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Current Approaches to Pelvic Inflammatory Disease

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Current Approaches to Pelvic Inflammatory Disease REVIEW ARTICLE Current approaches to pelvic inflammatory disease Abordagem atual da doença inflamatória pélvica Roberta Maia de Castro Romanelli1, Stella Soares Sala Lima2, Luciana Vilela Viotti3, Wanessa Trindade Clemente4, Regina Amélia Lopes Pessoa de Aguiar5, Agnaldo Lopes Silva Filho5 DOI: 10.5935/2238-3182.20130055 ABSTRACT Pelvic inflammatory disease (PID) is an inflammatory process of infectious nature that 1 Adjunct Professor, Department of Pediatrics, School of Medicine, Universidade Federal de Minas Gerais (UFMG); can affect structures and organs of the upper genital tract. Considering this disease’s Commission for Nosocomial Infection Control, Hospital epidemiological relevance and severe complications, this article provides an update das Clínicas da UFMG. Belo Horizonte, MG – Brazil. 2 Doctoral candidate, School of Medicine, UFMG. Noso- and proposes a systematic approach to PID. The main etiological agents are Neisseria comial Infection Control Committee of the Hospital das gonorrhoeae, Chlamydia trachomatis and other etiological agents of urethritis, cervicitis, Clinicas UFMG. Belo Horizonte, MG – Brazil. 3 Physician. Specialist in obstetrics and Gynecology vulvovaginitis and vaginoses. These are generally of polymicrobial origin, which deter- specialist by Hospital das Clínicas da UFMG. mines the treatment basis for pelvic inflammatory diseases. Women must be checked Belo Horizonte, MG – Brazil. 4 Adjunct Professor, Department of Complementary for PID when experiencing abdominal discomfort, backache, dyspareunia, or presenting Propedeutics, School of Medicine, UFMG. with stains during gynecological examination and prior to transcervical procedures. The Belo Horizonte, MG – Brazil. 5 Adjunct Professor, Department of Gynecology clinical and laparoscopic classification of PID can be divided into: a) stage I (endome- and Obstetrics, School of Medicine, UFMG. tritis/salpingitis without peritonitis), stage II (acute salpingitis with peritonitis), stage Belo Horizonte, MG – Brazil. III (acute salpingitis with tubal occlusion or tube-ovarian abscess), and stage IV (tube- ovarian abscess rupture). Defining the stage guides procedures and treatment, given that in mild forms (stage I) the treatment and follow-up can be performed in the ambulatory environment while moderate to severe cases require hospitalization so that intravenous treatment and treatment outcome monitoring can be started. Supportive treatment, re- moval of intrauterine device (IUD), sexual abstinence and rest are also indicated, as well as counseling on the implications of the disease and partner approach. Key words: Pelvic Inflammatory Disease; Neisseria gonorrhoeae, Chlamydia trachoma- tis; Mycoplasma; Vulvovaginitis; Vaginosis, Bacterial. RESUMO A doença inflamatória pélvica (DIP) é um processo inflamatório de natureza infecciosa que pode atingir estruturas e órgãos do trato genital superior. Devido à sua importância epidemiológica e de suas graves complicações, este artigo atualiza e propõe uma abord- agem sistemática da DIP. Os principais agentes etiológicos são a Neisseria gonorrhoeae, Chlamydia trachomatis e outros agentes etiológicos de uretrites, cervicites, vulvovaginites e vaginoses, em geral, polimicrobiana, o que é a base de sua terapêutica. A mulher deve ser investigada para DIP quando apresenta, especialmente, desconforto abdominal, dor lombar, dispareunia e nódoas ou manchas ao exame ginecológico, previamente a pro- cedimentos transcervicais. A classificação clínico-laparoscópica de DIP pode ser dividida Submitted: 03/29/2010 em: a) estágio I (endometrite/salpingite sem peritonite); estágio II (salpingite aguda com Approved: 01/04/2011 peritonite); estágio III (salpingite aguda com oclusão tubária ou abscesso tubo-ovariano); Institution: estágio IV (abscesso tubo-ovariano roto). A definição do estágio orienta a conduta e o Hospital das Clínicas – Universidade Federal de Minas Gerais tratamento, pois em formas leves (estágio I) o tratamento e seguimento podem ser feitos Belo Horizonte, MG – Brazil ambulatorialmente, enquanto para os casos moderados ou graves a internação hospita- Corresponding Author: lar está indicada para início do tratamento por via endovenosa e monitorização da res- Roberta Maia de Castro Romanelli E-mail: [email protected], posta ao tratamento. O tratamento suportivo, retirada de dispositivo intrauterino (DIU), [email protected] Rev Med Minas Gerais 2013; 23(3): 338-345 338 Current approaches to pelvic inflammatory disease abstinência sexual e repouso também são indicados, além de orientações sobre as implicações da doença e The selected references were included on ac- abordagem do parceiro. count of their relevance for