The accuracy of clinical findings and laparoscopy in pelvic inflammatory disease

Urologic complications of major pelvic surgery

The close proximity of pelvic organs makes the genitourinary system susceptible to injury during major pelvic surgery. Iatrogenic injury remains the most common cause of lower urinary tract trauma. Recent modifications in surgical technique, such as sharp mesorectal incision and nerve-sparing radical prostatectomy, have decreased the incidence of many of these complications. Genitourinary complications due to pelvic surgery remain common, however, and as new surgical advancements are made, new complications may present. An understanding of the prevention, recognition, and treatment of urologic complications is important for every surgeon performing major pelvic surgery.

Laparoscopic management of suspected acute pelvic inflammatory disease

STUDY OBJECTIVE

To evaluate the efficacy of acute-phase operative laparoscopy in women with suspected pelvic inflammatory disease (PID).

DESIGN

Open series (Canadian Task Force classification II-3).

SETTING

University hospital.

PATIENTS

Thirty-three patients with clinically suspected PID.

INTERVENTION

Acute-phase operative laparoscopy.

MEASUREMENTS AND MAIN RESULTS

Laparoscopy confirmed the diagnosis of PID in 20 (61%) patients; 11 (33%) women had other disease and 2 (6%) had no evidence of disease. Laparoscopic procedures in women with PID were pelvic irrigation (all patients), lysis of adhesions (most cases), drainage and irrigation of unilateral or bilateral pyosalpinx (7), drainage and irrigation of tubo-ovarian abscess (3), and extirpation of disease (2). Laparoscopic intervention was also performed in 11 (85%) of 13 women without PID. No major complications occurred.

CONCLUSION

Acute-phase operative laparoscopy provided a final diagnosis in all but three patients (91%).

MR imaging in pelvic inflammatory disease: comparison with laparoscopy and US

PURPOSE

To assess the value of magnetic resonance (MR) imaging in the diagnosis of pelvic inflammatory disease (PID) and to compare MR imaging with transvaginal ultrasonography (US) and laparoscopy.

MATERIALS AND METHODS

Thirty consecutive patients hospitalized because they were clinically suspected of having PID underwent transvaginal US and T1-weighted spin-echo, T2-weighted turbo spin-echo, and inversion-recovery MR imaging at 1.5 T. All patients underwent laparoscopy after MR imaging.

RESULTS

PID was laparoscopically proved in 21 (70%) patients. The MR imaging diagnosis agreed with that obtained with laparoscopy in 20 (95%) of the 21 patients with PID. The imaging findings for PID were as follows: fluid-filled tube, pyosalpinx, tubo-ovarian abscess, or polycystic-like ovaries and free pelvic fluid. Findings at transvaginal US agreed with those at laparoscopy in 17 (81%) of the 21 patients with PID. The sensitivity of MR imaging in the diagnosis of PID was 95%, the specificity was 89%, and the overall accuracy was 93%. For transvaginal US, the corresponding values were 81%, 78%, and 80%.

CONCLUSION

MR imaging is more accurate than transvaginal US in the diagnosis of PID and provides information about the differential diagnosis of PID. MR imaging may reduce the need for diagnostic laparoscopy.

Pelvic inflammatory disease. From diagnosis to prevention

Pelvic inflammatory disease (PID) refers to infection of the uterus, fallopian tubes, and adjacent pelvic structures that is not associated with surgery or pregnancy. PID causes major medical, social, and economic problems worldwide. Long-term sequelae, most notably tubal factor infertility and ectopic pregnancy, are common and extremely costly to the healthcare system. The most important causative micro-organisms are Chlamydia trachomatis, Neisseria gonorrhoeae, and micro-organisms associated with bacterial vaginosis. The clinical spectrum of PID ranges from subclinical endometritis to severe salpingitis, pyosalpinx, tubo-ovarian abscess, pelvic peritonitis, and perihepatitis. Clinical diagnosis of PID has limitations. The clinical diagnostic criteria are insensitive and nonspecific, and false-positive and false-negative diagnosis is common; however, direct visual diagnosis is not always feasible, requires general anesthesia, and is costly. More research is needed of noninvasive diagnosis of PID. Current treatment guidelines call for broad-spectrum antimicrobial coverage. Screening for asymptomatic chlamydial infection is the mainstay of prevention of PID. Emerging evidence from randomized controlled trials provides strong evidence that intervention with selective screening for chlamydial infection effectively reduces the incidence of PID.

