Pelvic Inflammatory Disease

Overview

Pelvic Inflammatory Disease (PID) is a polymicrobial infection of the upper female genital tract, including the cervix, uterus, fallopian tubes, and ovaries. PID may be spread sexually. Lower stomach discomfort, cervical discharge, and irregular vaginal bleeding are all common symptoms and indicators. Infertility, persistent pelvic discomfort, and ectopic pregnancy are long-term consequences. Polymerase chain reaction testing of cervical specimens for Neisseria gonorrhoeae and Chlamydia, microscopic inspection of cervical discharge (typically), and ultrasonography or laparoscopy are all used to make a diagnosis. Antibiotics are used in treatment.

 

What is pelvic inflammatory disease (PID)?

PID is a pelvic organ inflammatory condition. The infection normally spreads from the vagina and cervix to the uterus (womb), fallopian tubes, ovaries, and pelvic region. If the condition is severe, it can lead to a pelvic abscess (a collection of pus)

Acute PID is an infection-induced inflammation of the uterus, fallopian tubes, ovaries, and pelvic region. If left untreated, it might lead to future stomach discomfort and reproductive issues. Chronic PID occurs when inflammation persists for an extended period of time.

Preventive measures include not having intercourse or having few sexual partners, as well as utilizing condoms. Screening at-risk women for chlamydial infection, followed by treatment, reduces the incidence of PID. Treatment is usually recommended if the diagnosis is suspected. Treatment of a woman's sexual partners should also take place. A single injection of the antibiotic ceftriaxone, followed by two weeks of doxycycline and potentially metronidazole by oral, is indicated for people with mild or severe symptoms. Intravenous antibiotics should be given for patients who do not improve after three days or who have severe illness.

 

Epidemiology

In 2008, there were approximately 106 million cases of chlamydia and 106 million cases of gonorrhea worldwide. However, the number of PID cases is unknown. It is believed that roughly 1.5 % of young women are affected each year. PID is predicted to impact one million persons in the United States each year. Teenagers and first-time moms have the greatest rates. Every year, PID renders approximately 100,000 women infertile in the United States.

 

Etiology of PID

Microorganisms rising from the vagina and cervix into the endometrium and fallopian tubes cause PID. PID is commonly caused by Neisseria gonorrhoeae and Chlamydia trachomatis, both of which are transmitted sexually. Mycoplasma genitalium, which is also transmitted sexually, can cause or contribute to PID. Sexually transmitted PID is becoming less common; 50% of patients with acute PID test positive for gonorrhea or chlamydial infection.

Other aerobic and anaerobic bacteria, particularly pathogens linked with bacterial vaginosis, are commonly involved in PID. PID can be caused by vaginal bacteria such as Haemophilus influenzae, Streptococcus agalactiae, and enteric gram-negative bacilli, as well as Ureaplasma sp. Inflammation and bacterial vaginosis in the vaginal tract aid in the transmission of vaginal germs.

 

PID Risk factors

Pelvic inflammatory disease is more frequent in women over the age of 35. It is uncommon prior to menarche, following menopause, and during pregnancy.

Risk factors include

• Previous PID
• Presence of bacterial vaginosis or any sexually transmitted infection

Other risk factors, particularly for gonorrheal or chlamydial PID, include

• Younger age
• Nonwhite race
• Low socioeconomic status
• Multiple or new sex partners or a partner who does not use a condom
• Douching

 

Symptoms and Signs of PID

Pelvic inflammatory disease is characterized by lower abdomen discomfort, fever, cervical discharge, and abnormal uterine bleeding, often during or after menstruation.

• Cervicitis

Cervicitis causes the cervix to get red and hemorrhage freely. Mucopurulent discharge is widespread; it is generally yellow-green in color and can be seen seeping from the endocervical canal.