updates on diagnosis and Palavras-chave: Doença Inflamatória Pélvica; Neisseria treatment of PIDs. gonorrhoeae; Chlamydia trachomatis; Mycoplasma; Vulvovaginite; Vaginose Bacteriana. ETIOLOGY INTRODUCTION The etiological agents involved in PID are the main causes of urethritis, cervicitis, and vulvovaginitis and in- Pelvic inflammatory disease (PID) is an inflam- clude Neisseria gonorrheae and Chlamydia trachomatis, matory process of infectious nature that can affect besides Mycoplasma hominis, Mycoplasma genitalium, the structures of the upper genital tract, such as the Ureaplasma urealyticum, Gardnerella vaginalis, Bacte- uterus, fallopian tubes, ovaries and attached struc- roides spp. Other anaerobic bacteria that cause vagino- tures, causing endometritis, salpingitis, oophoritis, ses can also lead to PID, such as Gram-positive cocci tubo-ovarian abscess, and peritonitis. It is generally (e.g. Streptococcus agalactiae, Streptococcus group A, determined by the ascension of a vaginal or cervical Sthaphylococcus sp.) and Enterobacteriaceae (e.g. E. infectious agent, spontaneously or due to procedures coli). PIDs often have polymicrobial etiology, which is such as insertion of intrauterine device (IUD), endo- the basis for therapeutic recommendations.1-3,7 It is sug- metrial biopsy, and curettage.1-3 gested that the presence of bacterial vaginosis agents It affects one million women every year in the Unit- (Lactobacillus producers of hydrogen peroxide, Gard- ed States and is a significant cause of infertility, ectopic nerella vaginalis, Mycoplasma hominis, Gram-negative pregnancy, chronic pelvic pain, and other conditions rods and Ureaplasma urealyticum) increase the risk of of high morbidity and mortality rates among females.3-6 PID (RR = 2.03, 95% confidence interval: 1.16, 3.53).8,9 Its epidemiological and clinical importance, in ad- The most common etiologic agent is Chlamidia dition to its serious complications, means that every trachomatis, especially in women aged 20 to 24.10 Ap- woman should be examined for PID in case of suspi- proximately 70% of women infected with Chlamydia cion due to medical history or pelvic exam and before are asymptomatic, 15 to 80% of them evolve to PID, any transcervical procedure.3-6 of which 10 to 20% will have tubal infertility.11-14 The Defining the diagnosis in accordance with recom- immune response to Chlamydia seems to be involved mended criteria is important for classifying the dis- in the pathophysiology of the evolution into PID and ease, which then guides the therapeutic conduct.1,2,4 can result in infertility because of genetic polymor- This article aims to review and propose a system- phism in the production of cytokines and the type of atic approach to PID. human leukocyte antigen that appears to be associ- ated with that evolution, regardless of antimicrobial therapy.12,15 This microorganism also produces a toxin METHODS responsible for causing lesions and evolution into infertility.16 It is estimated that the incidence rate of This is an integrative review carried out in 2011 infection by this agent in adolescents is 30%, which including publications in the last 10 years with the de- justifies preventive educational policies.17 scriptors “pelvic inflammatory disease” and Neisseria Mycloplasma has been identified as an important gonorrheae, Chlamydia trachomatis, Mycoplasma, vul- agent of PID, found in the endometrium and Fallo- vovaginitis, and bacterial vaginosis. The scope limits pian tubes of patients with PID and also associated were set as studies with women, including random- with infertility.18-20 ized clinical trials, meta-analyzes, guidelines, and re- Several risk factors are associated with PID, espe- views, which resulted in 73 articles being identified. cially those related to sexual behavior (young age, The search used the Medline database via multiple partners, recent new partner, past or current Pubmed (www.pubmed.com), in addition to the infection by STD agents, no use of barrier protection), webpages of the Center for Disease Control and Pre- and uterine manipulation and instrumentation (inter- vention (www.cdc.gov) and the Brazilian Ministry of ruption of pregnancy, use of UID, hysterosalpingogra- Health (www.aids.gov.br). phy, in vitro fertilization, or insemination).3,21 339 Rev Med Minas Gerais 2013; 23(3): 338-345 Current approaches to pelvic inflammatory disease Due to its clinical importance and serious compli- Subclinical evolution complicates the diagnosis cations, every woman should be tested for PID in the and leads to long-term sequelae such as ectopic preg- following situations4: a) at any time in which specular nancy, tubal infertility, tubo-ovarian abscess, and or manual examination is performed; b) when report- chronic pelvic pain. Tubo-ovarian abscess is a severe ing vague abdominal discomfort,
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