Predicting acute pelvic inflammatory disease: a multivariate analysis

Clinical versus laboratory screening for sexually transmitted infections prior to insertion of intrauterine contraception among women living with HIV/AIDS: a randomized controlled trial

STUDY QUESTION

Does laboratory testing after syndromic screening for sexually transmitted infections (STIs) reduce the rate of intrauterine contraception (IUC) removal among women living with HIV/AIDS (WLHA)?

SUMMARY ANSWER

Additional laboratory testing after syndromic screening for STIs did not affect the likelihood that a woman would remove an IUC immediately or within 1 year of IUC use or the frequency of post-insertion unscheduled clinic visits. In low-risk WLHA, the incidence rate of IUC removal is low with or without laboratory testing.

WHAT IS KNOWN ALREADY

Fear of infectious morbidity remains an obstacle to uptake of IUC by WLHA. The value of laboratory testing after syndromic screening for STI before the insertion of IUC remains uncertain.

STUDY DESIGN, SIZE, DURATION

We enrolled WLHA from 2 September to 6 December 2013 and followed them up to 31 December 2014. After syndromic screening, 703 women free of STIs were randomized to either additional laboratory screening or no additional screening for STI before IUC insertion. The randomization sequence was generated by an independent statistician and randomization numbers placed in opaque sequentially numbered sealed envelopes. All women randomized had an IUC inserted and in all 672 participants completed the 1-year follow-up. The study staff who followed up the participants were blinded to the study allocation groups. Incidence rate ratios (IRRs) were used to compare the incidence rates of IUC removal, unscheduled clinic attendance and IUC continuation between the two groups.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women eligible to participate were 18-49 years old at study entry, in a relationship with a male partner, wanted to avoid pregnancy for at least 1 year and were undergoing HIV/AIDS care at Mulago Hospital, Uganda. Participants completed a baseline questionnaire and up to four follow-up questionnaires until discontinuation of IUC, loss to follow-up or end of study observation after 12 months.

MAIN RESULTS AND THE ROLE OF CHANCE

The rate of IUC removal was 8.8% (29/331) in the no additional screening group and 8.0% (27/341) in the additional laboratory screening group [IRR 1.1 (95% CI 0.63-1.93)]. Unscheduled clinic attendances were similar in the two groups at 1 year of IUC insertion: 13.6% (45/331) in the no additional screening group and 12.3% (42/241) in the additional laboratory screening group. During the 1-year follow-up, only five women, three from the no additional screening group and two from the additional laboratory screening group, developed pelvic inflammatory disease (PID), as defined by established diagnostic criteria.

LIMITATIONS, REASONS FOR CAUTION

We were not able to carry out STI risk assessment directly from the men thus women with high-risk partners could have been included in the study and this may be responsible for the lack of a demonstrable effect of additional laboratory screening on incidence rates of IUC removals and unscheduled clinic attendance. The diagnosis of PID was based on clinical signs and symptoms; therefore, subclinical PID could have been missed.

WIDER IMPLICATIONS OF THE FINDINGS

Among WLHA, the incidence rate of IUC removal is low and IUC continuation high. Syndromic screening for STIs could be sufficient in indentifying WLHA who are suitable for IUC use. However, our findings are only generalizable to women in HIV/AIDS care who have access to good follow-up.

STUDY FUNDING/COMPETING INTERESTS

The study was supported by Medical Education for Equitable Services to all Ugandans, a Medical Education Partnership Initiative grant number 5R24TW008886 from the office of Global AIDS Coordinator and the US Department of Health and Human Services, Health Resources and Services Administration and National Institutes of Health. Additional funding was from the Swedish International Development Agency, Swedish Research Council (SIDA/VR). The authors have no competing interests to declare.

TRIAL REGISTRATION NUMBER

This trial was registered at Pan African Clinical Trial, Registry. PACTR 201308000561212.

Increased plasma soluble CD40 ligand concentration in pelvic inflammatory disease

BACKGROUND

The role of soluble CD40 ligand (sCD40L) in pelvic inflammatory disease (PID) remains unclear. We sought to determine whether sCD40L was an efficient serum marker as with WBC and CRP in PID patients.

METHODS

Enzyme-linked immunosorbent assay was used to measure the plasma levels of sCD40L before and after routine protocol treatments in sixty-four PID patients and seventy healthy controls.