• Acute salpingitis

Even when both tubes are affected, lower abdomen discomfort is frequently present and bilateral, but it might be unilateral. Upper abdominal pain is also possible. When the pain is severe, nausea and vomiting are usual. Up to one-third of individuals experience irregular bleeding (induced by endometritis) and fever.

Signs may be minor or nonexistent in the early stages. Cervical motion pain, guarding, and rebound soreness are typical later in life. Dyspareunia or dysuria can develop on rare occasions. Many women with severe enough inflammation to induce scarring have little or no symptoms.

PID caused by N. gonorrhoeae is frequently more severe and acute than PID caused by C. trachomatis, which can be indolent. PID caused by M. genitalium, like PID caused by C. trachomatis, is mild and should be investigated in women who do not respond to first-line PID therapy.

 

Diagnosis of PID

Pelvic inflammatory disease is suspected in women of reproductive age who have lower abdomen discomfort, cervical or unexplained vaginal discharge, or both. When there is no explanation for irregular vaginal bleeding, dyspareunia, or dysuria, PID is explored. Lower abdominal, unilateral or bilateral adnexal, and cervical motion discomfort all increase the likelihood of PID. A palpable adnexal lump may indicate a tubo-ovarian abscess. Because even asymptomatic illness might have serious consequences, the index of suspicion should be high.

If PID is suspected, a pregnancy test and PCR of cervical specimens for N. gonorrhoeae and C. trachomatis (which is around 99 % sensitive and specific) are performed. If PCR is not accessible, cultures are performed. Even if cervical specimens are negative, upper tract infection is conceivable. Cervical discharge is often tested at the point of treatment to confirm purulence; a Gram stain or saline wet mount is employed, although these techniques are neither sensitive nor specific.

If a patient cannot be checked thoroughly due to soreness, ultrasonography is performed as soon as feasible. Although the white blood cell count may be increased, it is not diagnostic. If the pregnancy test is positive, investigate ectopic pregnancy, which can cause similar results.

Endometriosis, adnexal torsion, ovarian cyst rupture, and appendicitis are all prevalent causes of pelvic discomfort. The distinguishing characteristics of these illnesses are explored elsewhere. Fitz-Hugh- Curtis syndrome can be confused with acute cholecystitis, however it is generally distinguished by the presence of salpingitis on pelvic examination or, if required, with ultrasonography.

If an adnexal or pelvic mass is suspected clinically, or if patients do not react to treatments within 48 to 72 hours, ultrasonography is performed as quickly as feasible to rule out tubo-ovarian abscess, pyosalpinx, and associated illnesses (eg, ectopic pregnancy, adnexal torsion).

 

Further tests

Blood tests to screen for infection may be provided to you. A urine sample may be required. A HIV test may also be recommended. If there is a possibility that you are pregnant, you will be offered a pregnancy test. This is due to the fact that other illnesses, such as ectopic pregnancy (when a pregnancy develops outside the womb), can present symptoms identical to PID.

If your doctor feels you have a serious infection, you will be referred to a nearby hospital for more testing and treatment. An ultrasound scan may be recommended for you. This is frequently a transvaginal scan (in which a probe is softly placed into your vagina) to examine the uterus (womb), fallopian tubes, and ovaries more precisely. This might aid in the detection of irritated fallopian tubes or an abscess.

If the diagnosis is still questionable after ultrasonography, laparoscopy should be performed; purulent peritoneal material seen during laparoscopy is the gold standard for diagnosis.

 

Differential diagnosis

Other conditions that might cause comparable symptoms include appendicitis, ectopic pregnancy, hemorrhagic or ruptured ovarian cysts, ovarian torsion, and endometriosis, as well as gastroenteritis, peritonitis, and bacterial vaginosis.

Pelvic inflammatory disease is more likely to return if there is a history of infection, recent sexual contact, the beginning of menstruation, or an IUD (intrauterine device) is present, or if the partner has a sexually transmitted infection.

