User login
The presence and location of this mass, paired with the patient’s symptoms, led to the diagnosis of pelvic inflammatory disease (PID).
PID is an acute infection of the upper genital tract in women that is thought to be due to an ascending infection from the lower genital tract. Diagnosis of PID in middle-aged women is a challenge, given the broad differential diagnosis of nonspecific presenting symptoms, lower index of suspicion in this age group, and unknown exact incidence of PID in postmenopausal women. Delay in diagnosis in postmenopausal women can pose serious potential complications such as tubo-ovarian abscess (TOA)—as was seen with this patient—and concurrent gynecologic malignancy found on pathology of TOA specimens.
Risk factors for PID in the postmenopausal population include recent uterine instrumentation, history of prior PID, and structural abnormalities such as cervical stenosis, uterine anatomic abnormalities, or tubal disease.
The Centers for Disease Control and Prevention (CDC) 2015 Sexually Transmitted Diseases Treatment Guidelines recommend presumptive treatment for PID in women with pelvic or lower abdominal pain with 1 or more of the following clinical criteria: cervical motion tenderness, uterine tenderness, or adnexal tenderness. The CDC also suggests that the most specific criteria for PID include endometrial biopsy consistent with endometritis, imaging (transvaginal ultrasound or magnetic resonance imaging) demonstrating fluid-filled tubes, or laparoscopic findings consistent with PID.
Due to the polymicrobial nature of PID, antibiotics should cover not only gonorrhea and chlamydia but also anaerobic pathogens. CDC guidelines recommend the following treatment:
- intravenous (IV) cefotetan (2 g bid) plus doxycycline (100 mg PO or IV bid),
- IV cefoxitin (2 g qid) plus doxycycline (100 mg PO or IV bid), or
- IV clindamycin (900 mg tid) plus IV or intramuscular gentamicin loading dose (2 mg/kg) followed by a maintenance dose (1.5 mg/kg tid).
Due to the increased risk of malignancy in postmenopausal women with TOA, surgical intervention may be needed.
This patient underwent diagnostic laparoscopy, hysterectomy, left salpingo-oophorectomy, and right salpingectomy (with her right ovary left in place due to her perimenopausal status). Intraoperatively, she was found to have cervical stenosis. Postoperatively, she improved on IV cefoxitin (2 g qid) and IV doxycycline (100 mg bid), which was eventually transitioned to oral doxycycline (100 mg bid) and metronidazole (500 mg bid) on discharge. She made a full recovery and is doing well.
This case was adapted from: Khoo CP. Fever, abdominal pain, and adnexal mass. J Fam Pract. 2020;69:101-103
The presence and location of this mass, paired with the patient’s symptoms, led to the diagnosis of pelvic inflammatory disease (PID).
PID is an acute infection of the upper genital tract in women that is thought to be due to an ascending infection from the lower genital tract. Diagnosis of PID in middle-aged women is a challenge, given the broad differential diagnosis of nonspecific presenting symptoms, lower index of suspicion in this age group, and unknown exact incidence of PID in postmenopausal women. Delay in diagnosis in postmenopausal women can pose serious potential complications such as tubo-ovarian abscess (TOA)—as was seen with this patient—and concurrent gynecologic malignancy found on pathology of TOA specimens.
Risk factors for PID in the postmenopausal population include recent uterine instrumentation, history of prior PID, and structural abnormalities such as cervical stenosis, uterine anatomic abnormalities, or tubal disease.
The Centers for Disease Control and Prevention (CDC) 2015 Sexually Transmitted Diseases Treatment Guidelines recommend presumptive treatment for PID in women with pelvic or lower abdominal pain with 1 or more of the following clinical criteria: cervical motion tenderness, uterine tenderness, or adnexal tenderness. The CDC also suggests that the most specific criteria for PID include endometrial biopsy consistent with endometritis, imaging (transvaginal ultrasound or magnetic resonance imaging) demonstrating fluid-filled tubes, or laparoscopic findings consistent with PID.