RESULTS

The level of plasma sCD40L (pg/ml) was significantly elevated in PID patients (1632.83±270.91) compared to that in normal controls (700.33±58.77; p=0.001) and decreased significantly as compared to that in the same patients (928.77±177.25; p=0.0001) after they received treatment. The concentration of sCD40L was significantly correlated with the level of plasma C-reactive protein (CRP) in the blood (r=0.202, p=0.01, n=134). When the cutoff level of plasma sCD40L levels was determined to be 1612.26pg/ml based on ROC, the sensitivity, specificity, and the area under the curve of plasma sCD40L level for predicting PID were 0.26, 0.97, and 0.58 (95% confidence interval: 0.48-0.68), respectively, while the adjusted odds ratio (AOR) with their 95% CI of plasma sCD40L for PID risk was 7.09 (95% CI=1.14-43.87, p=0.03).

CONCLUSIONS

The expression of plasma sCD40L was increased in patients with PID and detection of plasma sCD40L could be useful for the diagnosis of PID.

Performance of clinical and laparoscopic criteria for the diagnosis of upper genital tract infection

Objective: The purpose of this study was to validate the standard minimal clinical criteria and the laparoscopic triad of tubal edema, erythema, and purulent exudate used to diagnose acute upper genital tract infection.

Methods: Subjects included women who either met the Centers for Disease Control and Prevention's (CDC) minimal criteria for acute pelvic inflammatory disease or had other signs of upper genital tract infection (i.e., atypical pelvic pain, abnormal uterine bleeding, or cervicitis). The subjects were evaluated with a baseline interview comprehensive laboratory testing, and either an endometrial biopsy or laparoscopy with endometrial and fimbrial biopsies for definitive diagnosis of upper genital tract infection. Patients were considered positive for upper genital tract infection if they had any of the following findings: 1) histologic evidence of endometritis or salpingitis; 2) laparoscopic visualization of purulent exudate in the pelvis without another source; or 3) positive testing for Neisseria gonorrhoeae or Chlamydia trachomatis from the endometrium, fallopian tubes, or pelvis.

Results: One hundred twenty-nine women with adequate endometrial samples were evaluated between August 1993 and September 1997, and 62 had complete laparoscopic evaluations. The sensitivities of the CDC's minimal clinical criteria for pelvic inflammatory disease and the laparoscopic triad of edema, erythema, and purulent exudate were 65% and 60%, respectively.

Conclusions: Commonly used minimal clinical criteria for pelvic inflammatory disease and the laparoscopic triad of tubal edema, erythema, and purulent exudate have limited sensitivity with correspondingly high false negative rates.

Diagnostic evaluation of pelvic inflammatory disease

Pelvic inflammatory disease (PID) is a serious public health and reproductive health problem in the United States. An early and accurate diagnosis of PID is extremely important for the effective management of the acute illness and for the prevention of long-term sequelae. The diagnosis of PID is difficult, with considerable numbers of false-positive and false-negative diagnoses. An abnormal vaginal discharge or evidence of lower genital tract infection is an important and predictive finding that is often underemphasized and overlooked. This paper reviews the clinical diagnosis and supportive laboratory tests for the diagnosis of PID and outlines an appropriate diagnostic plan for the clinician and the researcher.

Characteristics of women at low risk of STI presenting with pelvic inflammatory disease

OBJECTIVE

To investigate the background and reproductive history of women who are considered at low risk of sexually transmitted infection (STI) presenting with acute pelvic inflammatory disease (PID).

METHODS

Case-control study, investigating 51 women admitted to hospital with a diagnosis of acute PID and 50 healthy women attending for routine gynecological checkup.

RESULTS

Women with PID were older (p = 0.003) and more often unemployed (p = 0.008), and had a lower educational level (p = 0.000003). Healthy women reported more regular routine attendance to gynecologists (p = 0.0008) and were less often smokers (p = 0.0009). There was no difference between groups regarding age at first sexual intercourse, number of sex partners during life, duration of current sexual partnership, and frequency of sexual intercourse, total number of deliveries, spontaneous abortions, ectopic pregnancies and outcome of last pregnancy. The number of induced abortions was significantly higher in the PID group (p = 0.0004). There were no differences between the groups with regard to previous episodes of PID. Healthy controls more often reported a history of STI (p = 0.00007). IUD was the most commonly reported current contraceptive method in both groups, and there was no difference in contraceptive practices between groups.

CONCLUSION

Women with PID differed from healthy controls only with regard to socio-demographic characteristics and not with regard to common risk factors for PID.

