GYNECOLOGY

CHAPTER 23

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Pelvic Inflammatory Disease

Dr. Aida San Jose, MD, FPOGS INTRODUCTION INTRODUCTION TO
GONOCOCCUS ASCENDS TO FALLOPIAN TUBE Organism Selectively adheres to non-ciliated mucus-secreting cells

Pelvic Inflammatory Disease

Primary Prevention Teach adolescent safe sex practices Promote condom use and chemical barrier method Barrier methods Condoms porosity of latex in condoms is >1000x smaller than viral particles. routine condom use prevents deposition and transmission of infected organisms from the semen to the endocervix. Diaphragms Spermicidal preparations Nonoxynol 9 both bactericidal and viricidal kills: N. gonorrhoeae genital Mycoplasma species Trichomonas vaginalis Treponema pallidum herpes simplex virus human immunodeficiency virus (HIV) Oral contraceptive 2 Effects: incidence of acute pelvic inflammatory disease and a milder form of upper genital tract infection when it does occur. incidence of upper genital tract infection RATIONALE thicker cervical mucus produced by the progestin component of oral contraceptives inhibits sperm and bacterial penetration. in duration of menstrual flow accompanying oral contraceptive creates a shorter interval for bacterial colonization of the upper tract Secondary Prevention Universal screening of women at high risk for Chlamydia and gonorrhea Screening for acute cervicitis Increase use of sensitive test to diagnose lower genital tract infection Treat sexual partners male partner is frequently asymptomatic and should be treated empirically with antibiotics against both Chlamydia and gonorrhea Education to prevent recurrent infection Pelvic Inflammatory Disease Infection of upper genital tract NOT a/w pregnancy or intraperitoneal pelvic operations infection may incude any or all of the following anatomic locations: endometrium (endometritis) oviducts (SALPINGITIS) most characteristic & common component of PID ovary (oophoritis) uterine wall (myometritis) uterine serosa and broad ligaments (parametritis) pelvic peritoneum. Long term sequelae result from destruction of tubal architecture by the infection adhesions and hydrosalpinx bacteriologically sterile
Simulate an ACUTE Complement Inflammatory response in Ciliated cells

CELL DEATH & TISSUE DAMAGE

REPAIR

Scarring & tubal adhesions formation causing risk for ECTOPIC pregnancy & STERILITY

Pelvic infections are not active for several weeks or months with the exception of chronic colonization by C. trachomatis infection with rare organisms, such as tuberculosis actinomycosis. May start as a lower genital tract infection Ascending infection from the bacterial flora on the mucosal surface of the vagina and cervix (99%) Bacterial colonization and infection of the endometrium and fallopian tubes may spread to ovaries, nearby peritoneum & adjacent soft tissues such as broad ligament & pelvic blood vessels MODE of SPREAD Local/ Direct Extension Lymphatics Hemtogenous EPIDEMIOLOGY Acute pelvic inflammatory disease is the MC gynecologic condition that results in hospitalization of women of reproductive age in the United States. Rare in women the following women Women without menstrual periods Hence rare in: Prepubertal females Pregnant women Postmenopausal women If PID is diagnosed, other associated conditions are usually discovered such as genital malignancies diabetes concurrent intestinal diseases diverticulitis appendicitis carcinoma Women who are NOT sexually active 1% to 2% of all young, sexually active women annually Most common serious infection of women age 16-25 85% develop spontaneously in sexually active women 15% follow procedures that break cervical mucus barrier allowing vaginal flora to colonize the upper genital tract. Procedures include: endometrial biopsy curettage intrauterine device insertion hysterosalpingography hysteroscopy Lack of significant antibody titers explain why teenagers are more likely to develop upper genital tract infection than woman in late 20s Chamydia more prevalent than gonorrhea (4:1)