Due to the polymicrobial nature of PID, antibiotics should cover not only gonorrhea and chlamydia but also anaerobic pathogens. CDC guidelines recommend the following treatment:
- intravenous (IV) cefotetan (2 g bid) plus doxycycline (100 mg PO or IV bid),
- IV cefoxitin (2 g qid) plus doxycycline (100 mg PO or IV bid), or
- IV clindamycin (900 mg tid) plus IV or intramuscular gentamicin loading dose (2 mg/kg) followed by a maintenance dose (1.5 mg/kg tid).
Due to the increased risk of malignancy in postmenopausal women with TOA, surgical intervention may be needed.
This patient underwent diagnostic laparoscopy, hysterectomy, left salpingo-oophorectomy, and right salpingectomy (with her right ovary left in place due to her perimenopausal status). Intraoperatively, she was found to have cervical stenosis. Postoperatively, she improved on IV cefoxitin (2 g qid) and IV doxycycline (100 mg bid), which was eventually transitioned to oral doxycycline (100 mg bid) and metronidazole (500 mg bid) on discharge. She made a full recovery and is doing well.
This case was adapted from: Khoo CP. Fever, abdominal pain, and adnexal mass. J Fam Pract. 2020;69:101-103
The presence and location of this mass, paired with the patient’s symptoms, led to the diagnosis of pelvic inflammatory disease (PID).
PID is an acute infection of the upper genital tract in women that is thought to be due to an ascending infection from the lower genital tract. Diagnosis of PID in middle-aged women is a challenge, given the broad differential diagnosis of nonspecific presenting symptoms, lower index of suspicion in this age group, and unknown exact incidence of PID in postmenopausal women. Delay in diagnosis in postmenopausal women can pose serious potential complications such as tubo-ovarian abscess (TOA)—as was seen with this patient—and concurrent gynecologic malignancy found on pathology of TOA specimens.
Risk factors for PID in the postmenopausal population include recent uterine instrumentation, history of prior PID, and structural abnormalities such as cervical stenosis, uterine anatomic abnormalities, or tubal disease.
The Centers for Disease Control and Prevention (CDC) 2015 Sexually Transmitted Diseases Treatment Guidelines recommend presumptive treatment for PID in women with pelvic or lower abdominal pain with 1 or more of the following clinical criteria: cervical motion tenderness, uterine tenderness, or adnexal tenderness. The CDC also suggests that the most specific criteria for PID include endometrial biopsy consistent with endometritis, imaging (transvaginal ultrasound or magnetic resonance imaging) demonstrating fluid-filled tubes, or laparoscopic findings consistent with PID.
Due to the polymicrobial nature of PID, antibiotics should cover not only gonorrhea and chlamydia but also anaerobic pathogens. CDC guidelines recommend the following treatment:
- intravenous (IV) cefotetan (2 g bid) plus doxycycline (100 mg PO or IV bid),
- IV cefoxitin (2 g qid) plus doxycycline (100 mg PO or IV bid), or
- IV clindamycin (900 mg tid) plus IV or intramuscular gentamicin loading dose (2 mg/kg) followed by a maintenance dose (1.5 mg/kg tid).
Due to the increased risk of malignancy in postmenopausal women with TOA, surgical intervention may be needed.
This patient underwent diagnostic laparoscopy, hysterectomy, left salpingo-oophorectomy, and right salpingectomy (with her right ovary left in place due to her perimenopausal status). Intraoperatively, she was found to have cervical stenosis. Postoperatively, she improved on IV cefoxitin (2 g qid) and IV doxycycline (100 mg bid), which was eventually transitioned to oral doxycycline (100 mg bid) and metronidazole (500 mg bid) on discharge. She made a full recovery and is doing well.
This case was adapted from: Khoo CP. Fever, abdominal pain, and adnexal mass. J Fam Pract. 2020;69:101-103
