Pelvic Inflammatory Disease in Adolescents

Pelvic inflammatory disease in the adolescent and young adult: An update

Pelvic inflammatory disease (PID) is an infection of the female upper genital tract that is typically polymicrobial with classic core involvement of Neisseria gonorrhoeae and/or Chlamydia trachomatis, though other endogenous flora from the vagino-cervical areas can be involved as well. It is often a sexually transmitted disease but other etiologic routes are also noted. A variety of risk factors have been identified including adolescence, young adulthood, adolescent cervical ectropion, multiple sexual partners, immature immune system, history of previous PID, risky contraceptive practices and others. An early diagnosis and prompt treatment are necessary to reduce risks of PID complications such as chronic pelvic pain, ectopic pregnancy and infertility. Current management principles of PID are also reviewed. It is important for clinicians to screen sexually active females for common sexually transmitted infections such as Chlamydia trachomatis and provide safer sex education to their adolescent and young adult patients. Clinicians should provide comprehensive management to persons with PID and utilize established guidelines such as those from the US Centers for Disease Control and Prevention (CDC).

Unusual presentation of bilateral pyosalpinx mimicking an ovarian torsion: A case report

Introduction

A pyosalpinx is the acute inflammation of the Fallopian tube fills up and swells with pus, which commonly results from inadequate or delayed treatment of pelvic inflammatory disease. Herein we report a case of bilateral pyosalpinx mimicking an ovarian torsion.

Presentation of case

We reported the case of a 27-year-old female patient, who presented to the emergency department with complaints of constant, worsening lower abdominal pain for 2–3 days. Pelvic and transvaginal ultrasound examinations were performed which demonstrated a large, complex cystic structure in the right adnexa with peripheral flow on color Doppler imaging. The possibilities included ovarian torsion or hemorrhagic cyst. Intraoperative findings showed bilateral pyosalpinx and treated successfully by laparoscopic bilateral salpingostomy.

Conclusion

The present case highlights the diagnostic dilemma of bilateral pyosalpinx must be taken into account in the differential diagnosis of ovarian torsion or tumor, particularly in women of reproductive age.

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Bilateral pyosalpinx is a unique clinical challenge.

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Bilateral pyosalpinx must be taken into account in the differential diagnosis of ovarian torsion endometriosis, dermoid cysts or other cystic ovarian masses.

Association of pelvic inflammatory disease (PID) with ectopic pregnancy and preterm labor in Taiwan: A nationwide population-based retrospective cohort study

Background

Pelvic inflammatory disease (PID) is an infectious disease that causes tubal occlusion and other pelvic and abdominal adhesions. The incidence of pelvic inflammatory disease (PID) has increased due to the sexually active status of the young population. This leads to a more serious problem and a larger effect than previously observed. However, there have been few studies on this topic in Asian populations.

Aim

We aimed to evaluate the risk of preterm labor and/or ectopic pregnancy in Taiwanese women following PID.

Design

Using the Taiwan National Health Insurance Database, we designed a retrospective cohort study that included 12- to 55-year-old pregnant women between 2000 and 2010. We selected a 1:3 age-matched control group of non-PID women. The endpoint was any episode of preterm labor or ectopic pregnancy; otherwise, the patients were tracked until 31 December 2010.

Methods

The risk factors for preterm labor or ectopic pregnancy were explored. For cases included from the index date until the end of 2010, we analyzed the risk of incident preterm labor or ectopic pregnancy. With the use of a multivariate Cox proportional hazard regression analysis, we calculated the hazard ratio (HR) with a 95% CI and compared it with that of the control group.

Results

This study examined 30,450 patients with PID and 91,350 controls. During the follow-up period, patients in the PID group were more likely to develop preterm labor or ectopic pregnancy than patients in the control group. The cumulative incidence rates for developing preterm labor were 1.84% (561/30,450 individuals) in patients with PID and 1.63% (1492/91,350 individuals) in patients without PID. On the other hand, the cumulative incidence rate for developing ectopic pregnancy in patients with PID was 0.05% (14/30,450 individuals) but was only 0.04% (33/91,350 individuals) in patients without PID. Compared with those without PID, the patients with PID had a 1.864 times (P<0.001) higher risk of developing preterm labor and a 2.121 times (P = 0.003) higher risk of developing ectopic pregnancy.

Conclusion

Our study provided evidence of an increased risk of preterm labor or ectopic pregnancy in PID patients.

Sustained Simultaneous Delivery of Metronidazole and Doxycycline From Polycaprolactone Matrices Designed for Intravaginal Treatment of Pelvic Inflammatory Disease

Poly(ɛ-caprolactone) (PCL) intravaginal matrices were produced for local delivery of a combination of antibacterials, by rapidly cooling a mixture of drug powders dispersed in PCL solution. Matrices loaded with different combinations of metronidazole (10%, 15%, and 20% w/w) and doxycycline (10% w/w) were evaluated in vitro for release behavior and antibacterial activity. Rapid "burst release" of 8%-15% of the doxycycline content and 31%-37% of the metronidazole content occurred within 24 h when matrices were immersed in simulated vaginal fluid at 37°C. The remaining drug was extracted gradually over 14 days to a maximum of 65%-73% for doxycycline and 62%-71% for metronidazole. High levels of antibacterial activity up to 89%-91% against Gardnerella vaginalis and 84%-92% against Neisseria gonorrhoeae were recorded in vitro for release media collected on day 14, compared to "nonformulated" metronidazole and doxycycline solutions. Based on the in vitro data, the minimum levels of doxycycline and metronidazole released from PCL matrices in the form of intravaginal rings into vaginal fluid in vivo were predicted to exceed the minimum inhibitory concentrations for N. gonorrhea (reported range 0.5-4.0 μg/mL) and G. vaginalis (reported range 2-12.8 μg/mL) respectively, which are 2 of the major causative agents for pelvic inflammatory disease.

