View source for Pelvic inflammatory disease

{{short description|Infection of uterus, fallopian tubes, ovaries or the inner surface of pelvis}}
{{good article}}
{{Infobox medical condition (new)
| name            = Pelvic inflammatory disease
| synonyms        = Pelvic inflammatory disorder
| image           = Blausen 0732 PID-Sites.png
| caption         = Drawing showing the usual sites of infection in pelvic inflammatory disease
| field           = [[Gynecology]]
| symptoms        = Lower abdominal pain, [[vaginal discharge]], [[fever]], [[dysuria|burning with urination]], [[dyspareunia|pain with sex]], [[irregular menstruation]]<ref name=CDC2014Sym/>
| complications   = [[Infertility]], [[ectopic pregnancy]], [[chronic pelvic pain]], [[Infectious causes of cancer|cancer]]<ref name=Mit2013/><ref name=ChangParsonnet2010/><ref name=ChanSeraj1996/>
| onset           = 
| duration        = 
| types           = 
| causes          = Bacteria that spread from the vagina and cervix<ref name="NEJM PID Review 2015" />
| risks           = [[Gonorrhea]], [[chlamydia]]<ref name=Mit2013/>
| diagnosis       = Based on symptoms, [[ultrasound]], [[laparoscopic surgery]]<ref name=Mit2013/>
| differential    = 
| prevention      = [[abstinence|Not having sex]], having few sexual partners, using [[condom]]s<ref name=CDC2014Pre/>
| treatment       = [[Antibiotic]]s<ref name=CDC2010Tx/>
| medication      = 
| prognosis       = 
| frequency       = 1.5 percent of young women yearly<ref name=Esch2008/>
| deaths          = 
}}
<!-- Definition and symptoms -->
'''Pelvic inflammatory disease''', also known as '''pelvic inflammatory disorder''' ('''PID'''), is an [[infection]] of the upper part of the [[female reproductive system]], namely the [[uterus]], [[fallopian tubes]], and [[ovaries]], and inside of the [[pelvis]].<ref name="NEJM PID Review 2015">{{cite journal |vauthors=Brunham RC, Gottlieb SL, Paavonen J |title=Pelvic inflammatory disease |journal=The New England Journal of Medicine |volume=372 |issue=21 |pages=2039–48 |year=2015 |pmid=25992748 |doi=10.1056/NEJMra1411426 |s2cid=207846620 }}</ref><ref name=Mit2013>{{cite journal|last1=Mitchell|first1=C|last2=Prabhu|first2=M|title=Pelvic inflammatory disease: current concepts in pathogenesis, diagnosis and treatment.|journal=Infectious Disease Clinics of North America|date=December 2013|doi=10.1016/j.idc.2013.08.004|volume=27|issue=4|pages=793–809|pmid=24275271|pmc=3843151}}</ref> Often, there may be no symptoms.<ref name=CDC2014Sym>{{cite web|title=Pelvic Inflammatory Disease (PID) Clinical Manifestations and Sequelae|url=http://www2a.cdc.gov/stdtraining/self-study/pid/pid_clinical_self_study_from_cdc.html|website=cdc.gov|access-date=February 21, 2015|date=October 2014|archive-url=https://web.archive.org/web/20150222022835/http://www2a.cdc.gov/stdtraining/self-study/pid/pid_clinical_self_study_from_cdc.html|archive-date=February 22, 2015}}</ref> Signs and symptoms, when present, may include lower abdominal pain, [[vaginal discharge]], [[fever]], [[dysuria|burning with urination]], [[dyspareunia|pain with sex]], [[postcoital bleeding|bleeding after sex]], or [[irregular menstruation]].<ref name=CDC2014Sym/> Untreated PID can result in long-term complications including [[infertility]], [[ectopic pregnancy]], [[chronic pelvic pain]], and [[Infectious causes of cancer|cancer]].<ref name=Mit2013/><ref name="ChangParsonnet2010">{{cite journal|last1=Chang|first1=A. H.|last2=Parsonnet|first2=J.|author2-link=Julie Parsonnet|title=Role of Bacteria in Oncogenesis|journal=Clinical Microbiology Reviews|volume=23|issue=4|year=2010|pages=837–857|issn=0893-8512|doi=10.1128/CMR.00012-10|pmid=20930075|pmc=2952975}}</ref><ref name=ChanSeraj1996>{{cite journal|last1=Chan|first1=Philip J.|last2=Seraj|first2=Ibrahim M.|last3=Kalugdan|first3=Theresa H.|last4=King|first4=Alan|title=Prevalence of Mycoplasma Conserved DNA in Malignant Ovarian Cancer Detected Using Sensitive PCR–ELISA|journal=Gynecologic Oncology|volume=63|issue=2|year=1996|pages=258–260|issn=0090-8258|doi=10.1006/gyno.1996.0316|pmid=8910637}}</ref>

<!-- Causes and diagnosis -->
The disease is caused by bacteria that spread from the vagina and cervix.<ref name="NEJM PID Review 2015" /> It has been reported that infections by ''[[Neisseria gonorrhoeae]]'' or ''[[Chlamydia trachomatis]]'' are present in 75 to 90 percent of cases.<ref name=Mit2013/> However, in the UK it is reported by the NHS that infections by ''[[Neisseria gonorrhoeae]]'' and ''[[Chlamydia trachomatis]]'' are responsible for only a quarter of PID cases.<ref name=NHSPID>{{cite web |website=National Health Service | title=Acute Pelvic Inflammatory Disease | url=https://www.nth.nhs.uk/content/uploads/2020/01/NATLEAFLET-pi-acute-pid.pdf |archive-url=https://web.archive.org/web/20230124095157/https://www.nth.nhs.uk/content/uploads/2020/01/NATLEAFLET-pi-acute-pid.pdf |archive-date=2023-01-24}}</ref> Often, multiple different bacteria are involved.<ref name=Mit2013/> 