Purulent vaginal and cervical discharge in the diagnosis of pelvic inflammatory disease

In this structured review, we evaluated purulent vaginal and cervical discharge as diagnostic tests for pelvic inflammatory disease (PID). Using a pretest probability of PID (diagnosed clinically) of 50%, we used the odds-likelihood formulation of Bayes' theorem to calculate post-test probabilities of PID (proven by laparoscopy or endometrial biopsy). If abnormal discharge was present, the post-test probabilities of PID ranged from 50% to 73%, with a mean value of 57%. If abnormal discharge was absent, the post-test probabilities ranged from 24% to 52%, with a mean value of 39%. Therefore, the presence or absence of excess white blood cells in vaginal or cervical discharge was not particularly helpful in confirming or excluding PID in patients in whom the diagnosis was suspected from the clinical examination.

Plasma interleukin-1beta, -6, -8 and tumor necrosis factor-alpha as highly informative markers of pelvic inflammatory disease

BACKGROUND

The role of proinflammatory cytokines in pelvic inflammatory disease (PID) is unclear. We therefore determined whether plasma proinflammatory cytokines, interleukin-1beta (IL-1beta), IL-6, IL-8 and tumor necrosis factor-alpha (TNF-alpha) were useful plasma markers in PID patients.

METHODS

Multiplex bead array analysis was used to measure the plasma levels of proinflammatory cytokines in 50 healthy controls as well as in 41 PID patients before and after routine protocol treatments.

RESULTS

IL-1beta, IL-6, IL-8 and TNF-alpha were significantly elevated in PID patients before antibiotic treatment than after treatment. However, IL-8 was not significantly different between healthy controls and PID patients. The relative increase in ratio of IL-6 was significantly correlated with white blood cell count (r=0.448, p=0.003), neutrophil count (r=0.472, p=0.002) and C-reactive protein level (r=0.412, p=0.008).

CONCLUSIONS

IL-1beta, IL-6, IL-8 and TNF-alpha may play an important role in the pathogenesis of PID. These biomarkers, particularly IL-6, could be useful adjuncts for the clinical diagnosis of PID.

Emergency gynaecology

The management of gynaecological emergencies is directed at the preservation of life, health, sexual function and the perpetuation of fertility. Ectopic pregnancy (EP), pelvic inflammatory disease (PID) and miscarriages are common gynaecological emergencies and early recognition and appropriate treatment is essential to avoid unwanted sequelae. Controversy will always exist in clinical medicine because management is mainly based on uncontrolled studies, expert opinion and personal experiences. It is estimated that only 10% of clinical treatments have been validated by prospective, randomised trials. Recent advances have led to earlier diagnosis and more conservative treatment on an outpatient or day care basis in EP and miscarriages.

Laparoscopic and microbiological features of acute salpingitis in developing countries

One hundred and twenty-four out of 198 consecutive women who underwent diagnostic lasparoscopy for clinical symptoms and signs of acute salpingitis at the University College Hospital, Ibadan, Nigeria had acute salpingitis. These were slightly younger than those without acute salpingitis, otherwise there were no differences in the sociodemographic characteristics of the two groups. Urinary and gastrointestinal symptoms, abnormal vaginal discharge, fever (> 38 degrees C) and sexually transmitted organisms were significantly more in women with acute salpingitis. Ninety-five per cent of the Neisseria gonorrhoea cultured were of the PPNG strain. Pelvic adhesions were present in 69.4% of the women with acute salpingitis. Forty-one per cent of the women had tubal occlusion. It was concluded that laparoscopy rather than clinical findings alone would determine the severity of acute salpingitis. This should be performed along with culture of genital discharges and peritoneal fluid for optimum management. The use of a single dose broad spectrum antibiotics active against both PPNG and non-PPNG strains, and chlamydial infections is advocated for treatment in developing countries.

Diagnosis of pelvic inflammatory disease: time for a rethink

OBJECTIVES

To critically evaluate the available evidence base concerned with the diagnosis of pelvic inflammatory disease (PID) based on clinical presentation, and to investigate the relation between signs and symptoms and the presence of laparoscopically diagnosed PID using the largest available dataset.

METHODS

The evidence base was critically evaluated and data collected by Lund University between 1960 and 1969 were used to compare clinical presentation with the results of laparoscopic investigation. Three techniques were used in this investigation-sensitivity and specificity, likelihood ratios, and discriminant analysis.

