Diagnóstico de la Enfermedad Pelviana Inflamatoria

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El objetivo de este estudio fue evaluar los criterios de diagnóstico clínico y los hallazgos laparoscópicos en mujeres con enfermedad pelviana inflamatoria. El diagnóstico preliminar debe basarse en criterios de diagnóstico clínico. La laparoscopia diagnóstica temprana mejora la precisión diagnóstica y determina con mayor exactitud la gravedad de la enfermedad.

Autor:
Laima Maleckiene
Columnista Experta de SIIC
Institución:
Lithuanian University of Health Sciences
Artículos publicados por Laima Maleckiene

Coautores
RJ Nadisauskiene* E Barcaite**
Prof., Lithuanian University of Health Sciences, Kaunas 7, Lituania*
Assist. prof., Lithuanian University of Health Sciences, Kaunas 7, Lituania**

Recepción del artículo
8 de noviembre, 2011

Aprobación
2 de junio, 2012

Primera edición
27 de septiembre, 2012

Segunda edición, ampliada y corregida
7 de junio, 2021

Resumen
El objetivo de este estudio fue evaluar los criterios de diagnóstico clínico y los hallazgos laparoscópicos en mujeres con enfermedad pelviana inflamatoria (EPI). Métodos: Se inscribieron en el estudio setenta y tres mujeres de 18 a 35 años que acudieron al servicio de Ginecología del Hospital de la Universidad Lituana de Ciencias de la Salud con síntomas clínicos de enfermedad pelviana inflamatoria. Todas las pacientes fueron sometidas a un examen clínico y pruebas de laboratorio bajo el mismo protocolo. La laparoscopia diagnóstica se realizó dentro de las 12 horas posteriores al ingreso. Resultados: Se confirmó la presencia de EPI por laparoscopia en el 71.2% de los casos. La EPI verificada por laparoscopia tuvo una correlación significativa con los siguientes síntomas: dolor abdominal bajo, dolor a la movilización cervical y dolor anexial. Se detectó la presencia de Chlamydia trachomatis y de Neisseria gonorrhoeae en muestras endocervicales en el 46.1% y el 26.9% de las mujeres con EPI confirmada. Conclusiones: El diagnóstico preliminar de EPI debe basarse en criterios de diagnóstico clínico. La laparoscopia diagnóstica temprana mejora la precisión diagnóstica y determina con mayor exactitud la gravedad de la enfermedad.

Palabras clave
enfermedad pelviana inflamatoria, laparoscopia

Abstract
The aim of this study was to evaluate the clinical diagnostic criteria and laparoscopic findings in women with pelvic inflammatory disease (PID). Method: Seventy-three women 18-35 years old admitted at the gynaecological department of Lithuanian University of Health Sciences hospital with clinical symptoms of PID were enrolled into the study. All patients underwent clinical examination and laboratory tests under the same protocol. Diagnostic laparoscopy was performed within 12 hours after admission. Results: PID was confirmed at laparoscopy in 71.2% cases. Laparoscopically verified PID significantly correlated with lower abdominal pain, cervical motion pain and adnexal tenderness. Chlamydia trachomatis was detected in endocervical specimens in 46.1% and Neisseria gonorrhoea in 26.9% women with confirmed PID. Conclusion: Preliminary diagnosis of PID should be based on clinical diagnostic criteria. An early diagnostic laparoscopy improves diagnostic accuracy and determines more precisely the severity of the disease.

Key words
pelvic inflammatory disease, laparoscopy

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Especialidades
Principal: Cirugía, Obstetricia y Ginecología
Relacionadas: Atención Primaria, Bioquímica, Diagnóstico por Imágenes, Diagnóstico por Laboratorio, Epidemiología, Infectología, Medicina Interna

Enviar correspondencia a:
Laima Maleckiene, Dept. OB/GYN Lithuanian University of Health Sciences, LT-5000, Eiveniu st. 2, Kaunas 7, Lituania

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Artículos originales>
Expertos del Mundo