Without treatment, about 10 percent of those with a [[chlamydial infection]] and 40 percent of those with a [[gonorrhea infection]] will develop PID.<ref name=Mit2013/><ref name=WHO2012>{{cite web |author1=World Health Organization |title=Global incidence and prevalence of selected curable sexually transmitted infections - 2008 |url=http://apps.who.int/iris/bitstream/10665/75181/1/9789241503839_eng.pdf |website=who.int |access-date=February 22, 2015 |pages=2, 19 |date=2012 |url-status=live |archive-url=https://web.archive.org/web/20150319011717/http://apps.who.int/iris/bitstream/10665/75181/1/9789241503839_eng.pdf |archive-date=March 19, 2015 }}</ref> Risk factors are generally similar to those of [[sexually transmitted infection]]s and include a [[promiscuity|high number of sexual partners]] and [[Substance abuse|drug use]].<ref name=Mit2013/> [[Vaginal douching]] may also increase the risk.<ref name=Mit2013/> The diagnosis is typically based on the presenting signs and symptoms.<ref name=Mit2013/> It is recommended that the disease be considered in all women of childbearing age who have lower abdominal pain.<ref name=Mit2013/> A definitive diagnosis of PID is made by finding [[pus]] involving the fallopian tubes during [[laproscopic surgery|surgery]].<ref name=Mit2013/> [[Ultrasound]] may also be useful in diagnosis.<ref name=Mit2013 />

<!-- Prevention and treatment -->
Efforts to prevent the disease include [[Sexual abstinence|not having sex]] or having few sexual partners and using [[condom]]s.<ref name=CDC2014Pre>{{cite web |title=Pelvic Inflammatory Disease (PID) Patient Counseling and Education |url=http://www2a.cdc.gov/stdtraining/self-study/pid/pid_patient_counseling_self_study_from_cdc.html |publisher=Centers for Disease Control |access-date=February 21, 2015 |date=October 2014 |archive-url=https://web.archive.org/web/20150222021120/http://www2a.cdc.gov/stdtraining/self-study/pid/pid_patient_counseling_self_study_from_cdc.html |archive-date=February 22, 2015 }}</ref> Screening women at risk for chlamydial infection followed by treatment decreases the risk of PID.<ref name=CDC2014Pub /> If the diagnosis is suspected, treatment is typically advised.<ref name=Mit2013 /> Treating a woman's sexual partners should also occur.<ref name=CDC2014Pub>{{cite web |title=Pelvic Inflammatory Disease (PID) Partner Management and Public Health Measures |url=http://www2a.cdc.gov/stdtraining/self-study/pid/pid_partner_management_self_study_from_cdc.html |publisher=Centers for Disease Control |access-date=February 21, 2015 |date=October 2014 |archive-url=https://web.archive.org/web/20150222021754/http://www2a.cdc.gov/stdtraining/self-study/pid/pid_partner_management_self_study_from_cdc.html |archive-date=February 22, 2015 }}</ref> In those with mild or moderate symptoms, a single injection of the [[antibiotic]] [[ceftriaxone]] along with two weeks of [[doxycycline]] and possibly [[metronidazole]] by mouth is recommended.<ref name=CDC2010Tx/> For those who do not improve after three days or who have severe disease, intravenous antibiotics should be used.<ref name=CDC2010Tx>{{cite web |title=2010 STD Treatment Guidelines Pelvic Inflammatory Disease |url=https://www.cdc.gov/std/treatment/2010/pid.htm |publisher=Centers for Disease Control |access-date=February 22, 2015 |date=August 15, 2014 |url-status=live |archive-url=https://web.archive.org/web/20150222002803/http://www.cdc.gov/std/treatment/2010/pid.htm |archive-date=February 22, 2015 }}</ref>

<!-- Epidemiology and history -->
Globally, about 106 million cases of chlamydia and 106 million cases of gonorrhea occurred in 2008.<ref name=WHO2012/> The number of cases of PID, however, is not clear.<ref name=Esch2008/> It is estimated to affect about 1.5 percent of young women yearly.<ref name=Esch2008>{{cite journal |last1=Eschenbach |first1=D |title=Acute Pelvic Inflammatory Disease |journal=Glob. Libr. Women's Med. |date=2008 |doi=10.3843/GLOWM.10029 |s2cid=40912241 |issn=1756-2228|url=https://www.glowm.com/section_view/heading/Acute%20Pelvic%20Inflammatory%20Disease/item/29}}</ref> In the United States, PID is estimated to affect about one million people each year.<ref name=CDC2014Epi>{{cite web |title=Self-Study STD Modules for Clinicians&nbsp;— Pelvic Inflammatory Disease (PID) Next Centers for Disease Control and Prevention Your Online Source for Credible Health Information CDC Home Footer Separator Rectangle Epidemiology |url=http://www2a.cdc.gov/stdtraining/self-study/pid/pid_epidemiology_self_study_from_cdc.html |publisher=Centers for Disease Control |access-date=February 21, 2015 |date=October 2014 |archive-url=https://web.archive.org/web/20150222022710/http://www2a.cdc.gov/stdtraining/self-study/pid/pid_epidemiology_self_study_from_cdc.html |archive-date=February 22, 2015 }}</ref> A type of [[intrauterine device]] (IUD) known as the [[Dalkon shield]] led to increased rates of PID in the 1970s.<ref name=Mit2013/> Current IUDs are not associated with this problem after the first month.<ref name=Mit2013/>

