**5. Pathogenesis of PID**

tive value. A single, reliable, convenient, economical test that has a good degree of sensitivity and specificity is yet to be discovered. Diagnosis still remains subjective, and is done usually at the time of laparoscopy done for evaluating infertility or chronic pelvic pain. Pathognomic sign of appearance of small tubercles all over the peritoneum that represent caseating granu‐ lomas is seen only rarely. Other findings include appearance of tubo-ovarian masses with varying degree of intra-pelvic adhesions, bead like growths or rigid lead-pipe appearance of fallopian tubes, hydrosalpingx and military white tubercles on the serosa of the uterus. Samples can be taken for acid-fast bacilli staining (Figure 3) or culture. However both methods have low sensitivity. Polymerase chain reaction is highly sensitive, but may yield false positives due to contamination of sample from air or water contaminants. Mantoux test has

Extra pulmonary tuberculosis usually requires 8 to 10 months of continuous treatment particularly in developing countries to prevent emergence of multi-drug resistant tuberculosis, which is very common if treatment is given for a short period and stopped. Also, premature discontinuation of treatment may render the organisms resistant and lead to re-emergence of infection with much more severity. The therapeutic phase is divided into an intensive phase of about 2 to 4 months and continuation phase of 4 to 6 months. The two drugs used throughout

limited utility now.

12 Genital Infections and Infertility

**Figure 3.** Typical tubercular lesion in histo-pathology

*4.6.1. Treatment of tuberculosis*

In gonococcal and chlamydial salpingitis, the microorganisms ascend by surface extension from the lower genital tract through the cervical canal by way of the endometrium to the fallopian tubes (Figure 4A). There can be adhesion of the mucosal folds, destruction of cilia, occlusion of the infundibulum, and production of a pyosalpinx. The gonococcal infection may spread beyond the endosalpinx, with possible focal abscess formation and perisalpingitis. In some cases of nongonococcal salpingitis, particularly with *M. hominis*,[33] the pathogens may enter through lesions in the cervix or endometrium and spread to the parametria and tubes through lymphatics and blood vessels (Fig. 4B). The inflammatory swelling that affects the parametria and the tubes is more pronounced than in gonococcal salpingitis, but the endosal‐ pinx is usually intact.

**Figure 4.** Pathogenesis of pelvic inflammatory disease: Schematic drawings of pathways by which genital tract infec‐ tions spread. **A**. Direct spread by extension along luminal surfaces is characteristic of gonococcal and chlamydial infec‐ tion. **B**. Nongonococcal bacterial and genital mycoplasma infections probably spread to the parametria and fallopian tubes primarily through lymphatics and blood vessels.

The sequelae of PID that are responsible for infertility include chronic interstitial salpingitis, hydrosalpinx, salpingitis isthmicanodosa, and periadnexal adhesions. Infertility may also occur because of abnormal secretory, ciliary, and peristaltic function of the fallopian tube. The postulated interrelationships of STDs and endogenous organisms in the pathogenesis of tubal infertility secondary to PID are depicted in Figure 5.[34]

**Figure 5.** Postulated interactions of sexually transmitted microorganisms with endogenous lower genital tract micro‐ flora in the pathogenesis of pelvic inflammatory disease and tubal factor infertility.(Adapted from Sweet RL, Gibbs RS: Infectious Diseases of the Female Genital Tract, p 399. 3rd ed. Baltimore: Williams & Wilkins, 1995.)

#### **6. Treatment of PID**

There is controversy over the issue of outpatient versus inpatient treatment of patients with acute salpingitis. For economic and logistical reasons, most women are treated on an outpatient basis. The decision for hospitalization is usually based on the clinical severity of the illness, although criteria vary. It seems reasonable to treat major pathogens such as *N. gonorrhoeae* and *C. trachomatis* in every patient. An antibiotic regimen that takes into account the polymicrobial nature of the cause of acute salpingitis must be used. However, after treatment with different antibiotics, similar infertility rates have been found.[35] Women treated after 3 or more days of symptoms had significantly more infertility than those treated earlier.[36] Better recognition and treatment of cervicitis and endometritis before salpingitis develops is even more important in the prevention of infertility than the treatment of salpingitis *per se.* Recommended treatment schedules for uncomplicated salpingitis are shown as below:

For acute salpingitis

#### **Parenteral Regimen A**

Cefotetan 2 g, IV every 12 hours,

*or*

The sequelae of PID that are responsible for infertility include chronic interstitial salpingitis, hydrosalpinx, salpingitis isthmicanodosa, and periadnexal adhesions. Infertility may also occur because of abnormal secretory, ciliary, and peristaltic function of the fallopian tube. The postulated interrelationships of STDs and endogenous organisms in the pathogenesis of tubal