Especialidad principal:
Cirugía
Obstetricia y Ginecología

Relacionadas:
Atención Primaria
Bioquímica
Diagnóstico por Imágenes
Diagnóstico por Laboratorio
Epidemiología
Infectología
Medicina Interna

Artículo completo

Diagnosis of pelvic inflammatory disease

Introduction
Pelvic inflammatory disease (PID) is one of the most common infections in sexually active women. PID is a polimicrobial infection mainly caused by sexually transmitted microorganisms - Chlamydia trachomatis (C.trachomatis) and Neisseria gonorrhoea (N.gonorrhoea) and bacterial vaginosis associated microorganisms [1-7]. Well-known complications of PID are infertility, ectopic pregnancy and chronic pelvic pain. The incidence of PID cases in women of reproductive age is 2-8% [1; 2]. Risk factors related with PID are first intercourse at young age, multiple sex partners, high frequency of sexual intercourse and new sexual partners within the last 30 days. IUD, hormonal changes during menses and retrograde menses are cited as contributing factors of PID.
The diagnosis of PID is mostly based on clinical findings and is imprecise because patients often present with minimal or atypical symptoms. The diagnostic criteria for PID reported by the Centers of Diseases Control and Prevention (CDC) in 2006 are mainly used for clinical diagnosis in many countries. Minimal criteria for PID diagnosis are lower abdominal pain, bilateral adnexal tenderness and cervical motion tenderness. Patients with PID may be misdiagnosed with gastrointestinal, surgical or other gynaecological diseases [5-8]. Undiagnosed PID episodes results in delay or failure to treat and are associated with an increased risk of sequelae. Laparoscopy is the gold standard method for PID diagnosis, but routinely is not recommended. The aim of our study was to evaluate the risk factors, clinical diagnostic criteria, and laparoscopic findings in women with PID in a prospective way.

Material and Methods

Seventy three sexually active women from 18 to 35 years old admitted at the gynaecological department of Lithuanian University of Health Sciences hospital during three years period with suspicion of PID were enrolled into the study. Inclusion criteria were lower abdominal pain, bilateral adnexal tenderness and cervical motion tenderness. Exclusion criteria were: pregnancy within the previous 8 weeks, pelvic surgery during the last 4 weeks and antibiotic therapy during the last 48 hours before admission to the hospital. Background data (age, education, previous obstetric and gynaecological history, etc.) were retrieved from patients by personal interview. All women were asked to fill in the structured questionnaire with special attention to the risk factors of PID (sexual debut, number of sexual partners, number of sexual intercourse per week, contraception methods, etc.). All patients underwent clinical and transvaginal ultrasound examination according to the standardised protocol. Blood tests for white blood cell (WBC) count, C-reactive protein concentration (CRP), serological test for syphilis, pregnancy test, urine test and urine culture were performed in all patients. The specimens from endocervical canal for N. gonorrhoea were immediately inoculated into transport media (BBL Prepared Culture Media, Becton Dickinson Microbiology Systems, Cockeysville USA), were transported to the microbiology laboratory and processed immediately. Specimens from endocervical canal for C. trachomatis test by direct immunofluorescence reaction were taken in all women.
Diagnostic laparoscopy during 12 hours after admission was performed under general anaesthesia by one experienced surgeon. The diagnosis of laparoscopically verified PID was based on the following criteria: erythema of the tubal surface, swelling of the tubal wall and purulent exudate leaking from the fimbrial end. The inflammation of the most affected adnexa and pelvic adhesions at laparoscopy were graded according to the American Fertility Society classification as mild, moderate, or severe. The specimens for C.trachomatis and N. gonorrhoea were obtained during laparoscopy: the swab was introduced about 2 cm into the tubal lumen via the fimbrial end and rotated. The specimens were immediately inoculated into transport media for N. gonorrhoea (BBL Prepared Culture Media, Becton Dickinson Microbiology Systems, Cockeysville USA), were transported to the microbiology laboratory. Specimens for C. trachomatis test by direct immunofluorescence reaction were taken and transported to the laboratory. Antimicrobial therapy was started in cases of laparoscopically diagnosis PID after obtaining microbiological specimens.
Statistics
Relative risk (RR) with 95% confidence intervals (CI) was calculated. Differences with p value (0.05 were considered statistically significant in all analyses. For difference between proportions, (²-test with Yates correction of Fischer’s exact test was performed, where appropriate. Student’s t test was used for comparison of means.