When recent intercourse has not occurred or an IUD is not used, acute pelvic inflammatory illness is exceedingly rare. To rule out ectopic pregnancy, a sensitive serum pregnancy test is usually obtained. Culdocentesis can distinguish between a ruptured ectopic pregnancy or a hemorrhagic cyst or pelvic sepsis (salpingitis, ruptured pelvic abscess, or ruptured appendix).

Ultrasounds of the pelvic and vaginal regions can aid in the diagnosis of PID. The ultrasonography may seem normal in the early stages of infection. Nonspecific signs may include free pelvic fluid, endometrial thickening, and uterine cavity distension by fluid or gas as the illness advances. In certain cases, the uterus and ovaries appear to have blurred boundaries. PID is associated with enlarged ovaries and a rise in the number of tiny cysts.

Because laparoscopy is not widely available, it is rarely utilized to diagnose pelvic inflammatory disease. Furthermore, it may miss modest inflammation of the fallopian tubes and fails to detect endometritis. Nonetheless, if the diagnosis is uncertain or if the patient has not responded to antibiotic medication after 48 hours, a laparoscopy is performed.

There is no one test that is sensitive and specific enough to detect pelvic inflammatory disease. A major multisite investigation conducted in the United States discovered that including cervical motion discomfort as a minimum clinical criterion raises the sensitivity of the CDC diagnostic criteria from 83 percent to 95 %. Even the amended 2002 CDC standards, however, do not identify women with subclinical illness. 

 

Treatment of PID

The treatment of pelvic inflammatory disease (PID) focuses on relieving acute symptoms, eliminating current infection, and lowering the risk of long-term complications. Chronic pelvic pain, ectopic pregnancy, tubal factor infertility (TFI), and implantation failure with in vitro fertilization efforts may occur in up to 25% of patients.

If pelvic inflammatory disease isn't treated or went on a long time before being treated, girls can have problems such as:

• Ongoing pain in the lower belly
• Trouble getting pregnant (infertility)
• Pregnancy in the fallopian tube instead of the uterus (an ectopic pregnancy)
• An infection in the ovary and fallopian tube (a tubo-ovarian abscess)

Antibiotics are provided depending on laboratory test findings to cover N. gonorrhoeae and C. trachomatis. For numerous reasons, empirical therapy is required whenever the diagnosis is in doubt:

• Testing (particularly point-of-care testing) is not conclusive.
• Diagnosis based on clinical criteria can be inaccurate.
• Not treating minimally symptomatic PID can result in serious complications.

Cervicitis and clinically mild to severe PID do not necessitate hospitalization. Outpatient treatment regimens often attempt to remove bacterial vaginosis, which frequently coexists.

Sex partners of individuals infected with N. gonorrhoeae or C. trachomatis should be treated. If patients do not improve following standard pathogen therapy, PID attributable to M. genitalium should be explored. Patients can be treated empirically for 7 to 14 days with moxifloxacin 400 mg orally once a day (eg, for 10 days).

Women with PID are usually hospitalized if any of the following are present:

• Uncertain diagnosis, with inability to exclude a disorder requiring surgical treatment (eg, appendicitis)
• Pregnancy
• Severe symptoms or high fever
• Tubo-ovarian abscess
• Inability to tolerate or follow outpatient therapy (eg, due to vomiting)
• Lack of response to outpatient (oral) treatment

In these circumstances, IV antibiotics are administered as soon as cultures are collected and are maintained until the patient is afebrile for 24 hours.

A tubo-ovarian abscess may necessitate more extensive IV antibiotic therapy. If antibiotics alone are ineffective, ultrasound- or CT-guided percutaneous or transvaginal drainage may be tried. Drainage may necessitate laparoscopy or laparotomy. A burst tubo-ovarian abscess necessitates an urgent laparotomy. Surgery in women of reproductive age should seek to maintain the pelvic organs (with the hope of preserving fertility).

 

Why might I need hospital treatment?