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ETIOLOGY Usually a Polymicorbial Infection C. trachomatis N. gonorrhea Mycoplasma hominis Ureaplasma urealyticum Gardnerella Anaerobes 2 Classic sexually transmitted organisms MC organisms N. Gonorrhea C. Trachomatis may co-exist in the same individual in 25-50% cases type and number of species vary depending on the stage of the disease when the culture is obtained gonorrheal organisms frequently cultured during the first 24 to 48 hours of the disease often absent later. Anaerobic organisms tend to predominate later in the disease process Normal Vaginal flora is present in 50% of PID cases Bacterial Vaginosis organisms Gardnerella vaginalis ORGANISMS FOUND IN

demonstrated that an antibody against the outer membrane protein of the gonococcus develops in ~70% of women following severe pelvic infection. The lack of significant antibody titers may help explain why teenagers are more likely to develop upper genital tract disease than women in their late 20s. Recovery rates highest recovery rates occur in young, urban women in the United States. PATHOLOGY produces an intense inflammatory reaction in the tubes narrowing or occlusion of the tubal lumen d/t presence of necrotic debris and purulent material. Cellular destruction is much more extensive than the reaction associated with a chlamydial infection Chlamydia trachomatis an intracellular, sexually transmitted bacterial pathogen ratio of chlamydial to gonococcal PID diagnosed by laparoscopy of 4:1 Involved in at least 40% of women who are hospitalized with PID ~30% of women with documented acute cervicitis secondary to chlamydia subsequently develop acute pelvic inflammatory disease. May remain in the fallopian tubes for months after initial colonization while N. gonorrhea only stay for days Primary infection: self-limited with mild symptoms Tissue destruction is associated with Cell-Mediated Immune Mechanisms Chlamydia produces a disruption of the tubal mucosa by an immunopathologic mechanism rather than by a direct cytotoxicity, as is the case with N. gonorrhoeae. host cell-mediated immune response to a chlamydial heat shock protein produces the disruption of the tubal mucosa Women with antibodies to chlamydial heat shock protein more likely to develop tubal scarring and fitz-hughcurtis syndrome Chlamydia can still be isolated months after initial infection unlike gonorrhea, you cant isolate it anymore SILENT OR ATYPICAL PID

Pelvic Inflammatory Disease

Nisseria gonorrhea Highly virulent ~20% w/ cervical infection by N. gonorrhoeae subsequently develop acute pelvic inflammatory disease. ~ 50% w/ endocervical cultures positive for N. gonorrhoeae at the time of acute pelvic inflammatory disease will have the same organism cultured from the fallopian tubes. If N. gonorrhoeae is the only organism cultured from the tubes, a patient will usually respond rapidly to treatment. Immunologic studies

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Asymptomatic inflammation of the upper gentital tract often a/w chlamydial infection may be the more common form of upper tract infection than the symptomatic PID SEQUELAE of repeated Asymptomatic Chlamydial Infection Tubal infertility ectopic pregnancy risk 3-6 times

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Mycoplasma hominis route of spread of mycoplasmas is via the parametria rather than the mucosa primary upper genital tract infection is in the parametria and the tissue surrounding the tubes, not in the tubal lumen more of a commensal bacterium rather than a pathogen in the oviducts. Histologically, does not appear to produce damage to the tubal mucosa. are not highly pathogenic presence of genital mycoplasmas does not change the clinical presentation and clinical course of acute pelvic inflammatory disease. Endogenous Aerobic & Anaerobic Flora of the Vagina Normal flora of the vagina frequently ascend to colonize and infect the upper reproductive tract. Direct cultures of purulent material are taken from tubal lumen posterior cul-de-sac Aerobic organisms most common organisms are nonhemolytic Streptococcus Escherichia coli group B Streptococcus coagulasenegative Staphylococcus Anaerobic organisms tend to predominate over aerobes most common anaerobic organisms Bacteroides species Peptostreptococcus Peptococcus ubiquitous in pelvic abscesses a/w acute pelvic inflammatory disease. Tuboovarian complexes and abscesses more common in women with concurrent bacterial vaginosis or HIV infection.

often mistakenly diagnosed as pneumonia acute cholecystitis Persistent symptoms and signs SYMPTOMS PAIN acute onset pleuritic pain RUQ when liver is palpated w/ abdominal tenderness aggravated by breathing coughing movement referred to the right shoulder or into the back following an episode of PID SIGNS LFT Liver transaminases may be elevated Laparoscopy may be useful in the diagnosis of this syndrome FINDINGS liver capsule will appear inflamed classic "violin" string adhesions to the parietal peritoneum beneath the diaphragm. PATHOLOGY d/t transperitoneal or vascular dissemination of either the gonococcus or Chlamydia organism to produce the perihepatic inflammation. Chlamydia produces the majority of cases. Other organisms involved anaerobic streptococci Coxsackievirus Organisms cause a thinning of cervical mucus and allow bacteria from the vagina into the uterus and oviducts, causing infection and inflammation inflammation can cause scar tissue to form on Glisson's capsule, a thin layer of connective tissue surrounding the liver. Women with perihepatitis have higher prevalence of moderate to severe pelvic adhesions higher prevalence and higher titers of antibodies to the chlamydial heat-shock protein-60. Treatment same as the treatment for acute salpingitis.

