Introduction
A 24 year old female presented herself to the hospital complaining of lower abdominal pain, dysuria, light fever and abdominal cramps for the past 4 days (PID Module Case Study, 2008, p. 1). Jane Wheels is married to Joseph and is reported to have been using oral contraceptives for the past two years.
History
JW used oral contraceptives and had last seen her menstrual period two week ago but without dysmenorrhea. According to her, the commencement of the symptoms was very gradual and she begun feeling mild pain from her lower bilateral abdominal discomfort, abdominal cramps, fever and dysuria (PID Module Case Study, 2008, p. 2). However, the pain worsened progressively over the past four days. JW claims she did not experience any vaginal discharge, gastrointestinal discomfort of any sort or constipation. After experiencing these symptoms, she had taken Tylenol three times a day to suppress her fever.
JW claims that she is in a happy marriage and she is mutually monogamous with her husband and intended to get pregnant again in the next 6 months. She and her husband do not condoms whenever they have sexual intercourse at least twice a week (PID Module Case Study, 2008, p. 2). She does not engage in oral or rectal sex and has never suffered sexually transmitted infections but some yeast infection on occasional instances. She also douches regularly after sexual encounter and menstruation and she last douched this morning. JW also claims that she does not smoke, has a good appetite and does exercise on regular basis.
Physical Exam
Upon medical examination, the patient appeared to be healthy with a blood pressure of 104/72, a body temperature of 38°C and weighs 132 pounds. Her breasts, chest, heart and neck are normal with no flank pain (kidney problem) upon percussion (PID Module Case Study, 2008, p. 3). She experienced no Costovertebral angle tenderness.
Upon abdominal examination, JW reported to experience tenderness on her lower quadrant when palpated. Her doctor reported to palpate a number of small bilateral inguinal notes. Her external genitalia appeared normal and without signs of discharge but some visible signs of cervical mucus on speculum examination (PID Module Case Study, 2008, p. 4). Bimanual examination report revealed uterine and adnexal tenderness and painful cervical movement though the uterus anterior was smooth and not swollen.
Laboratory Tests
Test of urine for pregnancy was negative. Urine test for nitrates tested negative. Her vaginal pH was 4.5 upon vaginal saline wet mount. The KOH wet mount also tested negative for yeast.
Differential Diagnosis
It is important that Pelvic Inflammatory Disease (PID) is differentiated from a number of other infections that cause abdominal and pelvic problems. Female patients with unilateral adnexal mass lesion should be assessed cautiously for pyelonephritis, ectopic pregnancy and appendicitis or PID (Klaussner & Hook, 2008, p. 43). Other diseases that present related symptoms and must be excluded by differential diagnosis include ovarian cysts, Appendicitis, Diverticulitis, Endometriosis and ulcerative colitis (Klaussner & Hook, 2008, p. 43).
For Appendicitis rebound tenderness is not discriminator from PID but ultrasonic test can be a differentiator. For ectopic pregnancy, over 15% also experience PID (Bakken & Ghaderi, 2009, p. 130). Test for pregnancy, ultrasound imaging and laparoscopy are discriminators of this condition. Endometriosis is the condition where a tissue growth is experienced outside the uterine wall (Ross, 2010, p. 255). This can cause scarring or tubal damage. A discriminating factor is endometritis biopsy.
Laboratory Tests
No single lab tests can be very specific and sensitive enough to selectively settle on PID as a concise diagnosis. Lab tests for women in the childbearing age in emergency cases should include pregnancy test (Reyes et al, 2010, para. 1). Jane Wheels, tested negative for pregnancy. This helps in the elimination of ectopic pregnancy and statistics show that PID is the most common incident in missed ectopic pregnancy (Reyes et al, 2010, para. 1). Concurrence of pregnancy affects selection f medical therapy for PID.
In order to increase specificity, the tests below have to be considered. Saline and KOH preparations for are used to test vaginal secretion. Doctors should examine for clue cells, trichomoniasis and leucorrhea. Presence of leucorrhea is the most sensitive though not precise, lab indicator of tract infection while its absence is usually a negative prediction of PID (Bakken & Ghaderi, 2009, p. 130). Elevated erythrocyte sedimentation, white blood cell count and C-reactive are high and imprecise.
To verify diagnosis, the physician can request the laboratory to carry out Chlamydia and gonorrhea DNA cultures and probes. This step is useful in later stages when gonorrhea is negative (Hack & Hecht, 2009, p. 259). Chlamydia test help in identification of quickly replicating bacteria, a sign commonly associated with PID (Reyes et al, 2010, para. 5). Urinalysis tests should be conducted to assist exclusion of the upper urinary tract infection but positive test cannot be a basis for exclusion of PID, as any infection of the contiguous pelvis can cause white blood cells in urine (Hack & Hecht, 2009, p. 259). It’s not a must to carry out Blood cultures during the process of diagnosis PID.
Imaging Studies
Several other processes can be done to improve PID diagnosis although some may not necessary (Ross, 2010, p. 255). Nonetheless because of the complexity of ultimate clinical diagnosis and the number of critical surgeries and gynecologic emergencies that have resulted from similar symptom presentation, the examining physician should be aware on these modalities. Transvaginal ultrasonography is sometimes inefficient because of not being sensitive or specific in the mild cases of the disease or in a condition of atypical PID (81% sensitivity and 78% specificity).
Useful interpretation would therefore include thickened and fluid filled fallopian tubes especially when the disease case is acute and severe. These findings can expresses sufficient specificity for definitive diagnosis of PID. Nonetheless, pelvic abscesses could be very complicated, adnexal masses with several internal echoes (Taylor-Robinson et al, 2009, p. 713).