== Signs and symptoms ==
[[File:Blausen 0719 PelvicInflammatoryDisease.png|thumb|Illustration of pelvic inflammatory disease]]Symptoms in PID range from none to severe. If there are symptoms, [[fever]], [[cervix|cervical]] motion tenderness, lower [[abdominal pain]], new or different discharge, [[Dyspareunia|painful intercourse]], [[uterus|uterine]] tenderness, [[adnexa of uterus|adnexal]] tenderness, or irregular menstruation may be noted.<ref name=Mit2013/><ref name=CDC2014Sym/><ref>{{cite web |title=Pelvic Inflammatory Disease Empiric Therapy |publisher=Medscape |date=2015 |first1=Ritu |last1=Kumar |first2=Michael Stuart |last2=Bronze |url=http://emedicine.medscape.com/article/2011881-overview# |access-date=March 30, 2015 |url-status=live |archive-url=https://web.archive.org/web/20150403090002/http://emedicine.medscape.com/article/2011881-overview |archive-date=April 3, 2015 }}</ref><ref name=Zakher>{{cite journal |last1=Zakher |first1=Bernadette |last2=Cantor MD |first2=Amy G. |last3=Daeges |first3=Monica| last4=Nelson MD |first4=Heidi |title=Review: Screening for Gonorrhea and Chlamydia: A Systematic Review for the U.S. Prevententive Services Task Force |journal=Annals of Internal Medicine |pages=884–894 |date=December 16, 2014 |volume=161 |issue=12 |doi=10.7326/M14-1022|pmid=25244000 |citeseerx=10.1.1.691.6232 |s2cid=207538182 }}</ref>

Other complications include [[endometritis]], [[salpingitis]], [[tubo-ovarian abscess]], pelvic [[peritonitis]], periappendicitis, and [[perihepatitis]].<ref name=Sternak2014/>

=== Complications ===
[[File:Perihepatic adhesions 2.jpg|thumb|Fitz-Hugh–Curtis syndrome with perihepatic adhesions following a chlamydia infection]]

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.<ref>{{Cite web|url=https://www.cdc.gov/std/PID/STDFact-PID.htm|title=Pelvic Inflammatory Disease - CDC Fact Sheet|date=2017-10-04|website=www.cdc.gov|language=en-us|access-date=2018-11-07}}</ref> Occasionally, the infection can spread to the [[peritoneum]] causing inflammation and the formation of scar tissue on the external surface of the [[liver]] ([[Fitz-Hugh–Curtis syndrome]]).<ref>
{{cite web |title=Pelvic Inflammatory Disease |publisher=MedScape |date=March 27, 2014 |url=http://emedicine.medscape.com/article/256448-overview |access-date=March 10, 2015 |url-status=live |archive-url=https://web.archive.org/web/20150313235007/http://emedicine.medscape.com/article/256448-overview |archive-date=March 13, 2015 }}</ref>

== Cause ==
''Chlamydia trachomatis'' and ''Neisseria gonorrhoeae'' are common causes of PID. However, 
PID can also be caused by other untreated infections, like bacterial vaginosis.<ref name=Planned> {{cite web | author = Planned Parenthood | title=Pelvic Inflammatory Disease (PID) | url =https://www.plannedparenthood.org/learn/health-and-wellness/pelvic-inflammatory-disease-pid}} </ref>
Data suggest that PID is often polymicrobial.<ref name=Sternak2014/> Isolated [[anaerobes]] and [[Facultative anaerobic organism|facultative microorganisms]] have been obtained from the upper genital tract. ''N. gonorrhoeae'' has been isolated from fallopian tubes, facultative and anaerobic organisms were recovered from endometrial tissues.<ref name=Sharma2014>{{cite journal |vauthors=Sharma H, Tal R, Clark NA, Segars JH |title=Microbiota and pelvic inflammatory disease |journal=Seminars in Reproductive Medicine |volume=32 |issue=1 |pages=43–9 |year=2014 |pmid=24390920 |pmc=4148456 |doi=10.1055/s-0033-1361822 }}</ref><ref name="LisRowhani-Rahbar2015">{{cite journal |last1=Lis |first1=R. |last2=Rowhani-Rahbar |first2=A. |last3=Manhart |first3=L. E. |title=Mycoplasma genitalium Infection and Female Reproductive Tract Disease: A Meta-Analysis |journal=Clinical Infectious Diseases |year=2015 |issn=1058-4838 |doi=10.1093/cid/civ312|pmid=25900174 |volume=61 |issue=3 |pages=418–26|doi-access=free |hdl=1773/26479 |hdl-access=free }}</ref>

The anatomical structure of the internal organs and tissues of the female reproductive tract provides a pathway for pathogens to ascend from the vagina to the pelvic cavity through the [[infundibulum of uterine tube|infundibulum]]. The disturbance of the naturally occurring vaginal [[microbiota]] associated with [[bacterial vaginosis]] increases the risk of PID.<ref name=Sharma2014/>