Your doctor may recommend treatment in hospital if:

• Your diagnosis is unclear
• You are very unwell
• They suspect an abscess in your fallopian tube and/or ovary
• You are pregnant
• You are not getting better within a few days of starting oral antibiotics
• You are unable to take antibiotic tablets.

Antibiotics may be administered intravenously while you are in the hospital (directly into the bloodstream through a drip). This therapy is typically continued for another 24 hours after your symptoms have subsided. Following that, you will be given a course of antibiotic medications.

 

 Does my partner need to be treated?

Yes. Any other sexual partners during the last six months should also be checked for infection. If you haven't had sex in the last six months, your most recent sexual partner should be tested and treated. Whether or not an infection is discovered after testing, a course of antibiotics is typically recommended. This is due to:

• Chlamydia is the root cause of many PID cases. It is frequently passed on during intercourse.
• Men with chlamydia frequently have no symptoms, yet they can still spread the illness.
• The chlamydia test is not completely trustworthy. Treatment ensures that any probable infection that was overlooked by the testing is eliminated.
• If your sexual partner is infected and not treated, chlamydia may be spread to you after you have been treated.

 

What about follow-up?

If you have a moderate to severe infection, you will often be given a three-day appointment to return to the clinic. Attending this visit is critical so that your doctor can observe how your symptoms are reacting to the medications.

If your symptoms do not improve, you may be recommended to go to the hospital for more testing and treatment. If your symptoms improve, you will normally be offered a 2-4 week follow-up consultation to check:

• That your treatment has been effective
• Whether a repeat swab test is needed to confirm that the infection has been successfully treated; this is particularly important if you have ongoing symptoms
• That you have all the information you need about the long-term effects of PID
• Whether another pregnancy test is needed
• That you have all the information you need about future contraceptive choices
• That your sexual partner(s) have been treated.

 

Prognosis

Even if the PID infection is healed, the infection's symptoms may be permanent. As a result, early detection is critical. Treatment that results in cure is critical in preventing reproductive system harm. Scar tissue formation as a result of one or more episodes of PID can result in tubal obstruction, increasing the risk of infertility and long-term pelvic/abdominal discomfort. Certain events, such as a post-pelvic procedure, the period immediately following childbirth (postpartum), miscarriage, or abortion, increase the chance of contracting another infection that leads to PID. 

 

What are complications of pelvic inflammatory disease?

When PID is detected and treated early, complications are avoided in the majority of patients. One or more of the following problems are possible:

• Difficulties becoming pregnant (infertility). Scarring or damage to the Fallopian tubes can result from PID. This can happen whether or not the PID was the cause of the symptoms.
• If you become pregnant, you are more likely to have a pregnancy develop in a Fallopian tube (an ectopic pregnancy). The infection has caused harm to the Fallopian tube. If you have PID and become pregnant, you have a 1 in 10 risk of having an ectopic pregnancy.
• Pain may become chronic. This frequently involves sex pain.
• Pregnant women with untreated PID are more likely to experience pregnancy difficulties such as miscarriage, early delivery, and stillbirth.
• Reactive Arthritis. This is a rare cause of arthritis and inflammation of the eyes. It is an unusual PID complication. In certain situations, it is assumed to be caused to the immune system 'over-reacting' to pelvic infection.
• If the infection is severe, an abscess (a collection of pus) may form near to the womb (uterus).

If you start therapy within 2-3 days after the onset of symptoms, you are less likely to develop problems. This is possible if symptoms appear soon. However, some women with PID have quite minor symptoms or none at all. Before being discovered or treated, the infection may have progressed for some time.

 

Conclusion 

Pelvic inflammatory disease (PID) is an infection and inflammation of the uterus, ovaries, and other female reproductive organs. It promotes scarring in several organs. This can result in infertility, ectopic pregnancy, pelvic discomfort, abscesses, and other significant issues. PID is the most frequent avoidable cause of infertility in the United States.