ACUTE PELVIC INFECTION

M. Otero-Garcíamila.oterogarcia@gmail.com

Infection of:

- Upper genitalia (endometrium, fallopian tubes, ovaries)

- Adjacent pelvic structures

FEMALE PELVIC INFECTION

Gynecological causesPelv ic inf lammatory disease (PID )

Endomet r i t i s

Sa lp ing i t i s

Tubo-ovar ian abscess

F i t z -Hugh-Cur t i s Syndrome

Puerperal infect ions

Cesarean sec t ion

Vagina l de l ivery

Post-operat ive gynecolog ica l surgery

Pe lv ic abscess

Pos t l e iomyomas embol iza t ion in fec t ion

F i s tu lae

Abort ion-assoc iated infect ions Endomet r i t i s Incomple te sep t ic abor t ion

PELVIC INFECTION CAUSES

Non-Gynecological causes

Intestinal: appendicitis, diverticulitis, Crohn…

Urinary: ureteritis, cistitis

Tuberculosis, Actinomycosis: chronic, acute

No specific international data are available for PID incidence worldwide

The annual rate of PID in high-GNP countries has been reported to be as high as 10-20 per 1000 women of reproductive age (most < 25 year-old)

24% of visits to the E. departments for gynecological pain are attributable to PID

Annual cost: $ 10 billion (acute care and sequelae: tubal factor infertility, ectopic pregnancy, chronic pelvic pain, recurrent infection, life treatening condition if TOA rupture)

P o t t e r AW. R a d i o G r a p h i c s 2 0 0 8

C ro s s m a n S H . A m e r i c a n F a m i l y P h y s i c i a n . 2 0 0 6

S r i k a r A d h i k a r i . T h e J o u r n a l o f E m e rg e n c y M e d i c i n e , 2 0 0 8

PID

RISK FACTORS FOR PID

Young age Multiple sex partners High coital frequency Low socioeconomic status Douching Use of intrauterine device (particularly during the first few months

of insertion)

Barre t S e t a l . I n t e rna t i ona l Jour na l o f ST D & AIDS 2005

Mi ndy M. Horrow. U l t ra sound Quar t e r l y 2004

Extension to: parametrial structures

Direct ascent to the upper genital tract: pyosalpinx, TOA salpingitis endometritis

Acquisition of a vaginal or cervical infection: endocervicitis

Soper DE. Obs te t Gyneco l 2010

PIDPATHOPHYSIOLOGY

Beyond the pelvis

Less commonly: - Direct spread from nearby appendicitis or diverticulitis- Hematogenous, lymphatic, peritoneal spread: TB salpingitis

PID

70%• N. Gonorrhoeae • C. Trachomatis• Mycoplasma genitalium

30%

• Polymicrobial• Streptococcus species,

Escherichia coli, Hemophylus influenza, Bacteroides species, Peptostreptococcus, Peptococcus…………..

MICROBIAL ETHIOLOGY

Barret S. Int J STD AIDS. 2005Soper DE.Obstetrics and Gynecology 2010

PID DIAGNOSIS

Clinical history:

Asymptomatic (30%) - non-specific symptoms:

Abdominal/pelvic pain

Abnormal discharge Intermenstrual bleeding

FeverUrinary frequency

Low back pain Nausea/vomiting

PID should be suspected and treatment in i t ia ted i f :- High r i sk of PID and- Uter ine , adnexal , o r cerv ica l mot ion tenderness on b imanual pe lv ic examinat ion

Findings that support the diagnos i s (1 or more)- Cerv ica l o r vag ina l mucopuru len t (g reen or ye l low) d i scharge- Elevated ery t rocy te sed imenta t ion ra te or C-reac t ive pro te in- Labora tory conf i rmat ion of gonorrhea l or ch lamydia l in fec t ion- Oral t empera ture (38 .3 ºC) or g rea ter- White b lood ce l l s on vagina l secre t ion sa l ine wet mount ( per iphera l whi te b lood ce l l

count i s commonly normal )

Elaborate cr i ter ia (addi t ional f indings)- Pos i t ive l aparoscopy or endomet r ia l b iopsy- Pyosa lp inx , TOA on imaging

CDC: Centers for Disease Contro l and Prevent ion guide l ines on sexual ly t ransmi t ted d i seases . MMWR Recomm Rep 2006.