RISK FACTORS OF

Pelvic Inflammatory Disease

ASSOCIATED CONDITIONS IN

Pelvic Inflammatory Disease

Pitz-Hugh-Curtis Syndrome & Ectopic Pregnancy rare complication of PID extra pelvic disorder that is a complication of PID 5-10% of women with acute PID develop symptoms of perihepatic inflammationthe Fitz-Hugh-Curtis syndrome occurs almost exclusively in women Differential Diagnosis

Risk Factors for PID HIGHEST RISK FACTOR Menstruating teenager Multiple sexual partners chance of acute PID 5 fold does not use contraception lives in an area with a high prevalence of sexually transmitted disease OTHER RISK FACTORS st Young age of 1 sexual intercourse Older sex partner Involvement with a child protective agency Prior suicide attempt Alcohol use before sexual intercourse Current Chlamydia infection Vaginal douch 3-4 fold of relative risk of PID in women who douche >1x/month Can cause bacterial vaginosis d/t alkalinization of vagina, disappearance of lactobacilli & predominance of anaerobes Placement of IUD risk for PID occurs during this times: The time of insertion of the IUD

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1 3 weeks after placement. Previous acute PID definite risk factor for future attacks 25% of women w/ acute PID subsequently develop another PRIMARY PID or acute tubal infection microscopic tubal damage produced by the initial upper genital tract infection may facilitate repeat infection Untreated male partners ~50% of men w/ STD are free of symptoms, and thus they do not seek treatment Instrumentation of uterus Transcervical penetration of the cervical mucus barrier with instrumentation of the uterus may initiate "iatrogenic" acute pelvic inflammatory disease Change in VIRULENCE of organism
st

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Hypothesis as to Why Younger Women are at Higher Risk for PID than older Women 75% of acute PID occur in <25 years of age Incidence at >25 years old HYPOTHESIS of Teenage susceptibility to PID that allows colonization by C. trachomatis and N. gonorrhoeae Lack of antibody protection Wider area of cervical columnar epithelium Risks in Pregnancy Women with concurrent bacterial vaginosis have a higher risk for postabortal infection and thus should be treated with oral antibiotics with anaerobic coverage CLINICAL MANIFESTATIONS OF Minor Symptoms varies & non-specific Endocervical infection or purulent vaginal discharge: 75% nd 2 MC presenting symptom Abnormal uterine bleeding: 40% spotting or menorrhagia Nausea and vomiting: relatively late symptoms Varies w/ Organism N. gonorrhea rapid onset PID pelvic pain usually begins a few days after the onset of a menstrual period high grade fever C. trachomatis PID often may have an indolent course slow onset less pain less fever. SIGNS Adnexal Mass may represent edema inflammatory adhesions to either the small or large intestine adnexal complex or abscess: 10% higher incidence if also w/ HIV DIAGNOSIS & MANAGEMENT DIAGNOSIS OF

Pelvic Inflammatory Disease

Signs & Symptoms of PID Females tend to present w/ symptoms more than males Acute pelvic inflammatory disease often occurs with minimum symptoms ~50% of women who are infertile as a result of tubal obstruction do not remember ever having symptoms of acute pelvic infection HISTORICAL CLASSIC TRIAD Fever Elevated erythrocyte sedimentation rate Adnexal tenderness or a mass SYMPTOMS Major SYMPTOMS Symptoms that is most frequently seen PAIN & TENDERNESS Pain in the lower abdomen and pelvis Most frequent symptom > 90% of women present with diffuse bilateral lower abdominal pain Constant and dull, may become cramping AGGRAVATING FACTORS Motion Sexual activity Short duration (< 7 days) If the pain has been present > 3 weeks, it is unlikely that the patient has acute pelvic inflammatory disease Lower abdominal & Pelvic tenderness HALLMARK of Acute PID (+) DIRECT tenderness to palpation in the lower abdomen (+) rebound tenderness. (+) Bilateral tenderness of the parametria & adnexa on pelvic examination tenderness is especially noted with movement of the uterus or cervix