Ethical Consideration
The independent Ethics Committee of Lithuanian University of Health Sciences approved the study. Signed informed consents to participate in the study were obtained from all women.

Results
PID laparoscopic diagnosis was confirmed in 71.2( women with clinical suspicion of the disease. Mild PID was diagnosed in 40.4%, moderate 21.1% and severe PID in 38.5% of cases. Acute appendicitis was diagnosed in three patients, endometriosis in five and ruptured ovarian cyst in four women with clinically suspected PID. In nine women (12.3%) with clinical suspicion of PID entirely normal pelvic organs were observed at laparoscopy. Renal obstructive disease in 3 patients, inflammatory bowel disease in 2 patients was diagnosed in further work up of our patients.

Risk factors among women with laparoscopically diagnosed PID are presented in table 1. Intrauterine devices were found in seven women with PID. Age, menarche, sexual debut, number of previous deliveries were similar in women with and without PID. No significant difference in the number of sexual partners, duration of the disease and period between the last menstrual period and onset of the disease was found. The mean number of sexual intercourse per week in women with PID was 2.5(1.4 and in women without PID 1.8(1.1. Education and marital status of women was significantly different in women with and without PID. RR for PID in women with high education was 0.3 (95% CI 0.1–0.9), for single women was 2.6 (95% CI 1.1–6.6), RR for PID in women with one lifetime sexual partner was 0.8 (95% CI 0.7–0.9). The average number of sexual partners per month in patients with PID was 1.2(0.5 and 1.0(0.2 in women without PID.

Clinical and laboratory parameters and laparoscopic findings are presented in table 2. Lower abdominal pain, bilateral adnexal tenderness and cervical motion pain on bimanual examination was reported in all our patients; the positive predictive value of these symptoms is 71.2%. Abnormal vaginal discharge was reported by 59.6%, dysuria - 51.9%, fever – 25%, painful sexual intercourse by 26.9% of the women with confirmed PID. WBC >10(10⁹/L in 25 (48.1%) women with PID and in 5 (23.8%) patients without PID was detected, CRP >10mg/L in 39 (75%) and 10 (47.6%) women, respectively. C.trachomatis in endocervical specimens was detected in 24 (46.1%) and N. gonorrhoea in 14 (26.9%) women with confirmed PID. C. trachomatis was found in endocervical canal of one woman with clinically suspected but not laparoscopically confirmed PID. C. trachomatis in specimens taken from fallopian tubes during laparoscopy was detected in 12 patients and N. gonorrhoea in 1 patient with PID. Sensitivity, specificity, positive predictive values and negative predictive value of main clinical diagnostic criteria in laparoscopically confirmed PID cases are presented in table 2.

Discussion

In everyday medical practice, PID diagnosis mainly is based on clinical criteria and laparoscopy is not routinely performed. Unfortunately, clinical symptoms are not pathognomonic for PID and do not differentiate from other diseases [7]. Laparoscopy is used for diagnosis of PID since 1970. The results from different studies show that in 71-82% of patients with clinically suspected PID, the diagnosis was confirmed during laparoscopy. We conducted a prospective study designed to compare clinical and laparoscopic data of PID. All patients in our study presented the main clinical symptoms that are cited as criteria for the diagnosis of PID in the CDC guidelines. As other investigators we found that clinical symptoms and signs of PID provide inadequate information for accurate diagnosis of this disease.

