Pelvic inflammatory disease
|Pelvic inflammatory disease|
Drawing showing the usual sites of infection in pelvic inflammatory disease
|Classification and external resources|
|Patient UK||Pelvic inflammatory disease|
Pelvic inflammatory disease or pelvic inflammatory disorder (PID) is an infection of the upper part of the female reproductive system namely the uterus, fallopian tubes, or the ovaries. Often there may be no symptoms. Signs and symptoms, when present may include: lower abdominal pain, vaginal discharge, fever, burning with urination, pain with sex, or irregular menstruation. Untreated PID can result in long term complications including: infertility, ectopic pregnancy, chronic pelvic pain, and cancer.
Infections by Neisseria gonorrhoeae or Chlamydia trachomatis are present in 75 to 90 percent of cases. Often multiple different bacteria are involved. Without treatment about 10% of those with a chlamydial infection and 40% of those with a gonorrhea infection will develop PID. Risk factors are similar to those of sexually transmitted infections generally and include a high number of sexual partners and drug use. Vaginal douching may also increase the risk. The diagnosis is typically based on the presenting signs and symptoms. It is recommended that the disease be considered in all women of childbearing age who have lower abdominal pain. A definitive diagnosis of PID is made by finding pus involving the fallopian tubes during surgery. Ultrasound may also be useful in diagnosis.
Efforts to prevent the disease include: not having sex or having few sexual partners and using condoms. Screening women at-risk for chlamydial infection followed by treatment decreases the risk of PID. If the diagnosis is suspected, treatment is typically advised. Treating a woman's sexual partners should also occur. In those with mild or moderate symptoms a single injection of the antibiotic ceftriaxone along with 2 weeks of doxycycline and possibly metronidazole by mouth is recommended. For those who do not improve after three days or who have severe disease intravenous antibiotics should be used.
Globally about 106 million cases of chlamydia and 106 million cases of gonorrhea occurred in 2008. The number of cases of PID however, is not clear. It is estimated to affect about 1.5% of young women yearly. In the United States PID is estimated to affect about one million people yearly. A type of intrauterine device (IUD) known as the Dalkon shield led to increased rates of PID in the 1970s. Current IUDs are not associated with this problem after the first month.
Signs and symptoms
Symptoms in PID range from none to severe. If there are symptoms, then fever, cervical motion tenderness, lower abdominal pain, new or different discharge, painful intercourse, uterine tenderness, adnexal tenderness, or irregular menstruation may be noted.
The anatomical structure of the internal organs and tissues of the female reproductive tract provides a pathway for pathogens to enter the pelvic cavity thorough the infundibulum. Uterine lining is continuous with that of the vagina and vulva and it remains possible for infectious agents to ultimately spread to the peritoneal linings. The disturbance of the naturally occurring microbiota of the female genital tract increases the risk of PID.
N. gonorrhoea is isolated in 40–60% of women with acute salpingitis. C. trachomatis is estimated to be the cause in about 60% of cases of salpingitis, which may lead to PID. However, not all PID is caused solely by STIs; organisms that are considered normal vaginal flora can be involved, and individual cases of PID can be due to either a single organism or a co-infection of many different species. 10% of women in one study had asymptomatic Chlamydia trachomatis infection and 65% had asymptomatic infection with Neisseria gonorrhoeae. It was noted in one study that 10–40% of untreated women with N. gonorrhoea develop PID and 20–40% of women infected with C. trachomitis developed PID.
Upon examination, mucopurulent cervicitis and or urethritis may be observed. In severe cases more testing may be required such as laproscopy, intra-abdominal bacteria sampling and culturing, or tissue biopsy.
Other imaging methods can aid in diagnosis. These are: ulstrasonography, computed tomography (CT), and magnetic imaging (MRI) Blood tests can also help identify the presence of infection: the erythrocyte sedimentation rate (ESR), the C-reactive protein (CRP) level, and chlamydial and gonococcal DNA probes.
Nucleaic acid amplification tests (NAATs), direct fluorescein tests (DFA), and enszyme linked immunosorbent assays (ELISA) are highly sensitive tests that can identify specific pathogens present. Serology testing for antibodies is not as useful since the presence of the microorganisms in healthy people can confound interpreting the antibody titer levels, although aniitbody levels can indicate whether an infection is recent or long term.
Definitive criteria include: histopathologic evidence of endometritis, thickened filled Fallopian tubes, or laparoscopic findings. Gram-stain/smear becomes definitive in the identification of rare, atypical or and possibly more serious organisms. Two thirds of patients with laparoscopic evidence of previous PID were not aware they had PID, however even asymptomatic PID can cause serious harm.
