DIAGNOSIS AND MANAGEMENT OF PATIENTS WITH CLINICALLY SUSPECTED ACUTE

109 Pages·2003·0.52 MB·English

Department of Obstetrics and Gynecology
Helsinki University Central Hospital
University of Helsinki, Finland

DIAGNOSIS AND MANAGEMENT OF PATIENTS WITH CLINICALLY
SUSPECTED ACUTE PELVIC INFLAMMATORY DISEASE

Pontus Molander

ACADEMIC DISSERTATION

To be presented by permission of the Medical Faculty of the University of Helsinki for public
discussion in the Auditorium of the Department of Obstetrics and Gynecology, Helsinki University
Central Hospital, Haartmaninkatu 2, Helsinki, on June 6th, 2003, at 12 noon.
Supervised by
Professor Jorma Paavonen
Department of Obstetrics and Gynecology
University of Helsinki, Finland

Docent Bruno Cacciatore
Department of Obstetrics and Gynecology
University of Helsinki, Finland

Reviewed by
Professor Pentti K. Heinonen
Department of Obstetrics and Gynecology
University of Tampere, Finland

Docent Aydin Tekay
Department of Obstetrics and Gynecology
University of Oulu, Finland

Official opponent
Docent Jorma Penttinen
Department of Obstetrics and Gynecology
University of Kuopio, Finland

ISBN 952-91-5887-4 (paperback)
ISBN 952-10-1183-1 (PDF)
Yliopistopaino 2003
To Eva, Jan, and Jessica
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CONTENTS

List of original publications 7
Abbreviations 8
1. Introduction 10
2. Review of the literature 12
2.1. Definition and history of acute PID 12
2.2. Microbiology 14
2.3. Pathogenesis 17
2.4. Epidemiology 20
2.5. Clinical manifestations 27
2.5.1. Subclinical disease 27
2.5.2. Endometritis 28
2.5.3. Mild and moderate PID 30
2.5.4. Severe PID 30
2.5.5. Perihepatitis 32
2.5.6. Periappendicitis 33
2.6. Diagnosis 33
2.6.1. Clinical diagnosis 34
2.6.2. Endometrial biopsy 37
2.6.3. Laboratory diagnosis 38
2.6.4. Ultrasonographic diagnosis 40
2.6.5. Other imaging modalities 42
2.6.6. Laparoscopic diagnosis 43
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2.6.7. Differential diagnosis 47
2.7. Treatment 50
2.7.1. Conservative 50
2.7.2. Surgical 53
2.8. Prevention 55
2.9. Long-term sequelae of PID 57
3. Aims of the study 59
4. Material and methods 60
4.1. Subjects 60
4.2. Methods 61
4.2.1. Clinical diagnosis of acute PID (Studies I-IV) 61
4.2.2. Ultrasonography (Studies I-IV) 62
4.2.3. Magnetic resonance imaging (Study I) 63
4.2.4. Laparoscopy (Studies I-IV) 64
4.2.5. Observer reproducibility (Study V) 65
4.3. Biostatistical analyses 66
5. Results 68
5.1. Diagnosis of pelvic inflammatory disease and acute appendicitis 68
5.1.1. MRI in diagnosis of acute PID (Study I) 68
5.1.2. Power Doppler TVS in diagnosis of acute PID (Study III) 70
5.1.3. TVS in diagnosis of acute appendicitis (Study IV) 72
5.2. Laparoscopic management of pelvic inflammatory disease (Study II) 74
5.3. Accuracy of laparoscopic findings in pelvic inflammatory disease (Study V) 77
6. Discussion 78
6.1. Diagnosis of pelvic inflammatory disease and acute appendicitis 78
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6.1.1. MRI in diagnosis of acute PID 78
6.1.2. Transvaginal sonography in diagnosis of acute PID 79
6.1.3. Transvagnial and transabdominal sonography in diagnosis of acute
appendicitis 82

6.2. Laparoscopic management of pelvic inflammatory disease 84

6.3. Accuracy of laparoscopic findings in pelvic inflammatory disease 86

7. Conclusion and future prospects 88

8. Summary 91
Acknowledgements 93
References 96
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List of original publications

This thesis is based on the following original publications:

