PELVIC INFLAMMATORY DISEASE : DEFINITION : PID is defined as a spectrum of inflammatory disorders of the upper female genital tract , including any combination of endometritis, salpingitis,tubo-ovarian abscess and pelvic peritonitis. It is a serious complication of some STD's , especially chlamydia and gonorrhea. PID can damage the fallopian tubes and tissues in and near the uterus and ovaries. PID leads to serious consequences including infertility ,ectopic pregnancy,abscess formation and chronic pelvic pain. CAUSATIVE ORGANISMS : Causative organisms are bacteria ,fungi,virus and parasites Sexually transmitted organisms are implicated in most cases.especially N.GONORRHEA & C.TRACHOMATIS. Microorganisms that comprise the vaginal flora also have been associated with PID. Gardnerella vaginalis. Haemophilus influenza. Enteric gram negative rods. Streptococcus agalactiae. Other organisms involved are Cytomegalovirus. M.hominis. U.urealyticum. M.genitilium. RISK FACTORS : *H/O STDs,especially gonorrhea &chlamydia. *Teenage sex. *Multiple sexual partners. *Intra uterine device. *Prior episodes of PID. *HIV. TYPES: ACUTE PID : Patient has generalized symptoms. Lasts few days. May recur in episodes. Very infectious. CHRONIC PID : Patient may be asymptomatic. Occurs over months and years. Progressive organ damage. SYMPTOMS : 1.Lower abdominal pain,may worse when move 2.Dyspareunia 3.Dysuria. 4.Dysmenorrhoea. 5.Post coital bleeding /metrorrhagia. 6.Low back ache. 7.Fever . 8.Feeling of tiredness. 9.Abnormal vaginal discharge. 10.Nausea ,vomiting . SIGNS : 1.Lower abdominal tenderness. 2.Adnexal and cervical tenderness on bimanual palpation. 3.Muco purulent vaginal discharge. 4.Cervicitis seen on speculum examination. 5.May find palpable adnexal mass. 6.Pyrexia.

A 26 yrs married female c/o 3mts ammenorhea with severe pelvic pain and right illiac region lower abdominal pain .her pregcolour test is negative, USG suggest mild fatty change liver rest all WNL. but TLC COUNT 11.3thousand/mm3 suggestive of inflammation. reports r attached. pls suggest diagnosis and further followup.