RESULTS

None of the variables (abnormal vaginal discharge, fever >38 degrees C, vomiting, menstrual irregularity, ongoing bleeding, symptoms of urethritis, rectal temperature >38 degrees C, marked tenderness of pelvic organs on bimanual examination, adnexal mass, and erythrocyte sedimentation rate >or=15 mm in the first hour) had both high specificity and sensitivity-most had low specificity and sensitivity. There was little variation in either the likelihood ratios or the post-test probabilities between the variables. The lowest likelihood ratio (0.97) produced a post-test probability of 78% (95% CI: 74% to 81%) whereas the highest (1.73) had a post-test probability of 84% (95% CI: 81% to 87%). The pretest probability of having PID based on the presence of lower abdominal pain was 79% (95% CI: 76% to 82%). The discriminant analysis indicated that three variables significantly influenced the prediction of the presence of PID: erythrocyte sedimentation rate (p<0.0001), fever (p<0.0001), and adnexal tenderness (p<0.0001). These variables correctly classified 65% of patients with laparoscopically diagnosed PID (95% CI: 61% to 69%).

CONCLUSION

There is insufficient evidence to support existing diagnostic criteria, which have been based on a combination of empirical data and expert opinion. A new evidence base is urgently needed but this will require either a new investigation of the association between clinical presentation and PID based on a laparoscopic "gold standard" or the development of new diagnostic techniques.

The limited clinical usefulness of taking a history in the evaluation of women with tubal factor infertility

OBJECTIVE

To evaluate whether patient histories of gynecological infections predict tubal pathology seen at laparoscopic exam in infertile women.

DESIGN

Cross-sectional analysis from a subset of case-control subjects.

SETTING

Tertiary-level public hospitals with infertility clinics, Mexico City.

PATIENT(S)

Three hundred twenty-one nulligravid infertile women seeking diagnostic workup.

INTERVENTION(S)

Interviews conducted before evaluation by laparoscopy.

MAIN OUTCOME MEASURES(S)

Sensitivity, specificity, and predictive values for correlating previous pelvic inflammatory disease symptoms, vaginal discharge, genital tract infections, and antibodies to Chlamydia trachomatis to confirmed diagnoses of tubal pathology and to severe tubal pathology.

RESULT(S)

Tubal pathology was found in 58% of participants (n = 185), and severe pathology was found in 29% (n = 92). None of the historical infection-related factors alone was a good overall predictor of tubal pathology; high sensitivity values (up to 73%) were offset by low specificity (down to 30%) and vice versa, for each factor. When considered simultaneously, the factors improved the overall predictive ability just slightly (84% sensitivity and 29% specificity) over the individual factors. The validity measures did not improve when examining severe tubal pathology alone.

CONCLUSION(S)

History taking related to past genital tract infections appears to be of little use in the evaluation of infertile women.

Unusual presentations in obstetrics and gynecology

The key to evaluating any patient in the emergency department is to remember to keep an open differential when taking the history and conducting the physical examination. Many of the unusual conditions and complications of gynecologic diseases or procedures discussed in this article can be diagnosed with a careful and complete gynecologic history and examination.

Clinical management of chlamydia and gonorrhea infection in a county teaching emergency department--concerns in overtreatment, undertreatment, and follow-up treatment success

To date, several studies have examined overtreatment or undertreatment of Neisseria gonorrheae, Chlamydia trachomatis, or both in women. However, no study has looked at both subpopulations together, along with eventual treatment of disease-positive patients who were not empirically treated. This study is unique, for it looks at all of these subpopulations to assess overall efficacy of management of these diseases in women. A 1-year prospective, descriptive study was performed in a teaching county hospital Emergency Department (ED). There were 1260 women receiving a pelvic examination and routine GEN-PROBE testing for gonorrhea and chlamydia who were studied. The main outcome measures were the proportion of women disease positive and initially not treated (undertreated), the proportion of women disease negative who were initially treated (overtreated), as well as the follow-up treatment rate for those undertreated. Finally, the subpopulation of women disease positive and not empirically treated was examined in detail. Of 1260 GEN-PROBE-tested women, 81 (6.4%, 95% CI 1.1-11.7%) were disease positive and 31/81 (38.3%, 95% CI 21.2-55.4%) of these women were undertreated. Furthermore, 20/31 (64.5%, 95% CI 43.5-85.5%) women did not return for follow-up treatment. The billable health care dollars of routine GENPROBE testing per woman (n = 11/1260, 0.9%) returning for treatment as a result of the test was $4762.80 US dollars. Four hundred twenty-six (33.8%) of the 1260 women were empirically treated on the initial visit. Of these 426 initially treated women, 376 (88.3%, 95% CI 85.1-91.5%) were GEN-PROBE negative for disease (overtreated). The billable health care dollars of this overtreatment was $12,449.51 US dollars. This study demonstrates that health care providers are substantially overtreating women who are gonorrhea and chlamydia negative. This generates moral, ethical, health care, and financial concerns. Additionally, one-third of disease-positive women are not treated on initial visit and the majority of undertreated patients are not returning for subsequent treatment. This study provides support for investigating improved methods in the management of chlamydia and gonorrhea in women.