Design of the PID Evaluation and Clinical Health (PEACH) Study

This paper describes the PID Evaluation and Clinical Health Study (PEACH), a multicenter, randomized clinical trial designed to compare treatment with outpatient and inpatient antimicrobial regimens among women with pelvic inflammatory disease (PID). PEACH is the first trial to evaluate the effectiveness and cost-effectiveness of currently recommended antibiotic combinations in preventing infertility, ectopic pregnancy, chronic pelvic pain, recurrent PID, and other health outcomes. It is also the largest prospective study of PID ever conducted in North America. We describe the PEACH study's specific aims, study organization, patient selection criteria, conditions for exclusion, data collected upon entry, randomization and treatment, adherence measures, follow-up activities, quality-of-life measures, outcomes, and statistical analyses. In the first 11 months of enrollment (March 1996-January 1997), 312 women were randomized. Of eligible women, 59% consented to enroll. Participating women are primarily black (72%) and young (mean age 24 years). After a median of 5.5 months of follow-up, we were in contact with 95% of study participants. The PEACH study will provide a rationale for selecting between inpatient and outpatient antibiotic treatment, the two most common treatment strategies, for PID.

Pelvic inflammatory disease in the adolescent population

Statistics suggest that the adolescents have a higher rate of diagnosis of pelvic inflammatory disease than any other age group. Early recognition improves the chances of preventing the long-term consequences of ectopic pregnancy and tubal infertility. For a significant number of teens, the symptoms are mild or vague, requiring a high index of suspicion by the physician to initiate treatment. The purpose of this article is to review the currently accepted guidelines for diagnosis and management of pelvic inflammatory disease in the adolescent patient.

Can serology diagnose upper genital tract Chlamydia trachomatis infections? Studies on women with pelvic pain, with or without chlamydial plasmid DNA in endometrial biopsy tissue

BACKGROUND

Upper genital tract chlamydial infections in women are on the increase, and serology might be a convenient tool for diagnosis. Evaluations of this approach are needed in women with or without microbiologic evidence of organisms in the upper genital tract.

GOALS

To compare the results of antibody assays with cervical culture and upper genital tract histopathology in women with pelvic pain and chlamydial plasmid DNA in endometrial biopsies.

STUDY DESIGN

Chlamydia trachomatis plasmid DNA was detected by polymerase chain reaction (PCR) on extracted deparaffinized endometrial biopsy tissue. Five antichlamydial antibody assays were performed measuring total antibodies or immunoglobulin G (IgG), IgM, and IgA classes on sera from 14 women with plasmid DNA as well as 31 without plasmid DNA.

RESULTS

Accepting the presence of plasmid DNA as the gold standard, no single test had total diagnostic accuracy. The best sensitivity and specificity occurred with the following assays: whole inclusion fluorescence (WIF) (100% and 80.6%); microimmunofluorescence IgM (MIF IgM) (78.6% and 93.6%); and heatshock protein-60 enzyme immunoassay (42.9% and 100%). Although recombinant anti-lipopolysaccharide enzyme-linked immunosorbent assays measured anti-chlamydial antibodies in a large proportion of these women, specificity was low. The sensitivity and specificity of cervical culture was 28.6% and 100% and of endometrial histopathology was 71.4% and 48.4%. Analysis of patient serological profiles suggested that and 6 women without plasmid DNA may have been cases that were missed by PCR.

CONCLUSIONS

Evaluations of assays to diagnosis Chlamydia trachomatis upper genital tract infections could use the presence of organisms or their markers in the upper genital tract as a standard of comparison. Some of these serological assays, such as WIF or MIF IgM, may be helpful in diagnosis, but more studies are needed.

The role of laparoscopy in the management of pelvic pain in women of reproductive age

OBJECTIVE

To review the diagnostic and therapeutic roles of laparoscopy in women of reproductive age with acute and chronic pelvic pain.

DATA IDENTIFICATION

Studies relating to the use of laparoscopy in women with acute and chronic pelvic pain were identified through the literature and MEDLINE searches.

CONCLUSION(S)

Laparoscopy has an important place in the management of conditions that cause acute pelvic pain in women of reproductive age, including ectopic pregnancy, pelvic inflammatory disease, tubo-ovarian abscess, and adnexal torsion. The procedure frequently facilitates the diagnosis and provides the necessary access for surgical treatment. Prompt diagnosis and effective management prevent complications and help preserve fertility. The role of laparoscopy in women with chronic pelvic pain is more controversial and limited, but abnormal laparoscopic findings are detected in approximately 60% of those who have undergone a multidisciplinary investigation and received a tentative clinical diagnosis. The access provided by laparoscopy permits the effective surgical treatment of many of the conditions encountered, including endometriosis, pelvic adhesions, ovarian lesions, and symptomatic uterine retroversion.

