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Urogynaecology
influence this risk. Polymorphisms within the host cell receptors that are apparently ‘uncomplicated’ endocervical infection is often associated
involved in immune response mechanisms are associated with an with endometrial inflammation.
43
This can also be detected in
increased risk of tubal pathology in women infected with chlamydia.
30,31
uninfected women around the time of menstruation.
44
The delay
In those women with PID the risk of subsequent fertility varies according associated with specimen processing, staining and reporting also
to certain HLA class II antigens.
29
The interaction between particular suggests that endometrial biopsy may be of limited benefit in the
strains of C. trachomatis and the host immune system may also influence routine diagnosis of PID.
the risk of upper genital tract infection, with a possible link to
Treating Pelvic Infammatory Disease
There have recently been two large, randomised controlled trials
The prevalence of chlamydia has
assessing different therapy options for women presenting with mild to
increased in many countries over the
moderate PID. The PID Evaluation and Clinical Health (PEACH) study
was performed in America with a high proportion of inner-city African-
past decade, in part as a result of
American women.
45
increased awareness of the disease and
A comparison was made between inpatient therapy (with parenteral
more sensitive tests becoming available.
cefoxitin and doxycycline followed by oral doxycycline therapy
once symptoms had settled) and outpatient treatment (using a single
C. trachomatis serovar F, although the data are somewhat sparse.
32
The dose of intramuscular cefoxitin combined with probenecid followed by
risk of pelvic infection developing is also higher for gonococcal strains oral doxycycline). One of the strengths of this study was its long
that exhibit specific nutritional requirements (AHU auxotype) and in follow-up period and assessment of the long-term sequelae of PID,
those strains that are more resistant to antibiotics.
33
with data reported out to seven years. The investigators found no
difference in reported rates of infertility, chronic pelvic pain or ectopic
Diagnosis
In practice, the diagnosis of PID is made clinically. In the past, a specific
combination of examination findings and investigations were used to
No difference was found in short-term
make a diagnosis (the Hagar criteria), but this algorithm lacks
sensitivity, with around one in five cases being missed.
34
Current
cure rates between the two arms,
recommendations are to start empirical treatment for PID in any young, although fewer gastrointestinal side
sexually active woman complaining of lower abdominal pain who has
effects were reported in women
localised tenderness on vaginal examination.
35–37
The specificity of
the diagnosis can be improved by performing laparoscopy, but the receiving moxifloxacin.
appearance of the tubes remains subjective with considerable observer
variation between operators.
38,39
pregnancy between the two treatment arms and also reported that
Ultrasound scanning is useful to identify a tubo-ovarian abscess, overall fertility rates in women with treated PID were no worse than
but is limited in its ability to identify tubal inflammation per se. The those of the background age and ethnicity matched population.
46
use of power Doppler ultrasound to identify areas of increased blood
flow associated with inflammation has shown promise in one small The MAIDEN Study was performed in Europe and South Africa.
47
study,
40
but other approaches – such as magnetic resonance (MR) Patients were randomised to receive either oral ofloxacin plus
scanning
41
– are unlikely to become widespread due to limited metronidazole, or oral moxifloxacin – the rationale being that
availability and cost. moxifloxacin provides additional anaerobic cover compared with
ofloxacin (and also the added advantage of being administered once-
An alternative approach is to confirm the diagnosis histologically daily). No difference was found in short-term cure rates between the
following endometrial biopsy. This is a simple outpatient procedure two arms, although fewer gastrointestinal (GI) side effects were
reported in women receiving moxifloxacin.
Around 10% of women infected
Two smaller studies, both performed in India, have assessed stat dose
with gonorrhoea or chlamydia
therapy for PID with either azithromycin
48
or a combination of
go on to develop pelvic inflammatory
fluconazole, azithromycin and secnidazole.
49
Both of these studies
reported high clinical cure rates. The results of these larger trials have
disease, and both host and
been incorporated into evidence-based guidelines suggesting that
pathogen characteristics are
therapy should be based on cephalosporin followed by doxycycline
plus metronidazole, a quinolone with/without metronidazole or
likely to influence this risk.
parenteral treatment with clindamycin and gentamicin.
35–37
tolerated by most patients and there is a strong correlation Quinolone resistance in N. gonorrhoeae is well established in the Far
between inflammation in the endometrium and salpingitis.
11,42
East and increasing in prevalence in both Europe and the US.
Unfortunately, the correlation is not 100% and, in particular, Fortunately, N. gonorrhoeae remains an uncommon cause of PID in
34 EUROPEAN GENITO-URINARY DISEASE 2007