Pelvic Inflammatory Disease

Differential Diagnosis of Acute PID Lower genital tract pelvic infection Ectopic Pregnancy Torsion or rupture of an adnexal mass Acute appendicitis Gastroentieritis

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Endometrosis Simple Cystitis Corpus Luteum Bleeding Pelvic Adhesions Benign Ovarian Tumor Chronic Salphingitis Acute Peritonitis Uterine Myoma Diagnosis HISTORY & PHYSICAL EXAM diagnosis is usually based on clinical criteria high false positive rate and a high false negative rate. LAPAROSCOPY GOLD STANDARD most accurate method of diagnosis of acute PID ADVANTAGES Direct visualization improve the diagnostic accuracy Gives opportunity for direct cultures of purulent material, which might help to establish optimum therapy concurrent operative procedures such as lysis of adhesions potential drainage of an abscess irrigation of the pelvic cavity DISADVANTAGE majority of women w/ acute PID do not undergo laparoscopy because of the expense of this invasive technique. Indications of for Laparoscopy or Laparotomy: Impending shock Acute surgical abdomen Complicated differential diagnosis in a postmenpusal woman Patients not responding to treatment FINDINGS red, indurated, edematous oviducts to pockets of purulent material large pyosalpinx tuboovarian abscess
SEVERITY OF DISEASE by Laparoscopic Examination FINDINGS Eryhtema, edema, no spontaneous purulent exudates, tubes freely movable Gross purulent material evident, erythema & edema more marked, tubes may NOT be freely movable, & fimbrial stoma may NOT be patent Pyosalpinx or Inflammatory complex Abscess

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< 50% of women with acute pelvic inflammatory disease have a WBC count of >10,000 cells per milliliter.

ESR ESR >15 mm/hour in ~75% of women w/ laparoscopically confirmed acute pelvic infection NON-specific because 53% of women with pelvic pain and visually NORMAL pelvic organs also have ESR

MANAGEMENT OF

Pelvic Inflammatory Disease

Important Point in Management 2 IMPORTANT GOALS of MEDICAL Therapy resolution of symptoms preservation of tubal function Antibiotic therapy should be started as soon as cervical cultures have been obtained and the diagnosis is suspected Women who are not treated in the first 72 hours following the onset of symptoms are 3x likely to develop tubal infertility or ectopic pregnancy Criteria for Initiating Treatment MAJOR or MINIMUM CRITERIA SIGNS Lower abdominal tenderness Adnexal Tenderness Cervical Motion tenderness CDC Recommendation IF MINIMUM criteria is present & no other cause can be identified in a sexually active young women: Empiric treatment should be initiated in sexually active young women and others at risk for STDs 6 MINOR/ ROUTINE criteria for diagnosing PID Oral temperature: >38C Abnormal cervical or vaginal discharge Presence of abundant WBCs on microscopy of vaginal secretions (+) lots of PUS cells Elevated ESR Elevated C reactive proteins Laboratory documentation of cervical infection with N. gonorrhea or C. trachomatis DEFINITIVE criteria for diagnosing PID: Histopathology evidence of endometritis on endometrial biopsy TVS or MRI showing thickened fluid-filled tubes (hydrosalphinx or pyosalphinx) with or w/o free pelvic or tuboovarian complex Laparoscopic Showing abnormalities consistent with PID CDC Ambulatory Management (2006) Done as OUTPATIENT management BROAD-SPECTRUM ORAL ANTIBIOTICS foundation of outpatient therapy of acute pelvic inflammatory disease PATIENT group community acquired infection NO tubo-ovarian abscess REGIMENS Regimen A Levofloxacin (Levox) 500mg PI OD X14 day or Ofloxacin 400mg PO BID X14 days effective as a single agent against both N. gonorrhoeae and C. trachomatis +/- Metronidazole 500 mg PO BID X 14 days For anaerobic coverage

SEVERITY MILD MODERATE SEVERE

ENDOMETRIAL BIOPSY Done to establish presence of ENDOMETRITIS Component of PID ULTRASOUND Limited value d/t low sensitivity TVS to document adnexal mass differentiate b/w tuboovarian abscess & tuboovarian complex noninvasive diagnostic aid for patients who are so tender during pelvic examination that the physician cannot determine the presence or absence of a pelvic mass FINDINGS suggestive for acute PID dilated and fluid-filled tubes free peritoneal fluid adnexal masses MRI Sensitive but EXPENSIVE LABORATORY TESTS CBC Leukocytosis not a reliable indicator of acute pelvic inflammatory disease does NOT correlate with the need for hospitalization or the severity of tubal inflammation.