Pelvic inflammatory disease in patients with bilateral tubal ligation

Classic teaching has stated that women who have undergone bilateral tubal ligation (BTL) are not susceptible to pelvic inflammatory disease (PID). The purpose of this study was to confirm the existence of PID in patients with BTL and to compare clinical parameters of these patients with PID patients who have not had BTL. A retrospective chart review of emergency department (ED) patients diagnosed with PID over a 1-year period at a large urban university hospital found 209 patients who fulfilled the criteria for a definition of PID. Of the 209 patients with PID, 24 (11.7%) had undergone BTL. Patients with and without BTL were compared with respect to age, white blood cell count (WBC), temperature, admission rate, length of hospitalization, prior history of PID, culture results, presence of bilateral abdominal pain, presence of rebound tenderness, and complications of tubo-ovarian abscess (TOA) and hydrosalpinx. Patients with BTL had lower WBCs (11,100/microL v14,700/microL) and were 2.5 times less likely to be hospitalized compared to those patients without BTL. These results show that PID in the setting of a prior BTL not only exists but occurs with surprising frequency and deserves further study. Patients with BTL and PID may have a clinically milder form of PID than those patients without BTL.

Oral contraception and the recognition of endometritis

OBJECTIVE

Oral contraceptive use has been associated with a lower risk of symptomatic pelvic inflammatory disease but a higher risk of chlamydial cervicitis. To explain these seemingly contradictory findings, we asked whether oral contraceptive use was more common among women with unrecognized endometritis than among women with recognized endometritis.

STUDY DESIGN

A multicenter case-control study was performed. Women without signs of pelvic inflammatory disease were ascertained through contact tracing of partners with sexually transmitted diseases or through presentation with cervicitis. Women with symptomatic pelvic inflammatory disease met a set of standard clinical criteria. We compared the 43 cases without signs of pelvic inflammatory disease but with endometritis ("unrecognized endometritis") with the 111 controls with recognized pelvic inflammatory disease and endometritis ("recognized endometritis").

RESULTS

Women with unrecognized endometritis were 4.3 times (95% confidence interval 1.6 to 11.7) more likely than women with recognized endometritis to use oral contraceptives.

CONCLUSION

Future studies need to fully characterize the risks and benefits of oral contraceptives in relation to sexually transmitted diseases.

Clinical, laparoscopic and microbiological findings in acute salpingitis: report on a United Kingdom cohort

OBJECTIVE

To determine the clinical features and microbial aetiology of acute salpingitis in women attending an inner city teaching hospital.

DESIGN

Prospective, longitudinal cohort study.

SUBJECTS

One hundred and forty-seven women presenting consecutively with acute abdominal pain and clinical signs of acute salpingitis were evaluated microbiologically and laparoscopically.

RESULTS

One hundred and four women (70.7%) had acute salpingitis diagnosed at laparoscopy. Other pathological conditions were identified in 20 women (13.6%). No visually identifiable pathology was found in 23 (15.6%). Thirty-five women with acute salpingitis had evidence of pelvic adhesions (33.7%). Bilateral tubal occlusion was present in 6 (5.8%) cases. Chlamydia trachomatis was identified in the genital tract in 40 (38.5%) of the women with acute salpingitis and Neisseria gonorrhoeae in 15 (14.4%). A dual infection was present in eight cases (7.7%). Serological evidence suggested that a further seven women (6.7%) had acute chlamydial infections at the time of diagnosis. C. trachomatis was identified in the genital tract of 5/23 (21.7%) of the women who had no laparoscopic evidence of intra-abdominal pathology.

CONCLUSIONS

The responsible care of women with suspected acute salpingitis depends on establishing an accurate diagnosis, so that appropriate therapy can be instigated. This study provides evidence to challenge the outpatient management of acute salpingitis on clinical grounds alone as potentially inadequate. Early laparoscopy in hospitalised women improves diagnostic precision and accurately determines disease severity, providing prognostic information for future fertility. In this urban population, sexually transmitted micro-organisms were the commonest pathogens found in the genital tract of women with acute salpingitis. The high prevalence of C. trachomatis in these women suggests that appropriate chemotherapy for acute salpingitis should always include a specific antichlamydial agent.