Descriptive studies: what they can and cannot do

Descriptive studies often represent the first scientific toe in the water in new areas of inquiry. A fundamental element of descriptive reporting is a clear, specific, and measurable definition of the disease or condition in question. Like newspapers, good descriptive reporting answers the five basic W questions: who, what, why, when, where. and a sixth: so what? Case reports, case-series reports, cross-sectional studies, and surveillance studies deal with individuals, whereas ecological correlational studies examine populations. The case report is the least-publishable unit in medical literature. Case-series reports aggregate individual cases in one publication. Clustering of unusual cases in a short period often heralds a new epidemic, as happened with AIDS. Cross-sectional (prevalence) studies describe the health of populations. Surveillance can be thought of as watchfulness over a community; feedback to those who need to know is an integral component of surveillance. Ecological correlational studies look for associations between exposures and outcomes in populations-eg, per capita cigarette sales and rates of coronary artery disease-rather than in individuals. Three important uses of descriptive studies include trend analysis, health-care planning, and hypothesis generation. A frequent error in reports of descriptive studies is overstepping the data: studies without a comparison group allow no inferences to be drawn about associations, causal or otherwise. Hypotheses about causation from descriptive studies are often tested in rigorous analytical studies.

Accuracy of five different diagnostic techniques in mild-to-moderate pelvic inflammatory disease

OBJECTIVE

To evaluate the clinical diagnosis of pelvic inflammatory disease (PID) compared with the diagnosis of PID made by laparoscopy, endometrial biopsy, transvaginal ultrasound, and cervical and endometrial cultures.

STUDY DESIGN

A diagnostic performance test study was carried out by cross-sectional analysis in 61 women. A group presenting PID (n = 31) was compared with a group (n = 30) presenting another cause for non-specific lower abdominal pain (NSLAP). Diagnosis provided by an evaluated method was compared with a standard diagnosis (by surgical findings, histopathology, and microbiology). The pathologist was unaware of the visual findings and presumptive diagnoses given by other methods.

RESULTS

All clinical and laboratory PID criteria showed low discrimination capacity. Adnexal tenderness showed the greatest sensitivity. Clinical diagnosis had 87% sensitivity, while laparoscopy had 81% sensitivity and 100% specificity; transvaginal ultrasound had 30% sensitivity and 67% specificity; and endometrial culture had 83% sensitivity and 26% specificity.

CONCLUSIONS

Clinical criteria represent the best diagnostic method for discriminating PID. Laparoscopy showed the best specificity and is thus useful in those cases having an atypical clinical course for discarding abdominal pain when caused by another factor. The other diagnostic methods might have limited use.

Clinical predictors of endometritis in women with symptoms and signs of pelvic inflammatory disease

OBJECTIVE

Careful detection and treatment of pelvic inflammatory disease are essential for the prevention of adverse sequelae. The purpose of this study was to evaluate the diagnostic test characteristics of clinical criteria for the diagnosis of pelvic inflammatory disease.

STUDY DESIGN

We performed a cross-sectional analysis of the baseline characteristics of 651 patients enrolled in a multicenter randomized treatment trial for pelvic inflammatory disease. Clinical and laboratory findings were recorded for all patients, and endometrial sampling was performed. We calculated sensitivity and specificity and performed receiver operating characteristic curve analysis and multivariate logistic regression, using histologic endometritis as the criterion standard.

RESULTS

The minimal criteria for pelvic inflammatory disease, as recommended by the Centers for Disease Control and Prevention, had a sensitivity of 83%, in comparison with a 95% sensitivity for adnexal tenderness (P =.001). Of the supportive clinical criteria, the finding most highly associated with endometritis was a positive test result for Chlamydia trachomatis or Neisseria gonorrhoeae (adjusted odds ratio, 4.3; 95% confidence interval, 2.89--6.63). A multivariate logistic regression model indicated that combinations of criteria significantly improve the prediction of endometritis.