''N. gonorrhoea'' and ''C. trachomati''s are the most common organisms. The least common were infections caused exclusively by anaerobes and facultative organisms. Anaerobes and facultative bacteria were also isolated from 50 percent of the patients from whom ''Chlamydia'' and ''Neisseria'' were recovered; thus, anaerobes and facultative bacteria were present in the upper genital tract of nearly two-thirds of the PID patients.<ref name=Sharma2014/> PCR and serological tests have associated extremely fastidious organism with endometritis, PID, and [[tubal factor infertility]]. <!-- In a Kenyan study, PCR was used to identify new, uncultivable bacteria found with cases of salpingitis. Bacteria in fallopian tubes, correlated with laparoscopic diagnosis of acute salpingitis. Phylotypes identified as Leptotrichia spp. were found as the only type in one specimen but were mixed with other bacterial phylotypes in two specimens. --> Microorganisms associated with PID are listed below.<ref name=Sharma2014/>

Cases of PID have developed in people who have stated they have never had sex.<ref name="ChoKoo2015">{{cite journal|last1=Cho|first1=Hyun-Woong|last2=Koo|first2=Yu-Jin|last3=Min|first3=Kyung-Jin|last4=Hong|first4=Jin-Hwa|last5=Lee|first5=Jae-Kwan|title=Pelvic Inflammatory Disease in Virgin Women with Tubo-ovarian Abscess: A Single-center Experience and Literature Review|journal=Journal of Pediatric and Adolescent Gynecology|year=2015|issn=1083-3188|doi=10.1016/j.jpag.2015.08.001|pmid=26260586|volume=30|issue=2|pages=203–208}}</ref>

=== Bacteria  ===
{{div col|colwidth=15em}}
*''[[Chlamydia trachomatis]]''<!-- ref name=Sharma2014/>-->
*''[[Neisseria gonorrhoeae]]''<!-- ref name=Sharma2014/>-->
*''[[Prevotella]]'' spp.<!-- <ref name=Sharma2014/>-->
*''[[Streptococcus pyogenes]]''<!--<ref name=Sharma2014/> -->
*''[[Prevotella bivia]]''<!-- <ref name=Sharma2014/>-->
*''[[Prevotella disiens]]''<!--ref name=Sharma2014/>-->
*''[[Bacteroides]]'' spp.<!-- ref name=Sharma2014/>-->
*''[[Peptostreptococcus asaccharolyticus]]''<!-- <ref name=Sharma2014/>-->
*''[[Peptostreptococcus anaerobius]]''<!-- <ref name=Sharma2014/>-->
*''[[Gardnerella vaginalis]]''<!-- <ref name=Sharma2014/>-->
*''[[Escherichia coli]]''<!-- <ref name=Sharma2014/>-->
*[[Group B streptococcus]]<!--<ref name=Sharma2014/>-->
*[[Streptococcus#Alpha-hemolytic|α-hemolytic streptococcus]]<!--<ref name=Sharma2014/>-->
*[[Coagulase-negative staphylococcus]]<!-- <ref name=Sharma2014/>-->
*''[[Atopobium vaginae]]''<!-- <ref name=Sharma2014/>-->
*''[[Acinetobacter]]'' spp. <!-- <ref name=Sharma2014/>-->
*''[[Dialister]]'' spp.<!-- <ref name=Sharma2014/>-->
*''[[Fusobacterium gonidiaformans]]''<!--<ref name=Sharma2014/>-->
*''[[Gemella]]'' spp.<!--<ref name=Sharma2014/>-->
*''[[Leptotrichia]]'' spp.<!-- <ref name=Sharma2014/>-->
*''[[Mogibacterium]]'' spp.<!-- <ref name=Sharma2014/>-->
*''[[Porphyromonas]]'' spp.<!-- <ref name=Sharma2014/>-->
*''[[Sphingomonas]]'' spp.<!-- <ref name=Sharma2014/> -->
*''[[Veillonella]]'' spp.<ref name=Sharma2014/>
*''[[Cutibacterium acnes]]''<!-- <ref name=Sharma2014/>-->
*''[[Mycoplasma genitalium]]''<ref name="LisRowhani-Rahbar2015" /><ref>{{cite journal|last1=Wiesenfeld|first1=HC|last2=Manhart|first2=LE|title=Mycoplasma genitalium in Women: Current Knowledge and Research Priorities for This Recently Emerged Pathogen.|journal=The Journal of Infectious Diseases|date=15 July 2017|volume=216|issue=suppl_2|pages=S389–S395|doi=10.1093/infdis/jix198|pmid=28838078|pmc=5853983}}</ref>
*''[[Mycoplasm hominis infection|Mycoplasma hominis]]''<!-- <ref name="LisRowhani-Rahbar2015" /> -->
*''[[Ureaplasma]]'' spp.<ref name=Sternak2014>{{cite journal |last1=Ljubin-Sternak |first1=Suncanica |last2=Mestrovic |first2=Tomislav |title=Review: Chlamydia trachonmatis and Genital Mycoplasmias: Pathogens with an Impact on Human Reproductive Health |journal=Journal of Pathogens |date=2014 |volume=2014 |issue=183167 |doi=10.1155/2014/183167 |pmc=4295611 |pmid=25614838 |page=183167|doi-access=free }}</ref>

{{div col end}}

== Diagnosis ==

[[File:Mucopurelent discharge.png|thumb|Mucopurulent cervical discharge seen on a cotton bud]]
[[File:Salpingitis - low mag.jpg|thumb|[[Micrograph]] of [[salpingitis]]&nbsp;– a component of pelvic inflammatory disease. [[H&E stain]].]]