The value of transvaginal color Doppler in the assessment of pelvic inflammatory disease

This study compares transvaginal color and pulsed Doppler (TVCD), laparoscopic and clinical findings in 102 women with proven pelvic inflammatory disease (PID). Seventy-two (72) of them had acute symptoms, 11 presented with chronic pelvic pain and 19 patients were infertility cases suspected of tubal etiology. Uterine sonographic findings were demonstrated in 72 patients (70.6%). Free fluid in the cul-de-sac was demonstrated in 39 (38.2%) patients. Ovarian enlargement as the only finding was demonstrated in 6 (5.9%) patients, 22 (21.6%) presented with tubular adnexal structure, while in 74 (72.5%) patients it was of a complex nature. Color flow was obtained in all 6 patients presenting with ovarian enlargement, in 12 (54.5%) of those presenting with tubular adnexal structure, and in 56 (75.7%) of those with complex adnexal mass. Ovarian morphology was clearly delineated from adnexal mass in 59 patients (55.9%). The ipsilateral ovarian flow was altered in 50 of them (84.7%). The mean resistance index (RI) in patients with acute symptoms was 0.53 +/- 0.09 (+/-SD). It significantly differed from those obtained in patients with chronic pelvic pain (RI = 0.71 +/- 0.07) and infertility cases (RI = 0.73 +/- 0.09). We concluded that transvaginal color Doppler is useful additional tool in diagnosis and treatment monitoring in patients with PID.

Observations concerning the microbial etiology of acute salpingitis

OBJECTIVES

The specific aims of this study were (1) to describe the microbiologic characteristics of patients with acute salpingitis and (2) to determine the incidence of bacterial vaginosis in patients with acute salpingitis and whether bacterial vaginosis microorganisms were common upper-genital-tract isolates in these patients.

STUDY DESIGN

Women with pelvic inflammatory disease underwent laparoscopy to confirm the diagnosis of acute salpingitis and for culture of the fallopian tubes and cul-de-sac. Endometrial and minute fimbrial biopsies were performed, and specimens were evaluated for evidence of inflammation. Bacterial vaginosis was diagnosed by vaginal Gram stain.

RESULTS

Eighty-four patients had visually confirmed acute salpingitis. Neisseria gonorrhoeae or Chlamydia trachomatis was isolated from 65 (77.4%) patients. Vaginal microorganisms were isolated from the endometrium in 16 (31.4%) of 51 cases and from the cul-de-sac in 12 (14.3%) of 84 cases. Bacterial vaginosis was present in 61.8% of patients with acute salpingitis, and 100% of anaerobes isolated from the upper genital tract of patients with acute salpingitis were bacterial vaginosis microorganisms. These anaerobes were isolated from the upper genital tract in the absence of a concurrent gonococcal, chlamydial, or Haemophilus influenzae infection in only two cases.

CONCLUSIONS

The initiation of acute salpingitis is predominantly due to the ascending spread of sexually transmitted microorganisms. Bacterial vaginosis is a common concurrent disorder of women with acute salpingitis, and bacterial vaginosis microorganisms are commonly isolated from the upper genital tracts of patients with pelvic inflammatory disease.

Test performance of erythrocyte sedimentation rate and C-reactive protein in assessing the severity of acute pelvic inflammatory disease

OBJECTIVE

The objective of the study was to evaluate the test performance of erythrocyte sedimentation rate and serum C-reactive protein in assessing the severity of acute pelvic inflammatory disease and to determine clinically useful cutoff levels to discriminate mild from severe pelvic inflammatory disease.

STUDY DESIGN

The study population consisted of 72 women with acute pelvic inflammatory disease verified by laparoscopy and endometrial histopathologic studies; 37 patients had mild and 35 had severe pelvic inflammatory disease. Cutoff levels for erythrocyte sedimentation rate and C-reactive protein were determined to reach best sensitivity and specificity to discriminate between severe and mild disease. Clinical and microbiologic data were analyzed by chi 2, or t test. Logistic regression analysis was used to analyze risk factors for severe pelvic inflammatory disease.

RESULTS

Patients with severe pelvic inflammatory disease had higher erythrocyte sedimentation rates and C-reactive protein levels than did those with mild disease. In detecting severe disease an erythrocyte sedimentation rate > or = 40 mm/hr and C-reactive protein levels > or = 60 mg/L had a sensitivity of 97%, a specificity of 61%, a negative predictive value of 96%, and a positive predictive value of 70%. All patients with tuboovarian abscess or perihepatitis and six of seven patients who had anaerobic bacteria isolated from the fallopian tubes tested positive with these cutoff levels.