Pelvic organs have the same innervations and it is often difficult to determine if visceral abdominopelvic pain is of gynecologic, urologic or intestinal origin [8; 9]. Entirely normal pelvis in nine women with clinically suspected PID was found at laparoscopy in our study despite uniform clinical inclusion criteria. Lower abdominal pain, bilateral adnexal tenderness and cervical motion tenderness are common symptoms in patients with peritoneal endometriosis and only laparoscopy can reveal exact diagnosis.
Most studies confirm that clinical criteria of PID have relatively low sensitivity and specificity and their prognostic value increases only in cases of moderate or severe disease [10; 11]. The data of meta-analyses show that bilateral adnexal tenderness sensitivity is 95% and specificity - 74%, lower abdominal tenderness - 58% and 92%, cervical motion pain - 82% and 72%, respectively [7; 12]. Sensitivity of adnexal tenderness, lower abdominal tenderness and cervical motion pain was 71.2% in our study. The additional criteria like fever and abnormal laboratory tests (increased WBC count, elevated CRP) are of limited importance in the diagnosis of PID [13]. In our study only 25% of PID cases had elevated body temperature =38^oC. The sensitivity of elevated CRP was 75% and specificity 52.4% in our study. Results from other studies show the sensitivity of elevated CRP in ranges from 74 to 93% and specificity from 50 to 90% [7; 10; 14].

Nowadays it is evidence based that sexually transmitted microorganisms are mainly associated with PID [15]. C.trachomatis and N.gonorrhoea are dominant causative agents. It is thought that gonococcal PIDis more symptomatic than chlamydial PID [16]. The prevalence of infection caused by C.trachomatis and N.gonorrhoea varies in vast ranges in different studies and populations, but in most industrialised countrieschlamydial genital tract infection is more prevalent than gonorrhoea [17]. In our study C.trachomatis was detected in 46.1% and N.gonorrhoea in 26.9% endocervical specimens in women with laparoscopically confirmed PID. C.trachomatis was detected in fallopian tubes in 23% and gonococci in 1.9% women with PID.
Laparoscopy has been shown to add considerable accuracy to PID diagnosis. The minimal laparoscopic criteria for the diagnosis of acute salpingitis include pronounced hyperemia of the tubal surface, edema of the tubal wall and a sticky exudate on the tubal surface or from the fimbriated ends. Laparoscopy is referred to be the “gold standard” for diagnosis of PID, but data regarding its accuracy are mixed. In different studies in women with clinically suspected PID during laparoscopy, the normal pelvic organs were found in almost one-third of patients [11]. We appreciated clinical and laparoscopic findings in a cohort of prospectively evaluated women who were enrolled into the study with classical symptoms of PID. According to our data 28.8( of patients would be misdiagnosed without laparoscopy. Laparoscopy in cases of PID avoids delay of specific therapy and allows an accurate assessment of severity of the disease and future fertility prognosis [10; 11].
In conclusion, we confirmed that preliminary diagnosis of PID should be based on clinical diagnostic criteria. An early diagnostic laparoscopy improves diagnostic accuracy and more precisely determines the severity of the disease.

Bibliografía del artículo
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4. Trent M, Bass D, Ness RB, Haggerty C. Recurrent PID, Subsequent STI, and Reproductive Health Outcomes: Findings From the PID Evaluation and Clinical Health (PEACH) Study. Sex Transm Dis 38(9):879-881, 2011.
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12. Westrom L. Clinical manifestation and management of pelvic inflammatory disease. J Reprod Med 28:703-707, 1983.
13. Baveja G, Saini S, Sangwan K, Arora DR. A study of bacterial pathogens in acute pelvic inflammatory disease. J Commun Dis 33(2):121-125, 2001.
14. Barrett S, Taylor C. A review on pelvic inflammatory disease. Int J STD AIDS 16(11):715-720, 2005.
15. Adams EJ, Charlett A, Edmunds WJ, Hughes G. Chlamydia trachomatis in the United Kingdom: a systematic review and analysis of prevalence studies. Sex Transm Infect 80(5):354-362, 2004.
16. Bevan CD, Johal BJ, Mumtaz G, Ridgway GL, Siddle NC. Clinical, laparoscopic and microbiological findings in acute salpingitis: report on a United Kingdom cohort. Br J Obstet Gynecol 102:407-414, 1995.
17. Simms I, Vickers MR, Stephenson J, Rogers PA, Nicoll A. National assessment of PID diagnosis, treatment and management in general practice England and Wales. Int J STD AIDS 11(7):440-444, 2000.

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