Upon a [[pelvic examination]], [[cervical motion tenderness|cervical motion]], [[uterine]], or adnexal tenderness will be experienced.<ref name="NEJM PID Review 2015" />  Mucopurulent [[cervicitis]] and or [[urethritis]] may be observed. In severe cases more testing may be required such as [[laparoscopy]], intra-abdominal bacteria sampling and culturing, or tissue biopsy.<ref name=Sternak2014/><ref name=SMoore>{{cite web |last1=Moore MD |first1=Suzanne |editor1-last=Rivlin MD |editor1-first=Michel |title=Pelvic Inflammatory Disease |url=http://emedicine.medscape.com/article/256448-overview |website=Medscape, Drugs and Diseases, Background |publisher=Medscape |date=Mar 27, 2014 |access-date=March 31, 2015 |url-status=live |archive-url=https://web.archive.org/web/20150325205543/http://emedicine.medscape.com/article/256448-overview |archive-date=March 25, 2015 }}</ref>

Laparoscopy can visualize "violin-string" [[adhesion]]s, characteristic of [[Fitz-Hugh–Curtis syndrome|Fitz-Hugh–Curtis perihepatitis]] and other abscesses that may be present.<ref name=SMoore />

Other imaging methods, such as ultrasonography, computed tomography (CT), and magnetic imaging (MRI), can aid in diagnosis.<ref name=SMoore /> 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.<ref name=Sternak2014 /><ref name=SMoore />

Nucleic acid amplification tests (NAATs), direct fluorescein tests (DFA), and enzyme-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 antibody levels can indicate whether an infection is recent or long-term.<ref name=Sternak2014 />

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 and possibly more serious organisms.<ref name="isbn0-7216-8179-4">{{cite book |last1=Andreoli |first1=Thomas E. |last2=Cecil |first2=Russell L. |title=Cecil Essentials Of Medicine |publisher=W. B. Saunders |location=Philadelphia |year=2001 |edition=5th |isbn=978-0-7216-8179-5}}</ref> Two thirds of patients with laparoscopic evidence of previous PID were not aware they had PID, but even asymptomatic PID can cause serious harm.

Laparoscopic identification is helpful in diagnosing tubal disease; a 65 percent to 90 percent [[positive predictive value]] exists in patients with presumed PID.<ref name="isbn0-8385-1401-4">{{cite book |first2=Lauren |last2=Nathan |last1=DeCherney |first1=Alan H. |title=Current Obstetric & Gynecologic Diagnosis & Treatment |publisher=Lange Medical Books/McGraw-Hill |location=New York |year=2003 |isbn=978-0-8385-1401-6}}</ref>

Upon [[gynecologic ultrasound]], a potential finding is ''tubo-ovarian complex'', which is [[edema]]tous and dilated pelvic structures as evidenced by vague margins, but without [[abscess]] formation.<ref>{{cite web |last1=Wasco |first1=Emily |last2=Lieberman |first2=Gillian |url=http://eradiology.bidmc.harvard.edu/LearningLab/genito/Wasco.pdf |title=Tuboovarian complex |publisher=Beth Israel Deaconess Medical Center |date=October 17, 2003 |access-date=July 14, 2015 |archive-url=https://web.archive.org/web/20160304083602/http://eradiology.bidmc.harvard.edu/LearningLab/genito/Wasco.pdf |archive-date=March 4, 2016 }}</ref>

=== Differential diagnosis ===

A number of other causes may produce similar symptoms including appendicitis, ectopic pregnancy, hemorrhagic or ruptured [[ovarian cysts]], [[ovarian torsion]], and endometriosis and [[gastroenteritis]], peritonitis, and bacterial vaginosis among others.<ref name=Mit2013 />

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]].<ref name=CDCPID2010>{{cite web |title=Pelvic Inflammatory Disease |publisher=CDC Fact Sheet |url=https://www.cdc.gov/std/pid/stdfact-pid.htm |date=May 4, 2015 |access-date=July 15, 2015 |url-status=live |archive-url=https://web.archive.org/web/20150715211211/http://www.cdc.gov/std/PID/STDFact-PID.htm |archive-date=July 15, 2015 }}</ref>

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).<ref name="Hoffman42" />

Pelvic and vaginal ultrasounds are helpful in the diagnosis of PID. In the early stages of infection, the ultrasound may appear normal. As the disease progresses, nonspecific findings can include free pelvic fluid, endometrial thickening, uterine cavity distension by fluid or gas. In some instances the borders of the uterus and ovaries appear indistinct. Enlarged ovaries accompanied by increased numbers of small cysts correlates with PID.<ref name="Hoffman42">{{cite book |last=Hoffman |first=Barbara |title=Williams gynecology |edition=2nd |publisher=McGraw-Hill Medical |page=42 |location=New York |year=2012 |isbn=978-0-07-171672-7}}</ref>

Laparoscopy is infrequently used to diagnose pelvic inflammatory disease since it is not readily available.  Moreover, it might not detect subtle inflammation of the fallopian tubes, and it fails to detect endometritis.<ref name=CDC2010>{{cite web |title=Pelvic Inflammatory Disease, 2010 STD Treatment Guidelines |publisher=CDC |url=https://www.cdc.gov/std/treatment/2010/pid.htm |date=January 28, 2011 |access-date=July 14, 2015 |url-status=live |archive-url=https://web.archive.org/web/20150715122458/http://www.cdc.gov/std/treatment/2010/pid.htm |archive-date=July 15, 2015 }}</ref>  Nevertheless, laparoscopy is conducted if the diagnosis is not certain or if the person has not responded to antibiotic therapy after 48 hours.{{citation needed|date=July 2015}}