CONCLUSION

Sensitivity can be maximized by using the presence of adnexal tenderness as a minimal criterion for the diagnosis of pelvic inflammatory disease, and supportive criteria are helpful in estimating the probability of endometritis.

Association of lower genital tract inflammation with objective evidence of endometritis

The purpose of this report is to evaluate the association between lower genital tract inflammation and objectively diagnosed endometritis. We analyzed the first 157 patients enrolled in the PEACH study, a multicenter randomized clinical trial designed to compare the effectiveness of outpatient and inpatient therapy for PID. Women less than 38 years of age, who presented with a history of pelvic discomfort for 30 days or less and who were found to have pelvic organ tenderness (uterine or adnexal tenderness) on bimanual examination, were initially invited to participate. After recruitment of the first 58 patients (group 1) we added the presence of leukorrhea, mucopurulent cervicitis, or untreated positive test for N. gonorrhoeae or C. trachomatis to the inclusion criteria (group 2, N = 99). We compared rates of endometritis in the two groups and calculated the sensitivity, specificity, and predicted values of the presence of white blood cells in the vaginal wet preparation. The rate of upper genital tract infection in group 1 was 46.5% (27/58) compared to 49.5% (49/99) in group 2. Microbiologic evidence of either N. gonorrhoeae or C. trachomatis increased from 22.4% in group 1 to 38.3% in group 2. The presence of vaginal white blood cells or mucopus has a high sensitivity (88.9%), but a low specificity (19.4%) for the diagnosis of upper genital-tract infection. Assessment of the lower genital tract for evidence of infection or inflammation is a valuable component of the diagnostic evaluation of pelvic inflammatory disease. The presence of either mucopus or vaginal white blood cells is a highly sensitive test for endometritis in patients with pelvic pain and tenderness.

Use of sexually transmitted disease risk assessment algorithms for selection of intrauterine device candidates

Sexually transmitted diseases (STD) are an important contraindication for intrauterine device (IUD) insertion. Nevertheless, laboratory testing for STD is not possible in many settings. The objective of this study is to evaluate the use of risk assessment algorithms to predict STD and subsequent IUD-related complications among IUD candidates. Among 615 IUD users in Kenya, the following algorithms were evaluated: 1) an STD algorithm based on US Agency for International Development (USAID) Technical Working Group guidelines: 2) a Centers for Disease Control and Prevention (CDC) algorithm for management of chlamydia; and 3) a data-derived algorithm modeled from study data. Algorithms were evaluated for prediction of chlamydial and gonococcal infection at 1 month and complications (pelvic inflammatory disease [PID], IUD removals, and IUD expulsions) over 4 months. Women with STD were more likely to develop complications than women without STD (19% vs 6%; risk ratio = 2.9; 95% CI 1.3-6.5). For STD prediction, the USAID algorithm was 75% sensitive and 48% specific, with a positive likelihood ratio (LR+) of 1.4. The CDC algorithm was 44% sensitive and 72% specific, LR+ = 1.6. The data-derived algorithm was 91% sensitive and 56% specific, with LR+ = 2.0 and LR- = 0.2. Category-specific LR for this algorithm identified women with very low (< 1%) and very high (29%) infection probabilities. The data-derived algorithm was also the best predictor of IUD-related complications. These results suggest that use of STD algorithms may improve selection of IUD users. Women at high risk for STD could be counseled to avoid IUD, whereas women at moderate risk should be monitored closely and counseled to use condoms.

Recognition of tubo-ovarian abscess in adolescents with pelvic inflammatory disease

PURPOSE

Ultrasonography of the pelvis is commonly used to diagnose tubo-ovarian abscess (TOA) in patients with pelvic inflammatory disease (PID). Our objective was to determine whether the clinical features of PID differ in adolescents with and without TOA.

METHODS

A retrospective design was used to derive and validate a clinical model differentiating adolescents with PID who did and did not have TOA. The study population consisted of hospitalized adolescents with a discharge diagnosis of PID. Of the 208 patients discharged from January 1, 1990, to July 31, 1993, 87 (42%) met published criteria for PID and comprised the derivation set. Of the 63 patients from August 1, 1993, to June 24, 1994, 30 (48%) met criteria and comprised the validation set. All patients had pelvic ultrasonography performed during hospitalization. The ultrasonography records were reviewed retrospectively for TOA, ovarian and uterine size, clarity of tissue planes, and endometrial or cul-de-sac fluid. Medical records were reviewed for sociodemographic characteristics, medical and sexual history, physical examination, laboratory results, and hospital course.