I Tukeva T, Aronen HJ, Karjalainen PT, Molander P, Paavonen T, Paavonen J. MR imaging in
pelvic inflammatory disease: comparison with laparoscopy and US. Radiology 1999;210:209-
216.
II Molander P, Cacciatore B, Sjöberg J, Paavonen J. Laparoscopic management of suspected acute
pelvic inflammatory disease. J Am Assoc Gyn Lap 2000;7:107-110.
III Molander P, Sjöberg J, Paavonen J, Cacciatore B. Transvaginal power Doppler findings in
laparoscopically proven acute pelvic inflammatory disease. Ultrasound Obstet Gynecol
2001;17:233-238.
IV Molander P, Paavonen J, Savelli L, Sjöberg J, Cacciatore B. Transvaginal sonography in the
diagnosis of acute appendicitis. Ultrasound Obstet Gynecol 2002;20:496-501.
V Molander P, Finne P, Sjöberg J, Sellors J, Paavonen J. Observer agreement study of laparoscopic
diagnosis of pelvic inflammatory disease using photographs. Obstet Gynecol (in press).

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Abbreviations

AFS American Fertility Society
ASS acute salpingitis score
AV aerobic vaginitis
BV bacterial vaginosis
CDC Centers for Disease Control and Prevention
CHSP-60 chlamydial heat shock protein-60
CI confidence interval
CRP c-reactive protein
CT computed tomography
DNA deoxyribonucleic acid
ESR erythrocyte sedimentation rate
HHSP-60 human heat shock protein-60
HSG hysterosalpingography
IM intramuscularly
IUD intrauterine device
IV intravenously
κ kappa
LCR ligase chain reaction
LGTI lower genital tract infection
MRI magnetic resonance imaging
NAA nuclein acid amplification
NSU non-specific urethritis
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NPV negative predictive value
OC oral contraceptive
PCE plasma cell endometritis
PCR polymerase chain reaction
PI pulsatility index
PID pelvic inflammatory disease
PPV positive predictive value
STI sexually transmitted infection
STIR short inversion time inversion recovery
TAS transabdominal sonography
TFI tubal factor infertility
TOA tubo-ovarian abscess
TVS transvaginal sonography
UGT upper genital tract
US ultrasonography
WBC white blood cell count
WHO World Health Organization

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1. Introduction

Despite the development of new diagnostic aids, pelvic inflammatory disease (PID) is still poorly
recognized and managed. In 1990, J. Pearce stated: ”PID is a sexually transmitted disease with
potentially serious sequelae usually managed badly by doctors with little interest in the condition”.
Unfortunately, no great breakthroughs have taken place since that time in the management of PID
(Simms and Stephenson 2000). Women of fertile age represent an especially difficult patient group
because of a variety of gynecologic and non-gynecologic diagnostic possibilities (Porpora and Gomel
1997, Tarrazza and Moore 1997, Cibula et al. 2001). Diagnostic accuracy regarding PID has not
improved throughout the last decades in laparoscopic studies, reaching maximally 60 to70%
(Jacobson and Weström 1969, Paavonen et al. 1987, Bevan et al. 1995). The rate of not only false
positive but also false negative findings in all studies concerning clinical accuracy of PID diagnosis is
high (Jacobson 1980, Sellors et al. 1991). About one-third of patients with a clinical diagnosis of
PID in fact have another disease or normal findings, while two-thirds reveal PID of some degree
when laparoscopy is used to confirm the diagnosis (Munday 2000). No decline has occurred in the
misdiagnosis of the most common nongynecologic differential diagnostic disease, acute appendicitis.
The rate of misdiagnosis of appendicitis in fertile women has been as high as 40%, and surprisingly,
among women of reproductive age, misdiagnosis has even increased (Flum et al. 2001).
Because of the lack of reliable diagnostic methods, the technique playing a central role in the
management of acute abdomen in women of reproductive age is laparoscopy. It offers the possibility
to diagnose and manage both PID and non-PID cases. In the management of acute pelvic pain,
laparoscopy allows confirmation of the diagnosis and a possibility to treat the condition safely and
cost-effectively. Effective management prevents complications associated with delayed treatment and
often preserves the patient’s fertility (Porpora and Gomel 1997). Some studies indicate that
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