ABC OF : ENDOMETRIOSIS. MAY BE USEFUL.       ***** ENDOMETRIOSIS :- MORE THAN 1 MILLION CASES PER YEAR (INDIA)....... TREATABLE BY A MEDICAL PROFESSIONALS....... REQUIRES A MEDICAL DIAGNOSIS....... LAB TESTS OR IMAGING OFTEN REQUIRED....... CHRONIC: CAN LAST FOR YEARS OR BE LIFELONG....... ** CONSULT A DOCTOR FOR MEDICAL ADVICE....... *** ENDOMETRIOSIS is an estrogen-dependent disease wherein endometrial-like tissue is found outside the uterus inducing a chronic inflammatory response.......   Pelvic organs (esp ovaries) & peritoneum are frequently affected....... *** SYMPTOMS :- MAIN CLINICAL FEATURES INCLUDE: CHRONIC PELVIC PAIN (found in 70-80% of patients) DYSPAREUNIA (suggests deep posterior infiltration) INFERTILITY (21% prevalence rate) OTHER SYMPTOMS may include severe dysmenorrhea, pain on ovulation, noncyclical pelvic pain, cyclical bowel or bladder symptoms w/ or w/o abnormal bleeding or pain, chronic fatigue, or dyschezia....... IN ADOLESCENTS, endometriosis is the most common cause of SECONDARY DYSMENORRHOEA....... Although it is vital to consider the patient's complaints affecting physical, mental & social well-being, it should be noted that patients w/ endometriosis may be completely ASYMPTOMATIC (w/ 2-22% prevalence rate).......   ***** DIAGNOSIS :- Diagnosis of endometriosis is made after taking the PATIENT'S HISTORY & doing PHYSICAL EXAMINATION LABORATORY TESTS, LAPAROSCOPY, & IMAGING studies are performed as well to confirm diagnosis.  *** PATIENT'S HISTORY :- Should include: Age (reproductive year, most commonly at 25-29 yr old) In utero exposure to environmental toxins like diethylstilbestrol which increases the incidence of endometriosis Family history of endometriosis (7x higher risk than w/ no family history) *** PHYSICAL EXAMINATION :- Ideally done during early menses because endometrial implants are likely to be largest & deep infiltrating, hence more easily detectable Diagnosis is more definite if deeply infiltrative nodules are found on the uterosacral ligaments or in pouch of Douglas, &/or lesions are directly seen in the vagina or cervix Note that there may be no abnormal findings on physical exam For patients who are not sexually active, a rectal-abdominal exam may be better tolerated than a vag-abdominal exam A cotton swab can be inserted into the vagina to document patency & exclude complete or partially obstructive anomalies such as a transverse vaginal septum, imperforate or microperforate hymen, or an obstructed hemivagina OTHER FREQUENT FINDINGS : Pain w/ uterine movement or pelvic tenderness Tender, enlarged adnexal masses Fixation of adnexa or uterus in a retroverted position *** LABORATORY TESTS :- Urinalysis & urine culture to identify pain originating in the urinary tract (eg cystitis, stones) Pregnancy test & tests for sexually transmitted infection (STI) like gonorrhea, chlamydia, when appropriate....... *** LAPAROSCOPY :- Gold standard for diagnosis, unless lesions are visible in the vagina May also be used for therapeutic purposes Should not be done during or w/in 3 mth of hormonal treatment to avoid under-diagnosis Biopsy & histopathologic study of at least one lesion is ideal 3 cardinal features (ie ectopic endometrial glands, ectopic endometrial stroma, & hemorrhage into adjacent tissue) should be present In adolescents, features of endometriosis may be atypical (ie clear vesicles & red lesions) A negative laparoscopy does not exclude the diagnosis of endometriosis Depending on the severity of the disease found, it is best to remove the endometriotic lesion at the same time Differential diagnoses (eg endosalpingiosis, mesothelial hyperplasia, hemosiderin deposition, hemangiomas, adrenal rests, inflammatory changes, splenosis & reactions to oil-based radiographic dyes) can be excluded by biopsy Laparoscopic Classification (based on location, extent & severity of lesions) : Stages based on American Fertility Society (AFS) Minimal disease (stage I) - characterized by isolated implants & no significant adhesions Mild endometriosis (stage II) - consists of superficial implants <5 cm in aggregate, scattered on the peritoneum & ovaries; with no significant adhesions Moderate disease (stage III) - exhibits multiple implants, both superficial & invasive; peritubal & periovarian adhesion may be evident Severe disease (stage IV) - characterized by multiple superficial & deep implants, including large ovarian endometriomas; filmy & dense adhesions are usually present Severity of symptoms does not match w/ the above stages....... *** IMAGING STUDIES :- ** Transvaginal Sonography (TVS) Considered the 1st-LINE IMAGING TOOL to examine suspected endometriosis Should be performed to determine whether a pelvic mass or structural anomaly is present USEFUL IN DIAGNOSING OR EXCLUDING RECTAL ENDOMETRIOSIS May IDENTIFY an ovarian endometrioma & help identify other structural causes of pelvic pain, such as ovarian cysts, torsion, tumors, genital tract anomalies & appendicitis DISTINGUISHES endometrioma from other ovarian cysts w/ 83% sensitivity & 89% specificity Ovarian endometrioma may be diagnosed in premenopausal women w/ findings of ground glass echogenicity & 1-4 compartments & absence of papillary structures w/ blood flow ** MAGNETIC RESONANCE IMAGING (MRI) : May be helpful in some cases to better define an abnormality suspected by sonography Detects ovarian endometrial cysts w/ 90% sensitivity & 98% specificity Provides exact location of deep retroperitoneal lesion May be used as part of pre-op workup, but should not be used as 1st-line ** MISCELLANEOUS TESTS : Serum CA-125 Women w/ endometriosis may have HIGH serum CA-125 concentration NO VALUE AS DIAGNOSTIC TOOL in endometriosis ALSO ELEVATED in ovarian epithelial neoplasia, myoma, adenomyosis, acute PID, ovarian cyst, pregnancy....... ** BIOPSY : May be considered in suspected endometriosis lesions & endometriomas to help confirm the diagnosis & exclude possible malignancy In patients w/ endometriosis, prevalence of ovarian cancer is <1% *** TREATMENT :- Management of endometriosis includes medical therapy w/ first-line agents oral contraceptives & progestins....... Second-line agents include Danazol, gonadotropin-releasing hormone (GnRH) agonists, Levonorgestrel intrauterine system, & aromatase inhibitors....... Supportive therapy w/ nonsteroidal anti-inflammatory drugs (NSAIDs) may be given to provide pain relief....... Surgery should only be done in women w/ endometriosis-related pain after medical treatment has failed....... Combined medical/surgical therapy is medical therapy given before &/or after surgery.......  

A 35 years old female P3L3 presented with lower abdominal pain, dyspareunia and infertility. P/A Normal P/S Vagina healthy P/V Uterus normal but deviated towards left. Right adnexal mass felt. Tenderness and nodularity in posterior fornix. USG- Clear ovarian cyst Laparoscopy- Endometrioma present Treatment and advice to the patient?

A 42 yrs old married man with 2 kids ,suffering from suddenly pain and bending of penis during erecrtion since 6months. Pain is subside when penis become flaccid and increase during erection. He feel slight shortening of lenght of penis and bending of penis towards left side. He notice tenderness in penis. Tenderness is high during erection and less on flaccid. He feel circumference of root of the penis is decrease means root of penis thinner thn normal during erection. Here some pics he shows during erection. He is unable to perform intercourse. He is a known case of diabetes since 6 months. Pls suggest Dx & Rx