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Regimen B LESS expensive than regimen A. DRUG Regimen Ceftriaxone 250 mg IM single dose or Cefoxitin 2g IM single dose ADD either of the 2 drugs Probenecid 1g PO administered concurrently in a single dose rd Other parenteral 3 generation cephalosporin (Ceftizoxime or Cefotaxime) PLUS Doxcycline 100mg PO BID X 14 days Ceftizoxime has unparalleled coverage against N. gonorrhoeae cefotaxime has better anaerobic coverage. +/- Metronidazole 500 mg PO BID X 14 days prolonged coverage if w/ bacterial vaginosis ALTERNATIVE Oral Regimens Amoxicillin/Clavulanic Acid + Doxycycline for 14 days. FAILURE of OUTPATIENT regimen related to: Noncompliance Reinfection Inadequate antibiotic coverage for penicillinase-producing or chromosomally mediated resistant N. gonorrhoeae or facultative or anaerobic organisms involved in upper genital tract infection that are resistant to the drug prescribed. FOLLOW-UP reexamine women within 48 to 72 hours of initiating outpatient therapy to evaluate the response of the disease to oral antibiotics. The patient should be hospitalized when the therapeutic response is not optimal. If disease is responding well, ~4 to 6 weeks after therapy the endocervix should be cultured to test for microbiologic cure Indications for Hospitalization Questionable or suspected PID Patient is PREGNANT second-trimester uterus is a fertile ground for severe pelvic infection patient may develop widespread signs and symptoms of sepsis before the subtle inflammatory changes in the pelvis are recognized Does not respond clinically to oral antimicrobial tx Unable to follow or tolerate an outpatient oral regimen Seen in patient with gastrointestinal symptoms, such as nausea and vomiting Patient w/ severe illness, nausea and vomiting or high fever Patient w/ Tuboovarian abscess Adnexal mass almost absolute indication for hospitalization

Outpatient therapy does not provide high enough levels of appropriate antibiotics to successfully penetrate an abscess cavity Acute peritonitis in the right upper quadrant, especially liver tenderness without hepatomegaly Pelvic infections with an IUD in place and pelvic infections following operative or diagnostic procedures often due to anaerobic bacteria best to hospitalize these patients and use intravenous antibiotics immunodeficiency especially HIV infection with a low CD4 count Inpatient Management adolescent young women should be hospitalized with their first episode of acute pelvic inflammatory disease to ensure maximum levels of antibiotics in the hope of preventing microscopic tubal damage CONSERVATIVE Management Parenteral Regimen A excellent for COMMUNITY-ACQUIRED infection because it treats both gonorrhea and chlamydial infection DRUGS Cefotetan 2 g IV q 12 or Cefoxitin 2g IV q6 plus Doxycycline 100mg PO or IV q12 d/t pain a/w infusion, doxycycline should be administered orally even with the patient is hospitalized. Both IV and PO administration provide similar bioavailability should be included in the regimen of follow-up oral therapy ADVANTAGE Doxycycline + cefoxitin provide excellent coverage for N. gonorrhoeae C. trachomatis C. trachomatis has a 48- to 72hour life cycle inside of the mucosal cell. Prolonged therapeutic levels of the antichlamydial antibiotic are imperative Penicillinase producing N. gonorrhoeae Cefoxitin excellent antibiotic against Peptococcus Peptostreptococcus E. coli. DISADVANTAGE less than ideal for a pelvic abscess or for anaerobic infections. doxycycline

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should be administered orally whenever possible because of the marked superficial phlebitis produced by intravenous infusion

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Regimen B PREFERRED REGIMEN FOR patients with an abscess IUD-related infections pelvic infections after a diagnostic or operative procedure DRUG Regimen Clinadmycin 900 mg IV q8 plus Gentamicin (Aminoglycoside) loading dose IV or IM (2mg/kg) followed by maintenance dose (1.5 mg/kg) q8. Not used for patients w/ renal diseases Single daily dosing may be substituted ADVANTAGE excellent coverage for anaerobic infections facultative gram-negative rods. Clindamycin activity against 90% of bacterial strains of Chlamydia Aminoglycoside (Gentamycin) ONCE DAILY decreased toxicity if one dose only increased efficacy

