The bacteria that most frequently cause secondary pelviperitonitis are E. Coli, Proteus mirabilis, Bacteroides fragilis, and to a lesser extent gram positive. Less frequent are Streptococcus pyogenes, saprofitic bacteria from the oral cavity, PYR positive and sensitive to Bacitracine.
ObjectiveTo consider germs from other anatomical areas when making the differential diagnosis of acute abdominal pelviperitonitis and attempt to make the diagnosis hearlier.
Clinic historyA 40 year old woman admitted as an emergency with right iliac fossa pain of several hours duration. She had an IUD inserted 48 hours earlier.
Physical examinationSoft, depressible abdomen, pain on palpation in the right iliac fossa and other signs of peritoneal irritation. On the second post-insertion day the patient presented swelling of the right labia mayor, giving the impression of Bartholinitis. This evolved into edema of the declive zones of the vulvovaginal area. The IUD was removed and culture of free peritoneal liquid showed Group A Beta Hemolytic Streptococcus (Pyogenes). The patient began to suffer from acute respiratory distress syndrome and was admitted to the intensive care unit.
DiscussionIn the 1980’s pelviperitonitis following insertion of IUD was a rare diagnosis in women of fertile age. Today IUD is more commonly used. In Italy 15% of patients of reproductive age have an IUD. The most frequent complications are perforation, ectopic pregnancy, and pelvic inflammatory disease. Evolution from anexitis to pyosalpingitis occurs in 50% of cases, suppuration and endometritis in a third of cases, and parametritis in 10% of cases. And what is more, secondary post-implantation peritonitis and asymptomatic perforation may occur in 0.12-0.68/1000 insertions. Perforation in some cases is fatal.
Pyosalpingitis occurs most frequently in women with a median age of 26.8 years end the most frequent culture is Neisseria gonorrhoea (50%) and Chlamydia trachomatis Haemophillus parainfluenzae was also related to pelviperitonitis and perforation (caused by IUD 1977).
Differences exist between the results expected, and those obtained from culture. The prevalence of staphilococcus resistent to Oxaciclin, Gentamycin, and Vancomycin are increasing, and is a severe indicator of morbimortality in nosocomial patients (n = 365, 9% vs 23%, p < 0.001). There are studies in which enterococcus is starting to become relevant. Group A betahaemolytic streptococcus produces fewer but more severe pathologies, such as toxic shock in 5 year old patients. New attitudes and epidemiologies may condition changes in the results of cultures. Goup A streptococcus is associated with the practice of oral sex following IUD insertion, verified by culture of the oropharyngeal flora of the sexual partner which coincides with the serotype and group of that in the vaginal flora of the patient. The existence of E. coli and Bacterioides fragilis in cultures may become clinically unhelpful with respect to a possible change in treatment, due partly to difficulty in identifying antibiotic resistant organisms with the empirical therapy and the epidemiological change of direction.
ConclusionThe use of IUD in young patients continues to be a cause of acute abdomen due to post-insertion perforation. In making the differential diagnosis of acute abdomen in fertile women is relevant to check what type of contraception they are using, social situation and other related epidemiological data to decide the course of action to be taken, and what antibiotic therapy to use in order to avoid later complications.
Vulvar carcinoma in a patient with chronic lichen sclerosus.
