Porth's Essentials of Pathophysiology, 4e

1030

Genitourinary and Reproductive Function

U N I T 1 1

injection (Depo-Provera) has been associated with PID. Fever (>101°F), increased erythrocyte sedimentation rate, and an elevated white blood cell count (>10,000 cells/mL) commonly are seen, even though the woman may not appear acutely ill. Elevated C-reactive protein (CRP) levels equate with inflammation and can be used as another diagnostic tool. Laparoscopy, which allows for direct visualization of the ovaries, fallopian tubes, and uterus, is one of the most specific procedures for diagnosing PID, but is costly and carries the inherent risks of surgery and anesthesia. 27 Minimal criteria for a presumptive diagnosis of PID require only the presence of lower abdominal pain, adnexal (area adjoining the uterus, fallopian tubes, and ovaries) tenderness, and cer- vical motion tenderness on bimanual examination with no other apparent cause. Treatment may involve hospitalization with intrave- nous administration of antibiotics. If the condition is diagnosed early, outpatient antibiotic therapy may be sufficient. Treatment is aimed at preventing complica- tions, which can include pelvic adhesions, infertility, ectopic pregnancy, chronic abdominal pain, and tubo- ovarian abscesses. Endometriosis Endometriosis is the condition in which functional endometrial tissue is found in ectopic sites outside the uterus. 28–30 The site may be the ovaries, posterior broad ligaments, uterosacral ligaments, rectouterine pouch, pelvis, vagina, vulva, perineum, or intestines (Fig. 40-10). The cause of endometriosis is largely unknown. There appears to have been an increase in its incidence in developed Western countries during the past four

(which are not present in the normal endometrium) is required for diagnosis. The clinical picture is variable, but often includes abnormal vaginal bleeding, mild to severe uterine tenderness, fever, malaise, and foul- smelling discharge. Treatment involves oral or intrave- nous antibiotic therapy, depending on the severity of the condition. Pelvic Inflammatory Disease. Pelvic inflammatory disease (PID) is a polymicrobial infection of the upper reproductive tract (uterus, fallopian tubes, or ovaries) associated with sexually transmitted and endogenous organisms. 25–27 The organisms ascend through the endo- cervical canal to the endometrial cavity, and then to the fallopian tubes and ovaries (Fig. 40-9). The endocervical canal is slightly dilated during menstruation, allowing bacteria to gain entrance to the uterus and other pelvic structures. After entering the upper reproductive tract, the organisms multiply rapidly in the favorable environ- ment of the sloughing endometrium and ascend to the fallopian tube. Factors that predispose women to the development of PID include an age younger than 25 years; young age at first intercourse (<15 years); use of nonbarrier contracep- tion, especially IUD or oral contraception; history of new, multiple, or symptomatic sex partners; and previous his- tory of PID or sexually transmitted infection. 25 The symptoms of PID include lower abdominal pain, which may start just after a menstrual period; dyspa- reunia; back pain; purulent cervical discharge; and the presence of lower abdominal tenderness and exquisitely painful cervix on bimanual pelvic examination. New- onset breakthrough bleeding in women who are on oral contraceptives or medroxyprogesterone contraceptive

Salpingitis

Postpartum endometritis

Adhesions

Cervicitis

Vaginitis (e.g., Trichomonas vaginalis)

Endometritis

FIGURE 40-9. Pelvic inflammatory disease. Microbial agents enter through the vagina and ascend to involve the uterus, fallopian tubes, and pelvic structures.

Ascending infections (e.g., Gonococcus, Staphylococcus, anaerobes, Streptococcus, Chlamydia)