CDC DIAGNOSTIC CRITERIA FOR PID

PID DIAGNOSISPHYSICAL EXAMINATION AND LABORATORY STUDIES

TREATMENT

Up to 90% of women have mild PID - treated as outpatients

10% of women have severe PID: complications

The identification of patients who require hospitalization are usually accomplished with imaging studies

Imaging is required:

- to determine the origin and the extent of the process, if symptoms are nonspecific

- to evaluate for complications such as abscess, if the patient is not responding as expected to treatment, and

- to decide if a known abscess is amenable to percutaneous drainage.

Maryam Rezvani . RadioGraphics 2011

Abraham A. Ghiatas , Eur Radiol 2004

PID DIAGNOSISIMAGING

USTransvaginalSensitivity: 81%

Specificity:78%

Accuracy: 80%

Transabdominal

CTSensitivity: <65% Specificity: >90% Accuracy: 84%

- After-hours availability

- Symptoms are nonspecific

- Process beyond the pelvis - Limiting factor: ionizing radiation

MRSensitivity: 95%

Specificity: 89%

Accuracy: 93%

- No radiation

- Limiting factor: expensive, less available

- Pregnant patient

- Complex adnexal mass

- Diff. pyosalpinx/ hematosalpinx

- Chronic PID: fibrosis, adhesions

Tukeva TA et al. Radiology 1999Young SI et al. J. Obstet. Gynaecol. Res.2011

- No cooperate because they are suffering from excessive pain

- Large amounts of gas preventing ultrasound penetration

- Obesity

US

Transvaginal

Transabdominal

CT

MRACR: 9

ACR: 5 - Gyn 9 - N- Gyn

ACR: 6 - Gyn 3 - N- Gyn

• ACR Appropriateness Criteria® acute pelvic pain in the reproductive age group. http://www.guidelines.gov/content.aspx?id=15779&search=Acute+pelvic+pain

• Heverhagen JT. RadioGraphics 2009

The American College of Radiology Appropriateness Criteria® still rate MR imaging below CT and US for the evaluation of acute abdominal and pelvic conditions

1 = least appropriate; 9 = most appropriate

EARLY STAGE OF PIDIMAGING FINDINGS

Normal

Non- specific findings:

. Fluid in the endometrial and endocervical cavities

. Mild enlargement or indistinctness of the uterus

. Enlarged ovaries with “polycystic ” appearance

. Fluid in the cul-de-sac (50% of patients with PID)

Horrow MH. Ultrasound Quarterly 2004

EndometritisAbnormal endometrial enhancement and fluid

Mild oophoritis

Sam JW.RadioGraphics 2002

MILD STAGE OF PIDIMAGING FINDINGS

Mild salpingitisNot tubal dilatation but wall tickening (> 5mm), enhancement, and surrounding inflammation

Mild pelvic edemaThickening of the uterosacral l igaments and haziness of

the pelvic fat

Sam JW.RadioGraphics 2002

MILD STAGE OF PIDIMAGING FINDINGS

Pyosalpinx

ADVANCED STAGES OF PID

Most specific sign of PID at CT

Sam JW.RadioGraphics 2002

Potter AW. Radiographics 2008

- Stranding of the

pelvic fat

- Lymphadenopathy

ADVANCED STAGES OF PID

Jung SI et al. J. Obstet. Gynaecol. Res. 2011

Peritonitis- Thickening of

pelvic ligaments

- Obscuration of the pelvic fascial planes

MR Hematosalpinx/Pyosalpinx

FST1w

T2w

FST1w- Gd

T2w

PID

16 year-old girl: pelvic pain, fever, nauseaBimanual uterine and adnexal tendernessLeukocytosis (white blood cell count, 17,200/μL [reference value, <10,000/μL])

FS T1 w +C T2 w

STIR STIR

TVUS – guided drainage

HYDROSALPINX VS PYOSALPINX

PYOSALPINX: - Active and acute infection with obstruction of the FT- Thick enhancing wall and surrounding inflammation- Image: depends on the content of protein US: hipoechoic-hyperechoic. MR: hypointense, heterogeneous T1W, hyperintense T2W

HYDROSALPINX: - Chronic disease - Results from the obstruction of the ampullary segment: PID, tubal surgery…. - Thin-thick wall, no enhancement and no surrounding inflammation - Image: US: anechoic MR: hypointense T1W, hyperintense T2W