FOLLOW-UP Drug clindamycin 450 mg orally QID more efficacious anaerobic coverage than doxycycline OPERATIVE Management INDICATIONS Life threating infections Ruptured tuboovarian abscess Abscess a collection of pus within a newly created space Laparoscopic drainage of Pelvic abscess persistent masses in some older women for whom future childbearing is not a consideration removal of a persistent symptomatic mass. Unilateral removal of a tuboovarian complex or an abscess frequent conservative operation for acute pelvic inflammatory disease. Drainage of a culde-sac abscess via percutaneous drainage or a culpotomy incision results in preservation of the reproductive organs. Percutaneous Drainage accomplished under tomography guidance. ultrasonic or computer

may be transvaginal or transabdominal

decreased cost triple coverage with the addition of ampicillin PREFFERED if patient has a mass Alternative Parenteral Regimen Ofloxacin 400 mg IV q12 + Clindamycin or Metronidazole 500 mg IV q8 provide excellent broad-spectrum coverage Ciprofloxacin (Levofloxacin) 500mg IV OD + Clindamycin & Metronidazole provide excellent broad-spectrum coverage Ampicillin/Subactam 3g IV q6 + Doxycyline 100 mg PO or Iv q12 excellent anaerobic coverage good choice for women w/ a tuboovarian complex a collection of pus within an anatomic space created by adherence of adjacent organs Ciprofloxacin + BOTH doxycycline & metronidazole excellent broad-spectrum coverage Ciprofloxacin has poor coverage against C. trachomatis limited anaerobic spectrum. Doxycycline & Metronidazole Good anaerobic coverage Alternatives to Aminoglycoside in patients w/ renal disease Astreonam A monobactam antibiotic spectrum similar to aminoglycosides but without renal toxicity. much more expensive. 2g IV q 8 hours. 3rd-generation cephalosporin for patient with renal disease CDC recommends that IV antibiotics be continued at least 24 hours after substantial improvement in the patient Parenteral antibiotic therapy may be discontinued when the woman has been afebrile for 24 hours.

CONTRAINDICATION any suspicion of an infected carcinoma Laparoscopic aspiration of tuboovarian complexes good results but does not have greater benefit than percutaneous ultrasound-guided aspiration of abscess cavities. carries more operative risks than ultrasound-guided aspiration.

TUBOOVARIAN

Abscesses
Tuboovarian Abscess Complication seen in PID

Abscesses caused by acute pelvic inflammatory disease contain a mixture of anaerobes and facultative or aerobic organisms environment of an abscess cavity results in a low level of oxygen tension; hence, anaerobic organisms predominate Drugs clindamycin penetrates the human neutrophil w/c facilitates the level of clindamycin within the abscess. stable in the abscess environment, which is not true of many other antibiotics. COMBINATIONS clindamycin + aminoglycoside STANDARD FOR TREATMENT tuboovarian abscess. DISADVANATGE

of

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does not treat the enterococcus clindamycin + aminoglycoside + ampicillin added to treat the enterococcus Metronidazole effective alternative to clindamycin for anaerobic infections

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DIASADVANTAGE does not provide gram-negative coverage If abscesses do not respond to parenteral broad-spectrum antibiotics, DRAINAGE is imperative. OUTCOMES LONG TERM SEQUELAE OF

Pelvic Inflammatory Disease

Long Term Sequelae of PID Involuntary Infertility r/t tubal obstructions incidence of infertility following acute pelvic inflammatory disease varies widely (6% to 60%) depending on severity of the infection number of episodes of infection 11.4% after one episode 23.1% after two episodes 54.3% after three or more episodes age of the patient Ectopic pregnancy 6-10 fold w/ PID 50% of ectopic pregnancies occur in oviducts damaged by previous salpingitis PATHOLOGY damaged yet patent oviduct peritubular and periovarian adhesions severe tubal damage degeneration of endosalpingeal structures cilia dysfunction LOCATION of obstruction fimbrial end cornual region of the oviduct. Chronic pelvic pain 4 fold CAUSE Hydrosalpinx a collection of sterile, watery fluid in the fallopian tube end-stage development of a pyosalpinx. Adhesions surrounding the ovary Recurrent PID Death result from rupture of tuboovarian abscesses. Chronic abdominal pain 10x in subjects who had PID

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