No single test has adequate [[Sensitivity (tests)|sensitivity]] and [[Specificity (tests)|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 [[Centers for Disease Control and Prevention|CDC]] diagnostic criteria from 83 percent to 95 percent. However, even the modified 2002 CDC criteria do not identify women with subclinical disease.<ref name="pmid17343812">{{cite journal |last1=Blenning |first1=CE |last2=Muench |first2=J |last3=Judkins |first3=DZ |last4=Roberts |first4=KT |title=Clinical inquiries. Which tests are most useful for diagnosing PID? |journal=J Fam Pract |volume=56 |issue=3 |pages=216–20 |year=2007 |pmid=17343812 }}</ref>

== Prevention ==

Regular testing for [[sexually transmitted infections]] is encouraged for prevention.<ref name="pmid17888100">{{cite journal |last1=Smith |first1=KJ |last2=Cook |first2=RL |last3=Roberts |first3=MS |title=Time from sexually transmitted infection acquisition to pelvic inflammatory disease development: influence on the cost-effectiveness of different screening intervals |journal=Value in Health |volume=10 |issue=5 |pages=358–66 |year=2007 |pmid=17888100 |doi=10.1111/j.1524-4733.2007.00189.x|doi-access=free }}</ref> The risk of contracting pelvic inflammatory disease can be reduced by the following:

* Using [[barrier methods]] such as [[condoms]]; see [[Human sexual activity#Health and safety|human sexual behaviour]] for other listings.<ref name="Prevention">{{cite web |date=June 5, 2015 |title=Prevention&nbsp;— STD Information from CDC |url=https://www.cdc.gov/std/prevention/default.htm |url-status=live |archive-url=https://web.archive.org/web/20150213221411/http://www.cdc.gov/std/prevention/default.htm |archive-date=February 13, 2015 |access-date=February 21, 2015 |publisher=Center For Disease Control}}</ref> Using latex condoms to prevent STIs that may go untreated.
* Seeking medical attention if you are experiencing symptoms of PID.<ref name="Prevention" />
* Using hormonal combined contraceptive pills also helps in reducing the chances of PID by thickening the cervical mucosal plug & hence preventing the ascent of causative organisms from the lower genital tract.<ref name="Prevention" />
* Seeking medical attention after learning that a current or former sex partner has, or might have had a sexually transmitted infection.<ref name="Prevention" />
* Getting a STI history from your current partner and strongly encouraging they be tested and treated before intercourse.<ref name="Prevention" />
* Diligence in avoiding vaginal activity, particularly intercourse, after the end of a pregnancy (delivery, [[Spontaneous abortion|miscarriage]], or [[abortion]]) or certain gynecological procedures, to ensure that the cervix closes.<ref name="Prevention" />
* Reducing the number of sexual partners;<ref name=CDCPID2010/> As in sexual [[monogamy]].<ref name="Reichard,2003">{{cite book |first1=Ulrich H. |last1=Reichard |chapter=Monogamy: past and present |chapter-url=https://books.google.com/books?id=zIu2K6KFsXEC&pg=PA3 |pages=3–25 |year=2003 |editor1-first=Ulrich H. |editor1-last=Reichard |editor2-first=Christophe |editor2-last=Boesch |title=Monogamy: Mating Strategies and Partnerships in Birds, Humans and Other Mammals |publisher=Cambridge University Press |isbn=978-0-521-52577-0 |doi=10.1017/CBO9781139087247.001 |url-status=live |archive-url=https://web.archive.org/web/20160603161358/https://books.google.com/books?id=zIu2K6KFsXEC&pg=PA3 |archive-date=2016-06-03 }}</ref>

== Treatment ==

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 although there is no clear evidence of which antibiotic regimen is more effective and safe in the management of PID.<ref name="Savaris-2020">{{Cite journal|last1=Savaris|first1=Ricardo F.|last2=Fuhrich|first2=Daniele G.|last3=Maissiat|first3=Jackson|last4=Duarte|first4=Rui V.|last5=Ross|first5=Jonathan|date=20 August 2020|title=Antibiotic therapy for pelvic inflammatory disease|journal=The Cochrane Database of Systematic Reviews|volume=2020|issue=8|pages=CD010285|doi=10.1002/14651858.CD010285.pub3 |pmid=32820536|pmc=8094882|hdl=10183/180267|hdl-access=free}}</ref> 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.<ref name=CDC2014Pub/> There should be no wait for STI results to start treatment. Treatment should not be avoided for longer than 2-3 days due to increasing the risk of infertility.<ref name="Curry-2019">{{Cite journal |last=Curry |first=Amy |date=September 15, 2019 |title=Pelvic Inflammatory Disease: Diagnosis, Management, and Prevention |journal=American Family Physician |volume=100 |issue=6 |pages=357–364 |pmid=31524362 |url=https://www.aafp.org/pubs/afp/issues/2019/0915/p357.html}}</ref>

