Pelvic Inflammatory Disease

DESCRIPTION

PID is a clinical syndrome caused by the ascent of microorganisms from the vagina and endocervix to the endometrium, fallopian tubes, ovaries, and contiguous structures. PID is a broad term that includes a variety of upper genital tract infections, unrelated to pregnancy or surgical procedures, such as salpingitis, salpingo-oophoritis, endometritis, tubo-ovarian inflammatory masses, and pelvic or diffuse peritonitis.

Pathogenesis: The precise mechanism by which microorganisms ascend from the lower genital tract is not known. One possibility is that chlamydial or gonococcal endocervicitis alters the defense mechanisms of the cervix, allowing ascent of the vaginal flora with or without the original pathogen. Other possibilities suggest that polymicrobial infection can occur without N. gonorrhoeae or C. trachomatis. Factors that predispose to the ascent of bacteria include the use of an intrauterine device (IUD) and the hormonal and physical changes associated with menstruation.
System(s) affected: Reproductive
Genetics: N/A
Incidence/Prevalence in USA: Estimated 1 million women are treated each year; 100-200/100,000
Predominant age: 16-40 years
Predominant sex: Female only

SIGNS AND SYMPTOMS

May be asymptomatic
Lower abdominal pain
Fever and malaise
Vaginal discharge
Irregular bleeding
Urinary discomfort, proctitis
Nausea and vomiting
Abdominal tenderness
Tenderness with cervical motion
Adnexal tenderness
Unilateral or bilateral tender adnexal mass

CAUSES

Bacteriology - multiple organisms act as etiologic agents in PID and most cases are polymicrobial. Chlamydia trachomatis, Neisseria gonorrhoeae, and a wide variety of aerobic and anaerobic bacteria are recognized as etiologic agents. Mycoplasmas have also been implicated but their role is less clear. The proportion of cases infected with chlamydia or gonorrhea varies widely depending on the population studied. The most common anaerobes include Bacteroides, Peptostreptococcus, and Peptococcus species. The organisms involved in bacterial vaginosis are similar to the nongonococcal, nonchlamydial bacteria often found in the upper genital tract of women with PID, but the relationship between these conditions is unclear.

RISK FACTORS

Sexually active, reproductive age
Most common in adolescents
Multiple sexual partners
Use of an IUD, greatest risk in first few months after insertion
Previous history of PID; 20–25% will have a recurrence
Chlamydial or gonococcal cervicitis; 8–10% will develop PID
Gonococcal salpingitis occurs commonly within 7 days of onset of menses
Condoms and vaginal spermicides lessen the risks of PID
Oral contraceptives may reduce the risk of PID

LABORATORY

Pregnancy test
Leukocyte count greater than 10,000 cells per mm³
Endocervical gram stain for gram-negative intracellular diplococci
ESR of 15 mm/hour or higher
Endocervical culture for gonorrhea
Endocervical culture or antigen test for chlamydia
Plasma cell endometritis on endometrial biopsy

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

N/A

SPECIAL TESTS

Culdocentesis with culture of aspirated material
Diagnostic laparoscopy with culture of fallopian tubes

IMAGING

Pelvic ultrasound

DIAGNOSTIC PROCEDURES

PID diagnosis is elusive and even asymptomatic patients are at risk for sequelae. Diagnosis is incorrect in up to a third of women diagnosed. Laparoscopic diagnosis is best but impractical as routine and generally reserved for problem situations. In general, it is wiser to over-treat lower tract genital infection than to miss an upper tract infection.
Suggested criteria for diagnosis (sufficient for empiric treatment):
- Lower abdominal tenderness
- Cervical motion tenderness
- Adnexal tenderness
Additional criteria:
- Temperature ≥ 38°C
- WBC ≥ 10,500/mm³
- Purulent material by culdocentesis
- Adnexal mass
- ESR > 15 mm/hour
- Laboratory evidence of gonorrhea or chlamydia
- Elevated C-reactive protein
Definitive criteria:
- Histopathologic endometritis on biopsy
- Adnexal abscess on sonography
- Laparoscopic evidence of PID