RESULTS

TOA was present in 17% of the derivation set and 20% of the validation set. A six-variable model developed on the derivation set performed best in differentiating the TOA and non-TOA groups: last menstrual period > 18 days prior to admission (60% and 17%), previous PID (53% and 22%), palpable adnexal mass (13% and 3%), white blood cell count > or = 10,500/microliters (33% and 64%), erythrocyte sedimentation rate > 15 mm/h (33% and 64%), and heart rate > 90/min (40% and 78%). In the derivation and validation sets, the model correctly identified 78 and 83% of the TOA groups and 88 and 77% of the non-TOA groups. The area under the receiver operating characteristic curve of the model was 0.92 in the derivation set and 0.87 in the validation set.

CONCLUSIONS

We conclude that clinical characteristics help identify adolescents with acute PID who have TOA. These patients may have fewer signs of acute illness than those without TOA and may develop symptoms later in the menstrual cycle.

Tubal torsion appearing as acute pelvic inflammatory disease

Torsion of the fallopian tube is an uncommon event with variable features, and may occur in the absence of adnexal disease. A woman had signs, symptoms, and ultrasound findings consistent with acute pelvic inflammatory disease. Laparoscopy established the definitive diagnosis of tubal torsion.

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.

Abdominal pain in women attending a genitourinary medicine clinic: who has PID?

Eighty-one women who presented to a genitourinary medicine clinic with mild to moderate acute or chronic abdominal pain were studied in order to compare the clinical features of those who had pelvic inflammatory disease (PID) and those who did not. The diagnosis was made by laparoscopy, and PID was detected in 14%, adhesions in 11% and endometriosis in 16%. Women with PID were clinically indistinguishable from women with other diagnoses or no obvious cause.

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.

Pelvic inflammatory disease: findings during inpatient treatment of clinically severe, laparoscopy-documented disease

OBJECTIVES

We evaluated the relationship between clinically severe pelvic inflammatory disease and laparoscopic diagnosis and grading, comparative treatment with clindamycin plus cefamandole or doxycycline, and a management protocol for inpatient pelvic inflammatory disease treatment.

STUDY DESIGN

Thirty-three patients who met our clinical criteria for severe pelvic inflammatory disease underwent diagnostic laparoscopy. Pelvic inflammatory disease patients were randomized to double-blind treatment with clindamycin plus cefamandole or doxycycline within our management protocol; postdischarge oral antibiotics were omitted.

RESULTS

Laparoscopy confirmed pelvic inflammatory disease in 23 (70%) patients; 10 (44%) had mild pelvic inflammatory disease by laparoscopic grading. Laparoscopic grade alone predicted necessary duration of therapy to response: mild pelvic inflammatory disease, 2.3 +/- 0.5 days; moderate pelvic inflammatory disease, 2.7 +/- 1.5 days; and severe pelvic inflammatory disease, 3.9 +/- 1.5 days (p less than 0.05). Using the management plan presented, response rates for both antibiotic regimens were 100%.

CONCLUSIONS

Clinical diagnosis and grading of severe pelvic inflammatory disease has poor specificity. Laparoscopic grading of severity of pelvic inflammatory disease seems accurate. Both clindamycin plus cefamandole and clindamycin plus doxycycline are equally effective regimens for treatment of pelvic inflammatory disease and did not require supplementation after discharge. Our management plan is objective and practical; daily bimanual examination is the most sensitive indicator of persistent disease.

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.

Acute pelvic inflammatory disease after surgical sterilization

STUDY OBJECTIVE

Physicians are very cognizant of the possibility of pregnancy after surgical sterilization, but the potential for acute pelvic inflammatory disease (PID) is thought to be rare. This study was undertaken to determine if upper tract PID occurred more frequently than previously reported in patients remote from surgical sterilization.

DESIGN

Retrospective review of hospitalized patients with the primary discharge diagnosis of PID.

SETTING

Urban, university hospital.

PARTICIPANTS

Three hundred sixty-four hospitalized patients with the primary discharge diagnosis of PID over a six-year study period.

MEASUREMENTS AND MAIN RESULTS

Patients' age; gynecologic histories and diagnoses; and laboratory, clinical, and surgical findings were noted. Twenty-three cases of acute PID were identified in 21 patients previously sterilized (6%). Nine of the 23 cases had systemic toxicity warranting surgical evaluation; 18 of the 23 cases were admitted from the emergency department. Mean statistical characteristics of the study group were age, 27.3 +/- 0.8 (SE) years; time interval from sterilization, 49.8 +/- 7.4 months; WBC 15,000 +/- 1,200; and temperature, 38.0 +/- 0.2 C.