For women with PID of mild to moderate severity, parenteral and oral therapies appear to be effective.<ref>{{cite journal |last1=Ness |first1=RB |last2=Hillier |first2=SL |last3=Kip |first3=KE |title= Bacterial vaginosis and risk of pelvic inflammatory disease |journal=Obstet Gynecol |year=2004 |volume=4| issue = Supp 3 |pages=S111–22|doi=10.1097/01.AOG.0000139512.37582.17 |pmid=15458899 |s2cid=32444872 }}</ref><ref>{{cite journal |last1=Smith |first1=KJ |last2=Ness |first2=RB |last3=Wiesenfeld |first3=HC |title=Cost-effectiveness of alternative outpatient pelvic inflammatory disease treatment strategies |journal=Sex Transm Dis |year=2007 |volume=34 |issue=12 |pages=960–6|pmid=18077847 |doi=10.1097/01.olq.0000225321.61049.13 |s2cid=31500831 |doi-access=free }}</ref>  It does not matter to their short- or long-term outcome whether antibiotics are administered to them as inpatients or outpatients.<ref name=Walker2007>{{cite journal |last1=Walker |first1=CK |last2= Wiesenfeld |first2=HC |title=Antibiotic therapy for acute pelvic inflammatory disease: the 2006 Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines |journal=Clin. Infect. Dis. |volume=44 |issue=Suppl 3 |pages=S111–22 |year=2007 |pmid=17342664 |doi=10.1086/511424|doi-access=free }}</ref> Typical regimens include [[cefoxitin]] or [[cefotetan]] plus [[doxycycline]], and [[clindamycin]] plus [[gentamicin]]. An alternative parenteral regimen is [[ampicillin]]/[[sulbactam]] plus doxycycline. [[Erythromycin]]-based medications can also be used.<ref name=Daviserythro>{{cite web | url = http://davisplus.fadavis.com/3976/meddeck/pdf/erythromycins.pdf | access-date = March 24, 2017 | publisher = Davis | title = Erythromycin | date = 2017 | archive-url = https://web.archive.org/web/20170910175839/https://davisplus.fadavis.com/3976/meddeck/pdf/erythromycins.pdf | archive-date = 2017-09-10 }}</ref> A single study suggests superiority of azithromycin over doxycycline.<ref name="Savaris-2020" /> Another alternative is to use a parenteral regimen with [[ceftriaxone]] or cefoxitin plus doxycycline.<ref name="CDCPID2010"/>  Clinical experience guides decisions regarding transition from parenteral to oral therapy, which usually can be initiated within 24–48 hours of clinical improvement.<ref name=CDC2010/>

* When PID is caught early there are treatments that can be utilized, however these treatments will not undo any damage PID may has caused.
* If previously having a PID diagnosis and were to be exposed to another STI the risk of having PID reoccur is higher
* Early treatment can not prevent the following:
** chronic abdominal pain.
** infertility and or ectopic pregnancies.
** scar tissue within or outside the fallopian tubes.

== Prognosis ==
Early diagnosis and immediate treatment are vital in reducing the chances of later complications from PID. Delaying treatment for even a few days could greatly increase the chances of further complications. Even when the PID infection is cured, effects of the infection may be permanent, or long lasting. This makes early identification essential.

A limitation of this is that diagnostic tests are not included in routine check-ups, and cannot be done using signs and symptoms alone; the required diagnostic tests are more invasive than that.<ref name=Ross13>{{Cite journal |last=Ross |first=Johnathan |date=December 2013 |title=Pelvic Inflammatory Disease |journal=BMJ Clinical Evidence |volume=2013 |page=1606 |pmid=24330771 |pmc=3859178 }}</ref> Treatment resulting in cure is very important in the prevention of damage to the [[reproductive system]]. Around 20 percent of cis-gendered women with PID develop infertility.<ref name=Ross13/> Even women who do not experience intense symptoms or are asymptomatic can become infertile.<ref>{{Cite web |date=2023-04-10 |title=Pelvic Inflammatory Disease (PID) - STI Treatment Guidelines |url=https://www.cdc.gov/std/treatment-guidelines/pid.htm |access-date=2023-11-28 |website=www.cdc.gov |language=en-us}}</ref> This can be caused by the formation of scar tissue due to one or more episodes of PID, and can lead to tubal blockage. Both of these increase the risk of the inability to get pregnant,<ref name=CDCPID2010/> and 1% results in an ectopic pregnancy.<ref name=Ross13/> Chronic pelvic/abdominal pain develops post PID 40% of the time.<ref name=Ross13/> Certain occurrences such as a post pelvic operation, the period of time immediately after childbirth ([[Postpartum period|postpartum]]), [[miscarriage]] or [[abortion]] increase the risk of acquiring another infection leading to PID.<ref name="CDCPID2010" />

==Epidemiology==
Globally about 106 million cases of chlamydia and 106 million cases of gonorrhea occurred in 2008.<ref name=WHO2012 /> The number of cases of PID; however, is not clear.<ref name=Esch2008 />This is largely due to diagnostic tests being invasive and not included in routine check-ups, despite PID being the most common reason for individuals to admit themselves under gynecological care.<ref name=Ross13/> It is estimated to affect about 1.5 percent of young women yearly.<ref name=Esch2008 /> In the United States PID is estimated to affect about one million people yearly.<ref name=CDC2014Epi /> Rates are highest with teenagers and first time mothers. PID causes over 100,000 women to become [[infertile]] in the US each year.<ref name=CDCPID2010/><ref>{{cite journal |last1=Sutton |first1=MY |last2=Sternberg |first2=M |last3=Zaidi |first3=A |last4=t Louis |first4=ME |last5=Markowitz |first5=LE |title=Trends in pelvic inflammatory disease hospital discharges and ambulatory visits, United States, 1985–2001 |journal=Sex Transm Dis |volume=32 |issue=12 |pages=778–84 |date=December 2005 |pmid=16314776 |doi=10.1097/01.olq.0000175375.60973.cb |s2cid=6424987 |doi-access=free }}</ref>

== Prevalence ==
Records show that...

