Pelvic Inflammatory Disease (PID)

Alternative name :- PID; Oophoritis; Salpingitis; Salpingo-oophoritis; Salpingo-peritonitis

Pelvic inflammatory disease is a long lasting (chronic) infection affecting the womb (uterus), the tubes which deliver eggs to the womb (fallopian tubes) and the nearby structures in the lower abdomen. Normally, the cervix prevents bacteria in the vagina from spreading up into the internal organs. If the cervix is exposed to a sexually transmitted disease (STD) such as gonorrhea or chlamydia, the cervix becomes infected. If the disease travels up through the internal organs, they can also become inflamed and infected. It can damage the fallopian tubes and make it difficult to become pregnant.

According to the National Institutes of Health, pelvic inflammatory disease (PID) is "the most common and complication of sexually transmitted diseases (STD's) among women," aside from acquired immunodeficiency syndrome (AIDS). PID is any acute, subacute, recurrent, or chronic infection of the upper genital tract. It can affect the uterus, oviducts, ovaries, and other related reproductive structures with adjacent tissue involvement. It includes inflammation of the fallopian tubes (salpingitis) and ovaries (oophoritis), which can extend to the connective tissue lying between the broad ligaments (parametritis). Early diagnosis and treatment prevent damage to the reproductive system.

PID affects more than 1 million women each year, with the highest incidence among teenagers. PID causes infertility in more than 100,000 women each year. It's also the major cause of ectopic pregnancies.

What causes PID?

PID can result from infection with aerobic or anaerobic organisms that travel from the urethra and cervix into the upper genital tract. Although many different organisms can cause PID, Neisseria gonorrhoeae and Chlamydia trachomatis are two of the most common because they most readily penetrate the bacteriostatic barrier of cervical mucus.

Normally, cervical secretions have protective and defensive functions. Conditions or procedures that alter or destroy the cervical mucus impair these bacteriostatic mechanisms and allow bacteria present in the cervix or vagina to ascend into the uterine cavity; such procedures include conization or cauterization of the cervix.

Uterine infection can also follow the transfer of contaminated cervical mucus into the endometrial cavity by instrumentation. Consequently, PID can follow insertion of an intrauterine device, use of a biopsy curet or an irrigation catheter, or tubal insufflation. Other predisposing factors include abortion, pelvic surgery, and infection during or after pregnancy. Bacteria may also enter the uterine cavity through the bloodstream or from drainage from a chronically infected fallopian tube, a pelvic abscess, a ruptured appendix, diverticulitis of the sigmoid colon, or other infectious foci. Common bacteria found in cervical mucus are staphylococci, streptococci, diphtheroids, chlamydiae, and coliforms, including Pseudomonas and Escherichia coli. Uterine infection can result from one or several of these organisms or may follow the multiplication of normally nonpathogenic bacteria in an altered endometrial environment.

Risk factors for PID include:

• women with STDs
• prior episode of PID
• sexually active teenager
• increased number of sexual partners
• lack of consistent condom use
• lack of contraceptive use (including hormonal contraceptives that, while protecting against or reducing the severity of the symptoms of PID, don't protect against contracting STDs)
• douching.

Signs and symptoms of PID

Clinical features of PID vary with the affected area but generally include a profuse, purulent vaginal discharge, sometimes accompanied by low-grade fever and malaise (particularly if gonorrhea is the cause). The patient also experiences lower abdominal pain; movement of the cervix or palpation of the adnexa may be extremely painful. Other symptoms may include right upper abdominal pain, painful sexual intercourse, and irregular menstrual bleeding. PID caused by a chlamydial infection, however, may produce only mild symptoms.

If left untreated, PID may cause infertility, tubal pregnancy, chronic pelvic pain, and may lead to potentially fatal septicemia and shock.

Diagnosis information

For the most up-to-date guidelines for diagnosing PID from the Centers for Disease Control and Prevention (CDC), see Guidelines for diagnosing PID. Some diagnostic tests that are likely to be ordered are:

• urine pregnancy test
• urine or cervical testing for N. gonorrhea and C. trachomatis
• wet preparation of vaginal secretions for the presence of WBCs and clue cells that, along with findings of increased pH and a positive whiff test, indicates bacterial vaginosis, which is associated with PID
• urinalysis or urine dipstick and urine culture
• syphilis and HIV screening
• CBC, ESR, and C-reactive protein.

Differential diagnosis includes:

• ectopic pregnancy
• appendicitis
• urinary tract infection or pyelonephritis
• constipation
• gastroenteritis
• rupture, bleeding, or torsion of an ovarian cyst
• mittelschmerz pain
• irritable bowel syndrome
• renal colic.

Treatment of PID

To prevent progression of PID, antibiotic therapy begins immediately after culture specimens are obtained. Such therapy can be reevaluated as soon as laboratory results are available (usually after 24 to 48 hours). Infection may become chronic if treated inadequately.

Usually, because PID is caused by multiple organisms, the patient is prescribed at least two antibiotics. The CDC guidelines for outpatient treatment include ofloxacin (Floxin) and metronidazole (Flagyl) for 14 days or ceftriaxone (Rocephin) or another third-generation cephalosporin with doxycycline (Vibramycin) for 14 days.

For those women that must be hospitalized due to increased severity of the illness or other complications, such as pregnancy, AIDS, or inability to take oral forms of antibiotics, the CDC guidelines for inpatient treatment include doxycycline with cefoxitin (Mefoxin) or cefotetan (Cefotan) or a combination of clindamycin (Cleocin) and gentamicin (Garamycin). Alternative investigational inpatient regimens include ofloxacin and metronidazole, ampicillin and sulbactam (Unasyn) and doxycycline, and ciprofloxacin (Cipro) with mebendazole (Vermox) and doxycycline.

Development of a pelvic abscess necessitates adequate drainage. A ruptured abscess is life-threatening. If this complication develops, the patient may need a total abdominal hysterectomy with bilateral salpingooophorectomy to avoid shock and sepsis. Alternatively,laparoscopic drainage with preservation of the ovaries and uterus appears to hold promise.

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Complications

The risk for ectopic pregnancy increases from 1 in 200 to 1 in 20 after having PID.

Infertility risks also increase:

• 15% risk of infertility following the 1st episode of PID
• 30% risk of infertility following 2 episodes of PID
• 50% risk of infertility following 3 or more episodes of PID

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Special considerations and Prevention

• After establishing that the patient has no drug allergies, administer appropriate antibiotics and analgesics.
• Check for fever. If it persists, carefully monitor fluid intake and output for signs of dehydration.
• The risk of PID can be reduced by getting regular STD screening exams, and by couples being tested before initiating sexual relations.
• Avoiding multiple sexual partners helps.
• Watch for abdominal rigidity and distention, which are possible signs of developing peritonitis. Provide frequent perineal care if vaginal drainage occurs.
• To prevent a recurrence, explain the nature and seriousness of PID, and encourage the patient to comply with the treatment regimen.
• Because PID may cause painful intercourse, advise the patient to consult with her primary' health care provider about sexual activity.