CONCLUSION

We conclude that acute PID may occur more frequently than previously reported in patients with prior surgical sterilization. An increased awareness of this entity is warranted.

Laparoscopy-assisted vaginal hysterectomy

Intraoperative laparoscopy was used to evaluate pelvic pathology in 46 patients who had been anesthetized for abdominal hysterectomy. Because traditional indicators--clinical history, pelvic examination, and ultrasound studies--suggested the presence of more serious pelvic pathology, these patients were considered poor candidates for vaginal hysterectomy. Laparoscopic findings, however, revealed that 42 of the 46 (91%) could undergo uncomplicated vaginal surgery (which they did). Laparoscopy-assisted hysterectomy is recommended as an additional method of investigation in order to improve diagnostic accuracy and minimize surgical risk while allowing more frequent selection of the vaginal approach to hysterectomy.

Antisperm antibodies to sperm surface antigens in women with genital tract infection

Antisperm antibodies to sperm surface antigens in nulligravid women with primary upper genital tract infections were measured by the sperm mixed agglutination reaction assay. As many as 56% of women with a primary episode of pelvic inflammatory disease had antisperm antibodies. In addition, 69% of those women with no history of genital tract infection but with laparoscopic evidence of past pelvic infection had significant levels of circulating antisperm antibodies. Electroimmunoblots of sperm preparations probed with the sera of women who had either known or presumed upper genital tract infection revealed a uniformly recognized 69 kd antigen. In contrast, women with circulating antisperm antibodies before primary upper genital tract infection recognized up to five distinct sperm antigen determinants of 27, 54, 131, 146, and 174 kd. It is a distinct possibility that genital tract infections may lead to immunopotentiation of antisperm antibodies that could affect fertility.

The accuracy of clinical findings and laparoscopy in pelvic inflammatory disease

The accuracy of clinical diagnosis for pelvic inflammatory disease was determined in 95 women who presented with pelvic pain to primary care physicians and then were referred to gynecologists. Laparoscopy or laparotomy with endometrial biopsy and fimbrial minibiopsy revealed that prevalence of pelvic inflammatory was 46% (44/95) and positive and negative predictive values of gynecologists were 74% (23/31) and 67% (43/64) (p = 0.0002). If histopathologic diagnosis was the standard, clinical accuracies of the gynecologists were no better than chance (p = 0.43), suggesting an expectation bias for visual diagnosis. Laparoscopy had a sensitivity of 50% (12/24) and a specificity of 80% (40/50) for salpingitis if the standard was fimbrial histopathologic diagnosis (p = 0.01). These results support the routine use of laparoscopy, supplemented when negative by endometrial and fimbrial minibiopsy, to accurately diagnose pelvic inflammatory disease.

Pelvic inflammatory disease

The costs of PID to both individuals and society are enormous. Although primary prevention of PID through control of lower genital tract infections is the most effective prevention strategy, early diagnosis and treatment of acute PID may minimize some of its serious sequelae. Although laparoscopy is helpful for establishing the diagnosis of salpingitis, other less invasive tests along with selected clinical criteria may also be useful. Treatment of PID, which is empiric and broad spectrum, is oriented toward polymicrobial PID. Whenever possible, women with PID should be hospitalized for parenteral therapy. The 1989 CDC STD treatment guidelines recommend two regimens for inpatient parenteral therapy: clindamycin/gentamicin and cefoxitin, or equivalent cephalosporin/doxycycline. Outpatient management of PID should be monitored closely; the CDC-recommended regimen includes use of intramuscular cephalosporins and oral doxycycline. Oral penicillins are no longer recommended.

C-reactive protein is a marker for the diagnosis of adnexitis

The study reports the C-reactive protein (CRP) plasma concentrations in 115 women with a presumed diagnosis of acute adnexitis. In addition to CRP, blood sedimentation rate, white blood cell count and the body temperature were evaluated and compared with the clinical findings. Diagnosis was confirmed or excluded by laparoscopy (n = 69) or laparotomy (n = 9). Clinical examinations and conventional laboratory examinations were of limited value in the diagnosis of acute adnexitis. In contrast, CRP was a highly sensitive indicator of inflammatory pelvic disease. Furthermore, the CRP determination was superior in assessing the efficacy of an antibiotic treatment.