Is it a case of untreated PID?
A lady aged 36 yrs c/o dull pain abdomen throughout the month after her periods. pain increases during cycles from past 2 cycles. USG suggestive if para ovarian cyst and pyosalpinx. please suggest management. No H/o fever.
Endometritis and bilateral chronic salpingitis causing pyosalpinx- is to be treated with antibiotics, metronidazole and antiinflammatories for 1 to2 weeks
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PELVIC INFLAMMATORY DISEASE PID is infection and inflammation of the female reproductive tract that occurs especially as a result of Sexually transmitted disease. It includes endometritis,parametritis,salpingitis Oophoritis,tubo - ovarian abscess and peritonitis The etiological agent most often is not identified, but common causative agents are Chlamydia trachomatis,Neisseria gonorrhoea,aerobic and anaerobic flora. SYMPTOMS. Lower abdominal pain Dyspareunia Fever Back pain and vomiting Abnormal vaginal discharge. Post coital bleeding or metrorrhagia Foul smelling vaginal discharge and pruritis DIAGNOSIS DIAGNOSIS OF PID IS A CLINICAL DIAGNOSIS. IT IS BASED ON SYMPTOMS AND SIGNS BIMANUAL AND SPECULUM EXAMINATION AND TESTING FOR CHLAMYDIA AND GONORRHOEA SHOULD BE PERFORMED IN ALL WOMEN WITH SYMPTOMS OF GENITAL TRACT INFECTION CDC DIAGNOSTIC CRITERIA FOR PID PID should be suspected and treatment initiated if Patient is at risk of PID And Patient has uterine,adnexal or cervical motion tenderness with no other apparent cause Findings that support the diagnosis Cervical /vaginal mucopurulent greenish /yellow discharge Elevated ESR or CRP Laboratory confirmation of neisseria /Chlamydia Fever Whit blood cells on vaginal secretion saline wet mount MOST SPECIFIC CRITERIA Endometritis on endometrial biopsy Laparoscopic abnormalities consistent with PID Thickened,fluid filled tubes apparent on TVS /MRI CLASSIC FINDINGS OF ACUTE PID ON TVS Tubal wall thickness >>5 mm Incomplete septae within the tube. Fluid in the cul - de - sac. Cog wheel sign ( cogwheel appearance of the fallopian tube on cross section seen in scan ) Tubo ovarian abscess CT FINDINGS IN PID Subtle changes in the appearance of pelvic floor fascial planes Thickened uterosacral ligaments Inflammatory changes of tubes or ovaries Abnormal fluid collection. With progress of disease,reactive inflammation of surrounding pelvic and abdominal organs is seen. MRI FINDINGS Tubo ovarian abscess Pyosalpinx Fluid filled fallopian tube Polycystic like ovaries with free pelvic fluid TREATMENT. ALL REGIMENS USED TO TREAT PID SHOULD ALSO BE EFFECTIVE AGAINST GONORRHOEA AND CHLAMYDIA AND ANAEROBES. Hospitalization is needed in Surgical emergencies Tubo ovarian abscess Pregnancy Severe illness with fever,nausea and vomiting. Unable to follow or tolerate OP oral regime No clinical response to oral anti microbial therapy.Dr. Suvarchala Pratap15 Likes10 Answers
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ULTRASOUND SIGNS OF PID PID is inflammation of the female reproductive tract that occurs especially as a result of a sexually transmitted disease and is a leading cause of infertility in women. CAUSATIVE ORGANISMS. PRIMARY ORGANISMS Sexually transmitted 1.N.gonorrhea. 2.Chlamydia trachomatis. 3.Mycoplasma hominis. SECONDARY ORGANISMS Normally found in vagina. AEROBIC 1.Non-hemolytic streptococci. 2.E.coli. 3.Group -B streptococcus. 4.Staphylococcus. ANAEROBIC: 1.Bacteroides species-fragilis &bivius. 2.Peptostreptococcus. 3.Peptococcus. ACUTE PID : Acute PID does not usually show any characteristic pictures on Transvaginal examination.Nevertheless,occasionally increased tubal wall thickness due to oedema and free fluid with floating particles in the pelvis can be detected. Hyperaemia of the inflamed tube leads to INCREASED VASCULAR MARKINGS ON COLOR DOPPLER MAPPING. In severe cases oedematous intratubal folds on cross section can show COGWHEEL APPEARANCE of a thick walled multi locular pelvic mass with echogenic fluid collection. CHRONIC PID: Patients with chronic PID shows dilated tubes with thin or thick walls and atrophic mucosal folds.Cross sectional view of a thick dilated tube shows. "BEADS ON A STRING SIGN". Sometimes,you can see incomplete intra tubal septate. THE MOST COMMON ULTRASONIC FINDINGS IN CHRONIC SALPINGITIS ARE 1.THIN WALLED HYDROSALPINX. 2.BEADS ON A STRING APPEARANCE. 