CE T1 w

Courtesy: Dr. John SpencerTubal and peritubal adhesions with obstruction of the fimbrial end lead to:

Tubal shape changes - Sharp change of shape: “ beak sign”

HYDROSALPINX

”cogwheel sign”: or small round projections on axial imaging-- thickened longitudinal folds

Accurate findings for diagnosing hydrosalpinx

Tubular “C” “S”

“waist sign”: incomplete septa result from the distended tube folding on itself

1/3 women with severe PID

TOA

Heterogeneous mass Indistinct ovaries

- Fluid-containing mass with a thick enhancing wall and septations

- Anterior displacement of thickened broad ligament

Kim SH. RadioGraphics 2004

- Pyosalpinx adjacent to or in a portion of TOAs

- Extension to form abdominal abscesses

TOA

- A more specific sign of tubo-ovarian abscess: gas bubbles

TOA

30 % of patients with TOA respond to treatment: (parenteral antibiotics 48 h ---- oral antibiotics for up to 14 days)

If conservative treatment fails:- Image-guided percutaneous (US, CT) or surgical drainage

(laparotomy, laparoscopy)

L evenson RB . J Vasc In t e rv Rad i o l 2011

PID ABDOMINAL COMPLICATIONS

Spread of infection via the right paracolic gutter

Rezvani M.RadioGraphics 2011

- Perihepatitis: thickening and enhancement of the anterior liver capsule

- Subcapsular and periportal alterations of perfusion

Fitz-Hugh-Curtis Syndrome

Ureteral obstruction

PID COMPLICATIONS

Small or large bowel ileus or obstruction

Right ovarian vein thrombosis

EctopicRupture of ovarian cyst: corpus luteum, follicle, endometrial

cystAdnexal torsionOther pelvic cystic masses

PID DD

AppendicitisInflammatory bowel diseases (Crohn, ulcerative colitis), infectious

terminal ileitis (Yersinia enterocolitica, Y. pseudotuberculosis,Campylobacter jejuni, and M.tuberculosis)

DiverticulitisBladder – ureteral infection

Right ovarian torsion

Appendix diameter (>10 mm), wall (> 2 mm)

Appendicitis PID

Crohn disease

22 year-old woman

Terminal ileitis

Diverticulitis

65 year-old. Right adnexal tenderness, fever, leukocytosis

Chronic infection by Actinomyces israelii

Opportunistic pathogen: normally present in oral cavity or colon

Gynecological Actinomycosis is highly associated with the use of IUDs.

Chronic suppurative disease Abundant granulation Dense fibrous tissue Multiple abscesses Sinus tracts

ACTINOMYCOSIS

Heterogeneous, well or badly defined adnexal masses, contrast enhancement (rim-enhancement) in the solid portion

ACTINOMICOSIS IMAGING

Courtesy: Dr. A. J Van der Molen

ACTINOMICOSISIMAGING

- Abscess

- Thick, linear, enhancing lesions extending into the adjacent tissue planes, which reflects the invasive nature of actinomycosis

Courtesy: Dr. A. J Van der Molen

Genital tract involvement is detected in 1.3% of female patients with tuberculosis: endometrium (72%), salpinx (34%), ovary (12.9%), and cervix (2.4%).

It can mimic ovarian cancer by both radiological findings and

clinical settings (elevated serum CA-125)

TUBERCULOSIS

Findings can be various according to the stage and the route of this infection

General peritoneal tuberculosis, minimal salpingitis with enlarged FT, without obstruction

Image findings mimic those of peritoneal carcinomatosis

TUBERCULOSIS AT IMAGING

TUBERCULOSIS AT IMAGING

Tubo-ovarian involvement is usually caused by hematogenous or lymphatic spread.

- Cystic or both solid and cystic adnexal masses, usually bilateral

- Ascites, omental or mesenteric infiltrations, and peritoneal thickening

(*peritoneal carcinomatosis from ovarian cancer)

- Calcifications, not frequently observed

- Lymph node enlargement

PID and other gynecological issues

ACUTE PELVIC INFECTIONDIAGNOSIS

AppendicitisCrohn, terminal ileitis, diverticulitis TB, Actinomycosis

DiagnosisClinical history, laboratory,

US, MR US, CT, biopsy, MR

Imaging