Pelvic Inflammatory Disease


Table 1: Detection of Chlamydia Trachomatis at Different Genital Locations in Patients with Pelvic Inflammatory Disease


Erfurt Brunham Brihmer Hoyme, Study, 2010


No. of patients with PID 363 CT isolated from any


swabbed location CT isolated from the cervix


CT isolated from the


cervix and urethra CT isolated from the


cervix and Fallopian tubes CT isolated from the Fallopian tubes only


et al., 198832 36


103 (28.4 %) 5 55 (15.2 %) 4 4* (1.1 %) ND 23 (6.3 %) 2 47 (12.9 %) 1 * Cervical and urethral specimen collected in 1994–95. CT = Chlamydia trachomatis; ND = none detected; PID = pelvic inflammatory disease.


Table 2: Detection of Neisseria Gonorrhoeae at Different Genital Locations in Patients with Pelvic Inflammatory Disease


Erfurt Brunham Brihmer Hoyme, Study, 2010


No. of patients with PID 363 NG isolated from any


swabbed location NG isolated from the cervix


NG isolated from the


cervix and urethra NG isolated from the


cervix and Fallopian tubes NG isolated from the Fallopian tubes only


et al., 198832 36


6 (1.6 %) 5 (1.4 %) 0* 2 (0.6 %) 1 (0.3 %) 18 18 6 ND ND * Cervical and urethral specimen collected in 1994–95. ND = none detected; NG = Neisseria gonorrhoeae; PID = pelvic inflammatory disease.


Table 3: Erfurt Study (1994–2010) – Microbiological Results of Tubal Swabs in Women with Pelvic Inflammatory Disease (n=363)


Chlamydia trachomatis Neisseria gonorrhoeae Gram-positive cocci Escherichia coli


Anaerobes, Gardnerella vaginalis


19.3 % 1.6 %


25.9 % 5.0 % 7.2 %


Since salpingitis and PID are the only preventable causes of infertility and adverse pregnancy outcome, many organisations have published guidelines regarding the screening, diagnosis and treatment of C. trachomatis infection. In respect of the serious health and socioeconomic consequences of C. trachomatis infection, the European Centre for Disease Prevention and Control (ECDC) has recently started to evaluate and propose C. trachomatis control activities in European Union countries. However, so far, these efforts have not resulted in a satisfying level of secondary prevention of the sequelae of this genital infection.8,12,13


A Study to Evaluate the Efficacy of Routine Screening for Chlamydia Trachomatis Infection Our team at the Department of Obstetrics and Gynaecology at the HELIOS Hospital in Erfurt, Germany, undertook an analysis of


10


et al., 200634 198933 64


15 15 2 ND ND


71 5


5 ND ND ND


et al., 200634 198933 64


36 36 ND 12 0


71 17


11 10 8 3


women with laparoscopically proven PID, some of which had C. trachomatis infection. In that study, the rate of positive tubal specimens was correlated with C. trachomatis detection in cervical swabs, thus indirectly evaluating the potential efficacy of routine cervical or urine screening for C. trachomatis intended to prevent PID and its complications.


Patients and Methods


Between January 1994 and December 2010, 1,247 sexually active women with pelvic pain and/or suspected PID were referred to the hospital by their local physician (not necessarily a gynaecologist) and underwent laparoscopy within less than three hours of being admitted in order to:


• establish a diagnosis through objective criteria;2


• perform severity grading;14 • •


initiate surgical treatment where indicated; and obtain the relevant specimen for microbiological evaluation.


The specimens were collected by a special swab (EndoSwab®, Merete Medical GmbH, Berlin, Germany – see Figures 1 and 2) from the fimbria of the Fallopian tubes if visualised, and otherwise from the tubal peritoneum.10


In addition,


Over the years, there have been several improvements in the laboratory diagnosis of chlamydial infection, routinely performed first by enzyme immunoassay (EIA) and later by ligase chain reaction (LCR) followed by polymerase chain reaction (PCR).15


cervical specimen were obtained prior to laparoscopy, and in some cases in the 1994–95 urethral swabs as well. Microbiological evaluation was performed to identify all bacteria known to be relevant in PID, not only C. trachomatis – with the exception of mycoplasmata.


Results


Of the 1,247 women, 363 (29.1 %) were laparoscopically diagnosed as having PID – acute salpingitis or other forms (see Figure 3). Of those 363 women, 103 (28.4 %) had PID due to C. trachomatis found at any of the swabbed locations. Fifty-five of the 363 women with PID (15.2 %) were tested positive for C. trachomatis from the cervix. In 23 (41.8 %) of these 55 cervix-positive women (i.e., 6.3 % of the 363 women with PID), C. trachomatis was also found in the Fallopian tubes. In four of the 55 cervix-positive women, specimen simultaneously taken from the urethra were also found to be positive (no woman was found to be C. trachomatis-positive from a urethral swab only). However, only the tubal swab showed a positive result for C. trachomatis in 47 (12.9 %) of the 363 women with PID (i.e., 45.6 % of the 103 C. trachomatis-positive women) (see Table 1 and Figure 4).


Neisseria gonorrhoeae was found in 6 (1.6 %) of the 363 women with PID (see Table 2). Other intraperitoneally found facultative vaginal bacteria are detailed in Table 3. Tubo-ovarian abscess or complex was diagnosed in 91 women (25.1 % of all PID cases) (see Figure 3) at a relatively stable incidence of about five cases per year over the study period (1994–2010). The overall rate of PID has remained almost unchanged since 2000 at approximately 20 cases per year (see Figure 3). The difference between the total number of C. trachomatis-positive cases and the number of cases positive in the Fallopian tubes only remained stable until now (see Figure 4).


The differential diagnoses in those patients with pelvic pain and/or suspected PID who underwent laparoscopy but were not found to have acute salpingitis and/or PID are listed in Table 4.


EUROPEAN OBSTETRICS & GYNAECOLOGY


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