**Figure 5.** Postulated interactions of sexually transmitted microorganisms with endogenous lower genital tract micro‐ flora in the pathogenesis of pelvic inflammatory disease and tubal factor infertility.(Adapted from Sweet RL, Gibbs RS:

There is controversy over the issue of outpatient versus inpatient treatment of patients with acute salpingitis. For economic and logistical reasons, most women are treated on an outpatient basis. The decision for hospitalization is usually based on the clinical severity of the illness, although criteria vary. It seems reasonable to treat major pathogens such as *N. gonorrhoeae* and *C. trachomatis* in every patient. An antibiotic regimen that takes into account the polymicrobial nature of the cause of acute salpingitis must be used. However, after treatment with different antibiotics, similar infertility rates have been found.[35] Women treated after 3 or more days of symptoms had significantly more infertility than those treated earlier.[36] Better recognition and treatment of cervicitis and endometritis before salpingitis develops is even more important in the prevention of infertility than the treatment of salpingitis *per se.* Recommended treatment

Infectious Diseases of the Female Genital Tract, p 399. 3rd ed. Baltimore: Williams & Wilkins, 1995.)

schedules for uncomplicated salpingitis are shown as below:

**6. Treatment of PID**

infertility secondary to PID are depicted in Figure 5.[34]

14 Genital Infections and Infertility

Cefoxitin, 2 g, IV every 6 hours,

*plus*

Doxycycline, 100 mg, IV or orally every 12 hours

#### **Parenteral Regimen B**

Clindamycin, 900 mg, IV every 8 hours,

*plus*

Gentamicin loading dose IV or IM (2 mg/kg of body weight), followed by a maintenance dose (1.5 mg/kg) every 8 hours. Single daily dosing may be substituted.

#### **Regimen A**

Ofloxacin, 400 mg, orally twice each day for 14 days,

*plus*

Metronidazole, 500 mg, orally twice each day for 14 days.

#### **Regimen B**

Ceftriaxone, 250 mg, IM once,

*or*

Cefoxitin, 2 g, IM plus Probenecid, 1 g, orally in a single dose concurrently

*once,*

*or*

Other parenteral third-generation cephalosporin (e.g., ceftizoxime, cefotaxime),

*plus*

Doxycycline, 100 mg, orally twice each day for 14 days. (Include this regimen with one of the above regimens.)

(Centers for Disease Control and Prevention: 1998 Guidelines for treatment of sexually transmitted diseases. MMWR Morb Mortal Wkly Rep 1998;47(RR1):82–82.)

Patients with suspected abscesses or severe illness that may indicate the presence of organisms other than gonococci or chlamydiae should be hospitalized. Recommended treatment regi‐ mens inhibit not only *N. gonorrhoeae* and *C. trachomatis* but also a wide variety of aerobic and anaerobic bacteria. For instance, parenteral clindamycin is effective against *C. trachomatis* and anaerobes.

The concomitant use of steroids with antibiotics has been thought to reduce the sequelae of salpingitis, but in a prospective study, Falk [77] could show no beneficial effect as judged by hysterosalpingography findings or subsequent laparotomy. Prevention of PID recurrence and its adverse effects on fertility also requires treatment of asymptomatic male sexual partners.In patients with postinflammatory tubal disease, pregnancy outcome has been correlated with the presence or absence of fallopian tube rugaeon hysterosalpingograms. Pregnancy occurred in 61% of patients with moderate to excellent rugal patterns, whereas only 7% of patients with no demonstrable rugae conceived postoperatively.[38]

Today and in the foreseeable future, assisted reproductive technologies (ART), endoscopic surgery, and microsurgery have an important place in the management of infertility that results from tubal disease. There are some tubal causes of infertility for which surgery can offer little or no chance of success, such as after severe bilateral hydrosalpinx, multisite tubal obstruction, or in patients with extensive and dense pelvic adhesions. At the other end of the spectrum are patients who can achieve a 50% to 65% intrauterine pregnancy rate after microsurgical or laparoscopic adhesiolysis when the fimbriae are spared from disease and a male factor is not encountered.[39] In choosing between IVF and tubal surgery, the physician must compare success rates (which can are best defined by the birth of a live baby) and take into account the patient's age, presence of a male subfertility factor, the personal priorities of the couple, and the availability of expertise.
