent fever, persistent or worsening abdominopelvic tenderness, enlarging pelvic mass, new/persistent/increasing leukocytosis, sepsis

                                            iv.     IV regimens

1.     Those listed above plus:

a.     Amp-sulbactam (3g q6h) plus Doxy (100mg q12h)

2.     Second-line options for those with allergies

a.     Levofloxacin (500mg IV QD) plus Metronidazole (500mg IV q8h)

b.     Imipenem-cilastatin (500mg IV q6h)

                                              v.     PO regimens

1.     Transition to PO when patient stable on IV

2.     Levofloxacin OR Ofloxacin (500mg PO QD) plus Metronidazole (500mg q12h)

3.     Amox-clav XR (2000mg ER PO q12h)

c.      IR Guided Abscess Drainage

                                               i.     Appropriate for patients who fail antibiotic therapy, but still do not possess an outright indication for open surgery

                                              ii.     Challenging due to the multilocular nature of the infection, but increasing in popularity

d.     Posterior Colpotomy

                                               i.     Performed historically, but usual TOA location is higher in the pelvic and this approach has fallen out of favor

e.     Resolution of TOA

                                               i.     Usually a repeat TVUS is required to assess that the abscess has resolved at the conclusion of the abx course

                                              ii.     Abx treatment duration may be extended if abscesses have not completely resolved

5.     Other Considerations

a.     Avoid intercourse until treatment concluded, symptoms resolved, and partners treated

b.     Patients with PID/TOA who test positive for GC/CT should be retested in 3 months for reinfection/TOC

c.      Pregnant women are high risk for preterm delivery and maternal morbidity and should be hospitalized with IV abx

d.     IUD can stay in place, however if patient does not respond to treatment in 48-72h should consider removal

                                               i.     IUD PID risk itself is seen in first 3wks after placement