Mycoplasma genitalium: An Emerging Sexually Transmitted Infection

Mycoplasma genitalium has been recognized as a cause of male urethritis, and there is now evidence suggesting that it causes cervicitis and pelvic inflammatory disease in women. M. genitalium is a slow growing organism, and, with the advent of nucleic acid amplification test (NAAT), more studies are being performed, and knowledge about the pathogenicity of this organism elucidated. With NAAT detection, treatment modalities have been studied, and the next challenge is to determine the most effective antimicrobial therapy. Doxycycline, the first-line antibiotic for urethritis, is largely ineffective in the treatment of M. genitalium and furthermore, resistance to macrolide has also emerged. The most effective drug is Moxifloxacin although there are emerging reports of resistance to it in various parts of the world. This paper not only highlights the current research and knowledge, but also reviews the diversity of health implications on the health of men and women infected with M. genitalium. Alternate antibiotics and the impact of M. genitalium on infertility are areas that require more studies as we continue to research into this microorganism.

A case of adolescent pelvic inflammatory disease caused by a rare bacterium: Fusobacterium nucleatum

BACKGROUND

Pelvic inflammatory disease (PID) is a polymicrobial infection that typically occurs in sexually active females. PID is rare in premenarchal and/or noncoital young women; however, there are case reports of PID occurring in virginal females. We present the first reported case of PID associated with F. nucleatum. In this unusual case of PID in an adolescent, the responsible organism may have originated from the patient's oral cavity.

CASE

A 13-year-old noncoital Caucasian female presented to a tertiary children's hospital with fever and acute abdominal/pelvic pain. She had experienced a perforated appendix 14 months prior, which was treated by laparoscopy. Postoperatively, she experienced intermittent episodes of recurrent abdominal pain. During this presentation, the physical examination and ultrasound findings were suspicious for an ovarian torsion. She was taken to the operating room where she had an examination under anesthesia and a diagnostic laparoscopy. Findings at the time of laparoscopy were in keeping with a diagnosis of pelvic inflammatory disease. Oral and pelvic fluid cultures were positive for F. nucleatum. She was subsequently treated with antibiotics and her symptoms resolved.

SUMMARY AND CONCLUSION

This case highlights the importance of including PID in the differential diagnosis of noncoital adolescent females presenting with an acute abdomen. Although most Fusobacteria infections are periodontal in nature, translocated infections to the pelvis may have long-term implications for reproductive health. This case also highlights the importance of the role of diagnostic laparoscopy in young women who have persistent pain following previous surgery due to the potential of missed pathology or subclinical infection.

Status of adolescent pelvic inflammatory disease management in the United States

PURPOSE OF REVIEW

Pelvic inflammatory disease (PID) is a common and serious reproductive health disorder and disease rates remain unacceptably high among adolescent girls and young adult women in the United States. Despite data demonstrating that women experience major adverse health outcomes after PID, national recommendations for management of adolescents have become increasingly less cautious in an era of cost-containment. In this review, we take an alternative look at published data on adolescents with PID to frame the next steps for optimizing management for this vulnerable population.

RECENT FINDINGS

Several findings emerge from review of the literature. First, there is limited evidence to guide the best practice strategies for adolescents with PID due to low enrolment of early and middle adolescents in national trials. Second, adolescents and adult women in the United States receive suboptimal treatment regimens per Centers for Disease Control and Prevention (CDC) standards. Third, available evidence suggests that adolescents are at an increased risk for poor adherence to CDC recommendations for self-care, reacquisition of sexually transmitted infections (STIs) and PID, and subsequent adverse reproductive health outcomes.

SUMMARY

Efforts to develop and integrate adolescent-focused, evidence-based strategies for PID management and prevention of subsequent STIs and recurrent PID are warranted.

Bilateral Tubo-Ovarian Abscess Mimics Ovarian Cancer on MRI and (18)F-FDG PET/CT

A 20-year-old woman, who presented with a several-week history of abdominal pain, was referred for magnetic resonance imaging (MRI) and (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) after an ultrasound showed complex cystic masses arising from both ovaries. The MRI and (18)F-FDG PET/CT imaging characteristics of the ovarian masses were strongly suspicious for malignancy, and the masses were surgically removed. Histopathological evaluation revealed a bilateral tubo-ovarian abscess, with no evidence of malignancy. This case highlights a potentially serious pitfall in the evaluation of suspicious pelvic masses by (18)F-FDG PET/CT, whereby a complex bilateral tubo-ovarian abscess may mimic the PET/CT imaging characteristics of an ovarian or pelvic malignancy.

Ureterocele misdiagnosed as pelvic inflammatory disease in an adolescent

BACKGROUND

Acute pelvic pain in reproductive-aged women presents a diagnostic challenge. In the case that follows, we report the management of a patient initially misdiagnosed with pelvic inflammatory disease.

CASE

A 14-year-old nulligravida who presented with acute pelvic pain was diagnosed with pelvic inflammatory disease and possible tuboovarian abscess. Despite treatment with broad-spectrum parenteral antibiotics, the patient remained febrile with persistent pelvic pain. Com-puted tomography revealed a duplicated right collecting system with the upper pole of the kidney drained by a markedly dilated, tortuous ureter. An infected ureterocele was identified and incised during cystoscopy.

CONCLUSION

An infected ureterocele was misdiagnosed as pelvic inflammatory disease. In patients with acute pelvic pain who do not respond to appropriate interventions, it is important to consider alternative diagnoses.