Ultrasonography is usually helpful for assessment of other entities that mimic PID during the process of differential diagnosis. Its helps differentiate problems like appendicitis and endometrioma and ovarian cyst among others (Ross, 2010, p. 257).
Computerized tomography is helpful in the differential diagnosis of PID where its results entail thickened ligaments of uterosacral areas, complex accumulation of pelvic fluid, cervititis and oophoritis. The process is 90% both specific and sensitive. Magnetic resonance imaging is 95% both sensitive and specific but is extremely expensive and seldom used in PID (Taylor-Robinson et al, 2009, p. 713). However, when used, it shows tubes filled with fluid and thickened walls or a tubo-ovarian complex.
Procedures
Endometrial biopsy helps in histopathologic diagnosis of endometritis and this test has sensitivity and specificity of 90%. This test is limited in use because of the specific training requirements for its application and may not be readily available in emergency cases (Taylor-Robinson et al, 2009, p. 715).
Laparoscopy is one of the standard criteria to PID diagnosis and it’s more specific and sensitive compared to the clinical criteria only. The minimum criteria include edema in uterine tubes, exudates on the reproduction tubes and visible hyperemia. Laparoscopy has a failure or a false rate of over 20% instances.
PID Epidemiology
The prevalence of PID is very high among young adults, who are singe and sexually active and have a history of STDs. The exact incidence in unknown because if the difficulty of definitive diagnosis based on the clinical symptom (Ross, 2010, p. 255). PID affects about 1 million US women per pear and it’s the commonest gynecological reason for hospitalization. Among the industrialized nations, the peek incidence of PID is at the age of 20-24 years though most cases are diagnosed from the outpatient department and ambulatory set up (Hack & Hecht, 2009, p. 261). This is effected by early detection and diagnosis and therapy of Chlamydia.
Care and Treatment
First line of therapy
CDC provides standard treatment and management processes for PID. The first line of treatment is the use of Moxifloxacin a 400 mg per day. Moxifloxacin has been proven to be very effective and the best alternative to ofloxacin and metronidazole combination which taken twice a day. Most patients who do not show signs of complications are treated as outpatients. Other primary options include intramuscular dose of 250 mg of ceftriaxone as a single dose combined with 14 day doxycyline oral dose of 100 mg twice a day. The patient could be given cefoxitin as a single intramuscular dose of 2 g and 1 g probenecid single oral dose and doxycycline 100 g twice a day for 14 days. Another alternative is the use of ceftizoxime 2 g single IM dose and an oral dose of 100 mg of doxycycline twice a day for 14 days.
Second line of therapy
The physician can prescribe 2 g single oral dose of azithromycin and oral doxycycline 100 mg twice a day for 14 days. Metronidazole can be when anaerobic microorganisms are suspected. When parenteral use of cephalosporins is not practicable, the physician can prescribe flouroquinolones (Klaussner & Hook, 2008, p. 44). This will include oral administration of levofloxacin 500 mg one a day dose of ofloxacin 400 mg twice a day dose for 14 days. Metronidazole may or may not be included depending on the prevalence of the diseases in the community.
Parenteral antibiotics prescription include cefoteran 2 g intravenous administration twice a day (12 hour interval) or cefoxitin 2 g intravenous dose after every 6 hours plus oral or IV administration of 100 mg doxycycline twice a day or after every 12 hours (Klaussner & Hook, 2008, p. 44).
There should be follow up in 2 to 3 days after commencement of treatment and the physician to assess microbiological results. When improvement is note seen after 3 days of treatment, hospitalization should be considered to administer parenteral therapy and carry out more diagnostic tests. Another follow up should be scheduled 7 – 10 days after treatment to repeat the endocervical cultures for gonorrhea and Chlamydia (Klaussner & Hook, 2008, p. 44).
Managing partners
The sexual partners must be examined and tested for gonorrhea and Chlamydia by urethral smear in the preceding 4 weeks in spite of whether they present the symptoms or not (Klaussner & Hook, 2008, p. 45). Partners should be treated for N. Gonorrhea and C. trachomatis despite etiology of PID.
Reference List
Bakken, I.J & Ghaderi, S. (2009), Incidence of Pelvic Inflammatory Disease in a Large Cohort of Women Tested For Chlamydia Trachomatis: A Historical Follow-Up Study. BMC Infectious Diseases, 9: 130.
Hack, J.B & Hecht, C. (2009). Emergency Physicians’ Patterns of Treatment for Presumed Gonorrhea and Chlamydia in Women: One Center’s Practice. J Emerg Med, 37 (3), 257-63.
Klaussner, J.D. & Hook, W. (2008) “Chapter 8. Pelvic Inflammatory Disease,” Current Diagnosis & Treatment of Sexually Transmitted Diseases. McGraw Hill Medical.
PID Module Case Study. (2008). Ready-To-Use Curriculum For Clinical Educators. Web.
Reyes, I., Kumar, R Abbuhl, S. 2010. Pelvic Inflammatory Disease: Differential Diagnoses & Workup. Web.
Ross, J. (2010). Pelvic Inflammatory Disease. Medicine, 38(5), 255-59.
Taylor-Robinson, D, Stacey, C.M., Jensen, J.S., Thomas, B. J., & Munday, P.E. (2009). Further Observations, Mainly Serological, On a Cohort of Women with or Without Pelvic Inflammatory Disease. Int J STD AIDS, 20 (10), 712-8.