APPROPRIATE HEALTH CARE

Outpatient, normally
Hospitalization recommended in the following situations:
- Uncertain diagnosis
- Surgical emergencies cannot be excluded, e.g., appendicitis
- Suspected pelvic abscess
- Pregnancy
- Adolescent patient with uncertain compliance with therapy
- Severe illness
- Cannot tolerate outpatient regimen
- Failed to respond to outpatient therapy
- Clinical follow-up within 72 hours of starting antibiotics cannot be arranged
- HIV-infected

GENERAL MEASURES

Avoidance of sex until treatment is completed
Ensure that sex partners are referred for appropriate evaluation and treatment. Partners should be treated, irrespective of evaluation, with regimens effective against chlamydia and gonorrhea.

SURGICAL MEASURES

Reserved for failures of medical treatment and for suspected ruptured adnexal abscess with resulting acute surgical abdomen
Conservative surgery preferred. This allows a 10–15% postoperative fertility rate.
Hysterectomy and adnexectomy for older patients with completed childbirth
Failure of medical therapy is generally associated with adnexal abscess, which may be amenable to transabdominal or transvaginal drainage under guidance by ultrasonography, computed tomography, or laparoscopy

ACTIVITY

According to severity of illness

DIET

According to severity of illness

PATIENT EDUCATION

Information on written materials for patient distribution can be obtained from local and state health departments or from Information Services, CDC, E06, Atlanta, GA 30333, (404)639-1819

PREVENTION/AVOIDANCE

Educational programs about safe sex practices
Education, particularly for those who have had an episode of PID
IUD contraindicated in women with history of PID or lifestyle associated with STD
Oral contraceptive appears to decrease risk of PID in cases with cervicitis, and PID cases which do occur are generally less severe
Barrier contraceptives, especially condoms, and spermicidal creams or sponges provide protection, the extent of which is not well documented
Ensure evaluation and treatment of sex partners
Comply with management instructions
Seek medical care early when genital lesions or discharge appear
Seek routine check-ups for STDs if in non–mutually monogamous relationship(s)

POSSIBLE COMPLICATIONS

A tubo-ovarian abscess will develop in approximately 7–16% of patients
Recurrent infection occurs in 20–25% of patients
Risk of ectopic pregnancy increased by 7–10-fold to about 8% of women who have had PID
Tubal infertility in 15%, 35%, and 55% of women after one, two, and three episodes of PID, respectively
Chronic pelvic pain in 20% related to adhesion formation, chronic salpingitis, or recurrent infections

EXPECTED COURSE AND PROGNOSIS

Wide variation with good prognosis if early, effective therapy is instituted and further infection is avoided
Poor prognosis related to late therapy and continued unsafe lifestyle

ASSOCIATED CONDITIONS

In PID patients with an IUD in situ, especially if an adnexal abscess is present, the possibility of Actinomyces infection requiring penicillin treatment must be kept in mind
The IUD is contraindicated in women with a previous episode of PID
Rupture of an adnexal abscess is rare but life-threatening. Early surgical exploration is mandatory.
Chlamydial or gonococcal perihepatitis may occur with PID. This combination is termed the Curtis–Fitz-Hugh syndrome.

AGE-RELATED FACTORS

Pediatric:

PID is rare before puberty
Adolescents are highly vulnerable to sexually transmitted diseases (STDs), including PID. Early vigorous therapy to prevent infertility is especially important in this age group.

Geriatric: PID is rare after menopause, although postmenopausal adnexal abscess is a well-documented entity
Others: N/A

PREGNANCY

PID is rare during pregnancy but occurs occasionally and the possibility must be kept in mind

OTHER NOTES

N/A

ABBREVIATIONS

N/A

Clinical Investigations

ROLE OF HOMOEOPATHY

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