Pelvic inflammatory disease (or disorder) (PID) is a term for inflammation of the uterus, fallopian tubes, and/or ovaries as it progresses to scar formation with adhesions to nearby tissues and organs. This can lead to infertility. PID is a vague term and can refer to viral, fungal, parasitic, though most often bacterial infections. PID should be classified by affected organs, the stage of the infection, and the organism(s) causing it. Although a sexually transmitted infection (STI) is often the cause, many other routes are possible, including lymphatic, postpartum, postabortal (either miscarriage or abortion) or intrauterine device (IUD) related, and hematogenous spread.
Epidemiology
In the United States, more than 750,000 women are affected by PID each year, and the rate is highest with teenagers and first time mothers. PID causes over 100,000 women to become infertile in the US each year. N. gonorrhoea is isolated in 40â€"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 10â€"40% of untreated women with N. gonorrhoea develop PID and 20â€"40% of women infected with C. trachomitis developed PID.
Diagnosis
Symptoms in PID range from subclinical (asymptomatic) to severe. If there are symptoms, then fever, cervical motion tenderness, lower abdominal pain, new or different discharge, painful intercourse, or irregular menstrual bleeding may be noted. Laparoscopic identification is helpful in diagnosing tubal disease, 65â€"90% positive predictive value in patients with presumed PID. Regular Sexually Transmitted Infection (STI) testing is important for prevention. Treatment is usually started empirically because of the serious complications that may result from delayed treatment. Definitive criteria include: histopathologic evidence of endometritis, thickened filled fallopian tubes, or laparoscopic findings. Gram-stain/smear becomes important in identification of rare 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.
Upon gynecologic ultrasound, a potential finding is tubo-ovarian complex, which is edematous and dilated pelvic structures as evidenced by vague margins, but without abscess formation.
Differential diagnosis
Appendicitis, ectopic pregnancy, septic abortion, hemorrhagic or ruptured ovarian cysts or tumors, twisted ovarian cyst, degeneration of a myoma, and acute enteritis must be considered. Pelvic inflammatory disease is more likely to occur when there is a history of pelvic inflammatory disease, 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 should be 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.
Prognosis
Although the PID infection itself may be cured, effects of the infection may be permanent. This makes early identification by someone who can prescribe appropriate curative treatment 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.
Complications
PID can cause scarring inside the reproductive organs, 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 dangerous 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). Multiple infections and infections that are treated later are more likely to result in complications.
Fertility may be restored in women affected by PID. Traditionally tuboplastic surgery was the main approach to correct tubal obstruction or adhesion formation, however success rates tended to be very limited. In vitro fertilization (IVF) has been used to bypass tubal problems and has become the main treatment for patients who want to become pregnant.
Treatment
Treatment depends on the cause and generally involves use of antibiotic therapy. If the patient has not improved within two to three days after beginning treatment with the antibiotics, they should return to the hospital for further treatment. Drugs should also be given orally and/or intravenously to the patient while in the hospital to begin treatment immediately, and to increase the effectiveness of antibiotic treatment. Hospitalization may be necessary if the patient has Tubo-ovarian abscesses; is very ill, immunodeficient, pregnant, or incompetent; or because a life-threatening condition cannot be ruled out. Treating partners for STIs is a very important part of treatment and prevention. Anyone with PID and partners of patients with PID since six months prior to diagnosis should be treated to prevent reinfection. Psychotherapy is highly recommended to women diagnosed with PID as the fear of redeveloping the disease after being cured may exist. It is important for a patient to communicate any issues and/or uncertainties they may have to a doctor, especially a specialist such as a gynecologist, and in doing so, to seek follow-up care.
A systematic review of the literature related to PID treatment was performed prior to the 2006 CDC sexually transmitted infections treatment guidelines. Strong evidence suggests that neither site nor route of antibiotic administration affects the short or long-term major outcome of women with mild or moderate disease. Data on women with severe disease was inadequate to influence the results of the study.
For women with PID of mild to moderate severity, parenteral and oral therapies appear to have similar clinical efficacy. Many randomized trials have demonstrated the efficacy of both oral and parenteral regimens. Clinical experience should guide decisions regarding transition to oral therapy, which usually can be initiated within 24â€"48 hours of clinical improvement. Recommended parenteral regimens include cefoxitin or cefotetan plus doxycycline, and clindamycin plus gentamicin. An alternative parenteral regimen is ampicillin/sulbactam plus doxycycline. A recommended parenteral regimen is ceftriaxone or cefoxitin plus doxycycline.
Prevention
- Risk reduction against sexually transmitted infections through barrier methods such as condoms; see human sexual behavior for other listings.
- Going to the doctor immediately if symptoms of PID, sexually transmitted infections appear, or after learning that a current or former sex partner has, or might have had a sexually transmitted infection.
- Getting regular gynecological (pelvic) exams with STI testing to screen for symptomless PID.
- Discussing sexual history with a trusted physician in order to get properly screened for sexually transmitted diseases.
- Regularly scheduling STI testing with a physician and discussing which tests will be performed that session.
- Getting a STI history from your current partner and insisting they be tested and treated before intercourse.
- Treating partners to prevent reinfection or spreading the infection to other people.
- 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.