3.INCOMPLETE SEPTAE. For clinicsl reasons,it is always important to differentiate a tubo-ovarian complex which needs antibiotic treatment ftom a pelvic abscess which needs surgical drainage as well.The ovary and tube can be seen separately in a tubo-ovarian complex ,which is not usually possible in most cases with a pelvic abscess. COGWHEEL APPEARANCE: Cogwheel shaped structure visible in the cross section of the tube with thickened walls is sern in Acute PID. BEADS ON A STRING SIGN: Hyperechoic mural nodules sized 2-3 mm are appreciated along the inner contour of the tubal wall representing degenerated and flattened endosalpingeal fold remnants and seen ONLY in chronic PID. INCOMPLETE SEPTAE/WAIST SIGN: Triangular protrusions emanating from one side of the tubal wall bit not reaching the other side are seen quite often in both acute and chronic PID and are non-discriminatory. Tubular filled mass with diametrically opposite indentations has most likelihood of being a tubal lesion than other adnexal mass (WAIST SIGN). HYDROSALPINX: Hydrosalpinx results from an accumulation of secretions when the tube is occluded at its ends.NORMAL FALLOPIAN TUBES ARE NOT VISUALISED IN SCAN. PYOSAPINX: Distension of fallopian tubes with pus due to infection and inflammation.Ultrasound shows *Dilated serpentine tubular structure in the pelvis. *Low level echoes due to the higher protein content of the debris within the tube distinguish a pyosalpinx from Hydrosalpinx.Dr. Suvarchala Pratap5 Likes7 Answers
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BACTERIAL VAGINOSIS. BACTERIAL VAGINOSIS// NON SPECIFIC VAGINITIS// GARDNERELLA VAGINITIS BV is characterised by abnormal vaginal discharge which results from an overgrowth of atypical bacteria in the vagina.It is not a true injection but rather an imbalance of bacteria that are normally present in the vagina. In the past,this condition was called "Gardnerella vaginitis"after the bacteria that were thought to cause the condition.But now it is coined as "Bacterial vaginosis"due to the fact that there are a number of species of bacteria that naturally live in the vagina and imbalance of these normal resident flora of vagina leads to BV. Gardnerella vaginalis,lactobacillus,prevotella, mobiluncus,bacteroides,peptostreptococcus, fusobacterium,veillonella,eubacterium, mycoplasma hominis,ureaplasma urealyticum, streptococcus viridans &atopobium vaginae are all associated with bacterial vaginosis. SIGNS AND SYMPTOMS 1.Abnormal amounts of vaginal discharge. 2.Thin & grayish colored vaginal discharge. 3.Unpleasnt "FISHY ODOUR" 4.Discharge and odour are more noticeable after sexual intercourse. 5.Dyspareunia and dysuria rare. RISK FACTORS. 1.Recent antibiotic use. 2.Decreased estrogen production of the host. 3.Intra uterine device in situ. 4.Douching. 5.New partner or multiple partners. DIAGNOSIS. Microscopic examination is vital to the clinical diagnosis of bacterial vaginosis. Demonstration of 3 of the following 4 criteria "AMSEL CRITERIA" is essential to diagnose BV on microscopic examination of the discharge. AMSEL CRITERIA 1.Demonstration of "CLUE CELLS"on a saline smear.(The most specific diagnostic criterion) 2.A pH of >>4.5. 3.Characteristic thin,gray and homogeneous discharge. 4.Positive "WHIFF TEST" Whiff test is performed by adding a small amount of potassium hydroxide to a microscopic slide containing vaginal discharge A CHARACTERISTIC FISHY ODOUR IS CONSIDERED A POSITIVE WHIFF TEST AND IS SUGGESTIVE OF BACTERIAL VAGINOSIS. NUGENT'S CRITERIA. Bacteria are graded via gram staining of vaginal discharge sample.bacteria are graded and assigned score 1.Lactobacillus (score 0-4) 2.Bacteroides /Gardnerella (score 0-4) 3.Mobiluncus (score 0-2) Total scores are calculated and interpreted as follows. 0-3 Normal. 4-6Intermediate bacterial count. 7-10 Bacterial vaginosis. MANAGEMENT. 1.Antibiotics are the mainstay of therapy. 2.Asymptomatic women do not need treatment 3.BV in pregnant women should be treated. 4.BV should be treated before a caesarean section,hysterectomy or insertion of IUD. 5.Uncomplicated cases typically resolve after standard antibiotic treatment. 6.BV that does not resolve after one course of treatment may be given the second course of the same agent or by switching to another agent.(metronidazole to clindamycin or clindamycin to metronidazole) 7.Patients should be advised to stop douching or using bubble bath or over-the-counter vaginal hygiene products. 8. Patient should avoid soaps,liquid soaps and body washes. 9.Surgery is not indicated. 10.Testing for other infections like Neisseria gonorrhoea. Chlamydia trachomatis. Harper simplex virus (HSV-1) is appropriate. COMPLICATIONS. The prognosis for uncomplicated cases of bacterial vaginosis is excellent. Complicated cases of bacterial vaginosis lead to increased risk of. Salpingitis. Endometritis. Post caesarean endometritis. Post hysterectomy vaginal cuff cellulitis. In pregnancy Premature rupture of membranes. Premature labor. Chorioamnionitis. Post partum endometritis.Dr. Suvarchala Pratap16 Likes15 Answers
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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.Dr. Suvarchala Pratap10 Likes18 Answers
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F21. Married for 2yrs. Anxious to conceive. HSG.Dr. Syam Sundar Patro1 Like18 Answers