Pelvic Inflammatory Disease

Pelvic inflammatory disease should always be considered in the differential diagnosis of acute febrile abdominal pain. Infections of the uterus, tubes, and ovaries may cause infertility and can cause life-threatening sepsis in a significant number of women.

The most frequent acute infection in reproductive age, nonpregnant women is pelvic inflammatory disease. It is an enormous public health problem. In 1998, direct costs were estimated to be around 1.9 billion (11). Chlamydia is the most common infectious disease reported to health departments among young, sexually active females. Chlamydia and Neisseria gonorrhea are among the major causes of cervicitis and pelvic inflammatory disease. The U.S. Centers for Disease Control and Prevention, however, recommends coverage for a mix of pathogens not just limited to these two organisms. Chlamydia and Neisseria gonorrhea are included as well as a mix of anaerobes, gramnegative facultative bacteria, and streptococci.

Diagnosis of pelvic inflammatory disease is a clinical diagnosis. It is made based upon historical and clinical exam findings including a thorough pelvic exam. Laparoscopy is not necessary for the diagnosis of pelvic inflammatory disease. However, many authors have described the diagnosis using the laparoscope. In 1969, Jacobson and Westrom described visual criteria for the laparoscopic diagnosis of salpin-gitis (12). These include hyperemia of the tubal surface, edema of the tubal wall, and exudate on the tubal surface or from the fimbriated ends when the tubes are patent. Adhesions from pelvic inflammatory disease are usually described as thin and filmy, and involve the fimbriated ends of the fallopian tubes. Patients with active pelvic inflammatory disease may show an erythematous uterus and fallopian tubes. A yellowish-green exudate is sometimes seen around the tubes and ovaries or in the posterior cul-de-sac.

Obstruction to the end of the fallopian tube may result in a hydrosalpinx or pyosalpinx. It is not uncommon to encounter hydrosalpinx inadvertently in an asymptomatic patient while performing laparoscopic surgery for other pathology. Data on management of hydrosalpinx are mixed. The presence of hydrosalpinx reduces the pregnancy rate in patients undergoing in vitro fertilization. Removal of the fallopian tube has been shown to improve fertility rates from in vitro fertilization. However, it is not recommended that an incidentally discovered hydrosalpinx should

The most frequent acute infection in reproductive age, nonpregnant women is pelvic inflammatory disease. It is an enormous public health problem.

be removed without prior discussion with the patient. Consultation regarding the patient's future fertility desires is imperative before attempting to remove an existing hydrosalpinx.

Most patients with pelvic inflammatory disease are treated on an outpatient basis. The Pelvic Inflammatory Disease Evaluation and Clinical Health Study reported on 35 months of follow-up in patients who were diagnosed with mild to moderate pelvic inflammatory disease (13). A single intramuscular dose of cefoxitin (2 g) with probenecid and oral doxycycline for 14 days was as effective as a 48-hour administration of cefoxitin every six hours and the doxycycline course. At 35 months there was no difference in pregnancy rates, recurrence of pelvic inflammatory disease, chronic pelvic pain, or ectopic pregnancy.

The most severe cases of pelvic inflammatory disease will progress to form tuboovarian abscess. These pockets of inflammation are associated with tissue induration and may involve the uterus, ovaries, tubes, and in many cases the bowel. There have been cases of tuboovarian abscess as a cause of ureteral obstruction (14). This can occur unilaterally or bilaterally. Usually, treatment of the tuboovarian abscess will relieve the induration of the periureteral tissues, resulting in resolution of the hydronephrosis. Removal of the offending organ containing the abscess should be considered. In patients who desire future fertility laparoscopic or computed tomography-guided drainage can be performed.

If ovarian cyst rupture occurs during laparoscopy, it is often helpful to place the patient in the reverse Trendelenburg position, to prevent the cyst contents from spreading throughout the pelvis. Using warm irrigation fluid, copiously irrigate the pelvic cavity to prevent the peritonitis that may result from the cyst contents.

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