CONCLUSION

Combined use of erythrocyte sedimentation rate and C-reactive protein levels is useful in assessing the severity of acute pelvic inflammatory disease and augments the clinical decision making regarding treatment.

The role of serum amylase in the diagnosis of acute pelvic inflammatory disease

The use of serum amylase levels in the diagnosis of acute pelvic inflammatory disease (PID) was investigated prospectively. Eighty-five women presenting with the chief complaint of lower abdominal pain were entered into the study; all patients were examined by one of the principal investigators. In addition to the usual laboratory studies, a serum amylase level was obtained on all patients; the investigators were blinded to the results. Patients were diagnosed with PID if they fulfilled previously published clinical criteria. Forty-eight patients met the criteria for the diagnosis of PID (PID group); 37 patients were diagnosed with other disease processes (non-PID group). The average serum amylase level for the PID group was 62 U/L, with a standard deviation (STD) of 24; for the non-PID group, the average was 76 U/L with an STD of 32. Although there was a statistical difference between the two groups (P < .05), there was no clinically significant difference because both values fell within the normal range of serum amylase. The routine use of serum amylase in the diagnosis of acute PID seems to be of no value.

A comparison of pefloxacin/metronidazole and doxycycline/metronidazole in the treatment of laparoscopically confirmed acute pelvic inflammatory disease

A double-blind, randomised study was conducted to compare the efficacy and safety of a combination of pefloxacin and metronidazole versus doxycycline and metronidazole in patients with pelvic inflammatory disease (PID). The clinical diagnosis had to be confirmed by laparoscopy before patients were included. Of the 74 patients who fulfilled the clinical criteria for PID, laparoscopy confirmed the diagnosis in only 40 patients (54%). The microorganism most frequently found as causative pathogen was Chlamydia trachomatis. Both treatment groups showed a good response to the study-medication. At discharge 9 patients in the pefloxacin group (45%) were cured and 10 patients (50%) had improved. In the doxycycline group 7 patients (35%) were cured and 10 patients (50%) had improved. Obviously pefloxacin/metronidazole and doxycycline/metronidazole are equally effective in the treatment of PID.

Surgical considerations in the diagnosis and treatment of pelvic inflammatory disease

Pelvic inflammatory disease continues to be a common finding in young women with lower abdominal pain. Typical emergency room pelvic inflammatory disease, with classic symptoms of pain, fever, and a history of high-risk sexual behavior, is easily diagnosed with a high degree of specificity. However, the majority of patients with pelvic inflammatory disease have atypical symptoms, and their condition may be incorrectly diagnosed and treated. Careful attention to the physical signs of pelvic infection and the evaluation of the vaginal secretions for leukocytes improves diagnostic accuracy. Liberal use of diagnostic laparoscopy to confirm the possibility of acute salpingitis is recommended in young women, who have much to lose from a case of untreated salpingitis. Outpatient treatment with a beta-lactam antibiotic followed by a course of doxycycline adequately treats patients with N. gonorrhoeae and C. trachomatis infections. However, patients with suspected anaerobic upper genital tract infection such as those infections associated with tubo-ovarian abscess or IUD use should be admitted for parenteral antibiotic therapy and observation. Laparotomy and extirpative surgery should be reserved for seriously ill patients with generalized peritonitis associated with rupture of a tubo-ovarian abscess and for patients who do not respond to antibiotic therapy. Sound judgment regarding the extent of extirpative surgery, taking into consideration the wishes of the patient with respect to future fertility and hormone production, will lead to an acceptable outcome.

Diagnosis and laparoscopic grading of acute salpingitis

Pelvic inflammatory disease continues to be a major cause of morbidity in women of reproductive age. Findings of bilateral adnexal tenderness and signs of a lower genital tract infection (mucopus, or leukorrhea, or both) should prompt clinicians to consider the diagnosis of salpingitis in this group of women. Additional signs of infection, such as elevated temperature, palpable adnexal complex, leukocytosis, elevated erythrocyte sedimentation rate, or c-reactive protein, and positive tests for either Neisseria gonorrhoeae or Chlamydia trachomatis will improve the overall specificity of the clinical diagnosis. Endometrial biopsy offers an acceptable approach to documenting objectively inflammation of the upper genital tract. Diagnostic laparoscopy should be considered in all patients but may be especially helpful for those patients in whom a diagnosis is unclear. A laparoscopic grading system based primarily on tubal mobility and inflammation can be useful in predicting duration of in-hospital therapy and future tubal factor infertility.