* 18/10000 recorded discharges in the US after a diagnosis of PID.<ref name=Ross13/>
* Prevalence of self reported cases of PID for 18–44 was approximately 4.4%.
* Findings that PID has an associated risk with previous STI diagnosis compared to women with no previous STI diagnosis

* 1.1% of women, 16-46 years of age, in England and Wales are diagnosed with PID.<ref name=Ross13/>

Despite the indications of a general decrease in PID rates, there is an observed rise in the prevalence of gonorrhea and chlamydia. With that, in order to decrease the prevalence of PID, one should test for gonorrhea and chlamydia.<ref name="Curry-2019">{{Cite journal |last=Curry |first=Amy |date=September 15, 2019 |title=Pelvic Inflammatory Disease: Diagnosis, Management, and Prevention |journal=American Family Physician |volume=100 |issue=6 |pages=357–364 |pmid=31524362 |url=https://www.aafp.org/pubs/afp/issues/2019/0915/p357.html}}</ref>

Two nationally representative probability surveys referenced are the National Health and Nutrition Examination Survey (NHANES) and the National Survey of Family Growth (NSFG) surveyed women aged 18 to 44 from 2013 to 2014.<ref name=Kreisel17>{{Cite journal |last=Kreisel |first=Kristen |date=2017 |title=Prevalence of Pelvic Inflammatory Disease in Sexually Experienced Women of Reproductive Age — United States, 2013–2014 |url=https://www.cdc.gov/mmwr/volumes/66/wr/mm6603a3.htm |journal=MMWR. Morbidity and Mortality Weekly Report |volume=66 |issue=3 |pages=80–83 |doi=10.15585/mmwr.mm6603a3 |pmid=28125569 |pmc=5573882 }}</ref>

The results:

* 2.5 million women have had a PID diagnosis in the past.<ref name=Kreisel17/>
* The self-reported history decreased from 4.1% in 2013 to 3.6% in 2017.
* It is possible that increased screening at annual gynecologist appointments has led to an earlier detection and prevention of PID.
** In white non-Hispanic women, the prevalence decreased from 4.9% to 3.9%, and in Hispanic women, the prevalence decreased from 5.3% to 3.7%. In black non-Hispanic women, the prevalence increased from 3.8% to 6.3%.

* The highest burden of PID recently is in black women and women living in the Southern United States where there is a higher prevalence of STIs as well.
** Disparities between races could be due to lower socioeconomic status. Those with a lower income are less likely to get an annual gynecologist appointment or other preventative measures and are more likely to be uninsured.

== Population at risk.<ref name=CDCPID23>{{Cite web |date=2022-07-05 |title=STD Facts - Pelvic Inflammatory Disease |url=https://www.cdc.gov/std/pid/stdfact-pid.htm |access-date=2023-12-04 |website=www.cdc.gov |language=en-us}}</ref> ==
* Those who are sexually active with female (intact)reproductive organs and are under the age of 25

* Rarely observed in females who have had a hysterectomy

* Overall age range 18-44

* Those who have an STI that has gone untreated.
* Women with more than one sexual partner
* Inconsistent condom use for those not in a mutually monogamous relationship

== Etiology of PID:<ref name=CDCPID23/> ==
* Untreated STI
* multiple sexual partners
* Sexually active under the age of 25
* Usage of a douche
** Causes damage to the bacteria that lives within the vagina
* Slight increase risk when using an IUD not a massive increase in risk.

== References ==
{{Reflist}}

== External links ==
{{Medical resources
| ICD11           = {{ICD11|GA00}}–{{ICD11|GA07}}
| ICD10           = {{ICD10|N70}}–{{ICD10|N77}}
| ICD9            = {{ICD9|614}}–{{ICD9|616}}
| ICDO            = 
| OMIM            = 
| MedlinePlus     = 000888
| eMedicineSubj   = emerg
| eMedicineTopic  = 410
| DiseasesDB      = 9748
| MeshID          = D000292
| SNOMED CT       = 198130006
}}
* [https://www.cdc.gov/std/PID/STDFact-PID.htm CDC]
* [https://www.cdc.gov/std/training/webinars.htm#penis-microbiome Unpacking PID: Mysterious Microbes, Diagnostic Dilemmas and Triple Treatments Webinar - 2013]
* [https://www.std.uw.edu/ National STD Curriculum, University of Washington]
**{{cite web |first=D.H. |last=Spach |first2=K.A. |last2=Wendel |title=Pelvic Inflammatory Disease |date=April 2023 |work=Core Concepts |url=https://www.std.uw.edu/go/comprehensive-study/pelvic-inflammatory-disease/core-concept/all}}
**{{cite web |first=D.H. |last=Spach |first2=K.A. |last2=Wendel |title=Pelvic Inflammatory Disease |date=April 2023 |work=STD Lessons |edition=2nd |url=https://www.std.uw.edu/custom/self-study/pelvic-inflammatory-disease }}

{{Diseases of the pelvis, genitals and breasts}}
{{STD/STI}}
{{Authority control}}

[[Category:Abdominal pain]]
[[Category:Sexually transmitted diseases and infections]]
[[Category:Bacterial diseases]]
[[Category:Chlamydia infections]]
[[Category:Infections with a predominantly sexual mode of transmission]]
[[Category:Wikipedia medicine articles ready to translate]]
[[Category:Inflammatory diseases of female pelvic organs]]
[[Category:Mycoplasma]]
[[Category:Gonorrhea]]