A number of other causes may produce similar to PID symptoms including: appendicitis, ectopic pregnancy, hemorrhagic or ruptured ovarian cysts, twisted ovarian, and endometriosis and gastroenteritis among others.
Pelvic inflammatory disease is more likely to reoccur when there is a prior history of the infection, recent sexual contact, recent onset of menses, or an IUD (intrauterine device) in place or if the partner has a sexually transmitted infection.
Acute pelvic inflammatory disease is highly unlikely when recent intercourse has not taken place or an IUD is not being used. A sensitive serum pregnancy test is typically obtained to rule out ectopic pregnancy. Culdocentesis will differentiate hemoperitoneum (ruptured ectopic pregnancy or hemorrhagic cyst) from pelvic sepsis (salpingitis, ruptured pelvic abscess, or ruptured appendix).
Pelvic and vaginal ultrasounds are helpful in the differential diagnosis of ectopic pregnancy of over six weeks. Laparoscopy is often utilized to diagnose pelvic inflammatory disease, and it is imperative if the diagnosis is not certain or if the patient has not responded to antibiotic therapy after 48 hours.
No single test has adequate sensitivity and specificity to diagnose pelvic inflammatory disease. A large multisite U.S. study found that cervical motion tenderness as a minimum clinical criterion increases the sensitivity of the CDC diagnostic criteria from 83% to 95%. However, even the modified 2002 CDC criteria do not identify women with subclinical disease.
Regular sexually transmitted infections testing is important for prevention. The risk of contracting pelvic inflammatory disease can be reduced by the following:
- Using barrier methods such as condoms; see human sexual behavior for other listings.
- Seeking medical attention if you are experiencing symptoms of PID.
- Seeking medical attention after learning that a current or former sex partner has, or might have had a sexually transmitted infection.
- Scheduling regular gynecological (pelvic) exams with STI testing to screen for symptomless PID and to discuss sexual history.
- Getting a STI history from your current partner and insisting they be tested and treated before intercourse.
- Diligence in avoiding vaginal activity, particularly intercourse, after the end of a pregnancy (delivery, miscarriage, or abortion) or certain gynecological procedures, to ensure that the cervix closes.
Treatment is often started without confirmation of infection because of the serious complications that may result from delayed treatment. Treatment depends on the infectious agent and generally involves the use of antibiotic therapy. If there is no improvement within two to three days, the patient is typically advised to seek further medical attention. Hospitalization sometimes becomes necessary if there are other complications. Treating sexual partners for possible STIs can help in treatment and prevention.
The CDC guidelines state that the site route of antibiotic administration affects the short or long-term major outcome of women with mild or moderate disease.
For women with PID of mild to moderate severity, parenteral and oral therapies appear to be efficacious. Clinical experience should guide decisions regarding transition to oral therapy, which usually can be initiated within 24–48 hours of clinical improvement. Typical regimens include cefoxitin or cefotetan plus doxycycline, and clindamycin plus gentamicin. An alternative parenteral regimen is ampicillin/sulbactam plus doxycycline. Another alternative is to use a parenteral regimen with ceftriaxone or cefoxitin plus doxycycline.
Although the PID infection itself may be cured, effects of the infection may be permanent. This makes early identification essential. Treatment by medical providers who can prescribe appropriate curative treatment is very important in the prevention of damage to the reproductive system. Since early gonococcal infection may be asymptomatic, regular screening of individuals at risk for common agents (history of multiple partners, history of any unprotected sex, or people with symptoms) or because of certain procedures (post pelvic operation, postpartum, miscarriage or abortion). Prevention is also very important in maintaining viable reproduction capabilities.
If the initial infection is mostly in the lower tract, after treatment the person may have few difficulties. If the infection is in the fallopian tubes or ovaries, more serious complications are more likely to occur.
PID can cause scarring inside the reproductive system, which can later cause serious complications, including chronic pelvic pain, infertility, ectopic pregnancy (the leading cause of pregnancy-related deaths in adult females), and other complications of pregnancy. Occasionally, the infection can spread to in the peritoneum causing inflammation and the formation of scar tissue on the external surface of the liver (Fitz-Hugh-Curtis syndrome).
Globally about 106 million cases of chlamydia and 106 million cases of gonorrhea occurred in 2008. The number of cases of PID; however, is not clear. It is estimated to affect about 1. 5% of young women yearly. In the United States PID is estimated to affects about one million people yearly.
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