Pelvic inflammatory disease

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Pelvic inflammatory disease
Other namesPelvic inflammatory disorder
Blausen 0732 PID-Sites.png
Drawing showing the usual sites of infection in pelvic inflammatory disease
Specialty Gynecology
Symptoms Lower abdominal pain, vaginal discharge, fever, burning with urination, pain with sex, irregular menstruation [1]
Complications Infertility, ectopic pregnancy, chronic pelvic pain, cancer [2] [3] [4]
CausesBacteria that spread from the vagina and cervix [5]
Risk factors Gonorrhea, chlamydia [2]
Diagnostic method Based on symptoms, ultrasound, laparoscopic surgery [2]
Prevention Not having sex, having few sexual partners, using condoms [6]
Treatment Antibiotics [7]
Frequency1.5 percent of young women yearly [8]

Pelvic inflammatory disease, also known as pelvic inflammatory disorder (PID), is an infection of the upper part of the female reproductive system, mainly the uterus, fallopian tubes, and ovaries, and inside of the pelvis. [5] [2] Often, there may be no symptoms. [1] Signs and symptoms, when present, may include lower abdominal pain, vaginal discharge, fever, burning with urination, pain with sex, bleeding after sex, or irregular menstruation. [1] Untreated PID can result in long-term complications including infertility, ectopic pregnancy, chronic pelvic pain, and cancer. [2] [3] [4]

Contents

The disease is caused by bacteria that spread from the vagina and cervix. [5] It has been reported that infections by Neisseria gonorrhoeae or Chlamydia trachomatis are present in 75 to 90 percent of cases. [2] 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. [9] Often, multiple different bacteria are involved. [2]

Without treatment, about 10 percent of those with a chlamydial infection and 40 percent of those with a gonorrhea infection will develop PID. [2] [10] Risk factors are generally similar to those of sexually transmitted infections and include a high number of sexual partners and drug use. [2] Vaginal douching may also increase the risk. [2] The diagnosis is typically based on the presenting signs and symptoms. [2] It is recommended that the disease be considered in all women of childbearing age who have lower abdominal pain. [2] A definitive diagnosis of PID is made by finding pus involving the fallopian tubes during surgery. [2] Ultrasound may also be useful in diagnosis. [2]

Efforts to prevent the disease include not having sex or having few sexual partners and using condoms. [6] Screening women at risk for chlamydial infection followed by treatment decreases the risk of PID. [11] If the diagnosis is suspected, treatment is typically advised. [2] Treating a woman's sexual partners should also occur. [11] 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. [7] For those who do not improve after three days or who have severe disease, intravenous antibiotics should be used. [7]

Globally, about 106 million cases of chlamydia and 106 million cases of gonorrhea occurred in 2008. [10] The number of cases of PID, however, is not clear. [8] It is estimated to affect about 1.5 percent of young women yearly. [8] In the United States, PID is estimated to affect about one million people each year. [12] A type of intrauterine device (IUD) known as the Dalkon shield led to increased rates of PID in the 1970s. [2] Current IUDs are not associated with this problem after the first month. [2]

Signs and symptoms

Illustration of pelvic inflammatory disease Blausen 0719 PelvicInflammatoryDisease.png
Illustration of pelvic inflammatory disease

Symptoms in PID range from none to severe. If there are symptoms, fever, cervical motion tenderness, lower abdominal pain, new or different discharge, painful intercourse, uterine tenderness, adnexal tenderness, or irregular menstruation may be noted. [2] [1] [13] [14]

Other complications include endometritis, salpingitis, tubo-ovarian abscess, pelvic peritonitis, periappendicitis, and perihepatitis. [15]

Complications

Fitz-Hugh-Curtis syndrome with perihepatic adhesions following a chlamydia infection Perihepatic adhesions 2.jpg
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. [16] 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). [17]

Cause

Chlamydia trachomatis and Neisseria gonorrhoeae are common causes of PID. However, PID can also be caused by other untreated infections, like bacterial vaginosis. [18] Data suggest that PID is often polymicrobial. [15] Isolated anaerobes and 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. [19] [20]

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. The disturbance of the naturally occurring vaginal microbiota associated with bacterial vaginosis increases the risk of PID. [19]

N. gonorrhoea and C. trachomatis 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. [19] PCR and serological tests have associated extremely fastidious organism with endometritis, PID, and tubal factor infertility. Microorganisms associated with PID are listed below. [19]

Cases of PID have developed in people who have stated they have never had sex. [21]

Bacteria

Diagnosis

Mucopurulent cervical discharge seen on a cotton bud Mucopurelent discharge.png
Mucopurulent cervical discharge seen on a cotton bud
Micrograph of salpingitis - a component of pelvic inflammatory disease. H&E stain. Salpingitis - low mag.jpg
Micrograph of salpingitis  – a component of pelvic inflammatory disease. H&E stain.

Upon a pelvic examination, cervical motion, uterine, or adnexal tenderness will be experienced. [5] 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. [15] [23]

Laparoscopy can visualize "violin-string" adhesions, characteristic of Fitz-Hugh–Curtis perihepatitis and other abscesses that may be present. [23]

Other imaging methods, such as ultrasonography, computed tomography (CT), and magnetic imaging (MRI), can aid in diagnosis. [23] 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. [15] [23]

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. [15]

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. [24] 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. [25]

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. [26]

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. [2]

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. [27]

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). [28]

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. [28]

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. [29] 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 ]

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 percent to 95 percent. However, even the modified 2002 CDC criteria do not identify women with subclinical disease. [30]

Prevention

Regular testing for sexually transmitted infections is encouraged for prevention. [31] The risk of contracting pelvic inflammatory disease can be reduced by the following:

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. [34] 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. [11] 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. [35]

For women with PID of mild to moderate severity, parenteral and oral therapies appear to be effective. [36] [37] It does not matter to their short- or long-term outcome whether antibiotics are administered to them as inpatients or outpatients. [38] 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. [39] A single study suggests superiority of azithromycin over doxycycline. [34] Another alternative is to use a parenteral regimen with ceftriaxone or cefoxitin plus doxycycline. [27] Clinical experience guides decisions regarding transition from parenteral to oral therapy, which usually can be initiated within 24–48 hours of clinical improvement. [29]

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. [40] 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. [40] Even women who do not experience intense symptoms or are asymptomatic can become infertile. [41] 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, [27] and 1% results in an ectopic pregnancy. [40] Chronic pelvic/abdominal pain develops post PID 40% of the time. [40] Certain occurrences such as a post pelvic operation, the period of time immediately after childbirth (postpartum), miscarriage or abortion increase the risk of acquiring another infection leading to PID. [27]

Epidemiology

Globally about 106 million cases of chlamydia and 106 million cases of gonorrhea occurred in 2008. [10] The number of cases of PID; however, is not clear. [8] 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. [40] It is estimated to affect about 1.5 percent of young women yearly. [8] In the United States PID is estimated to affect about one million people yearly. [12] Rates are highest with teenagers and first time mothers. PID causes over 100,000 women to become infertile in the US each year. [27] [42]

Prevalence

Records show that...

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. [35]

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. [43]

The results:

Population at risk. [44]

Etiology of PID: [44]

Related Research Articles

<span class="mw-page-title-main">Bacterial vaginosis</span> Excessive growth of bacteria in the vagina

Bacterial vaginosis (BV) is an infection of the vagina caused by excessive growth of bacteria. Common symptoms include increased vaginal discharge that often smells like fish. The discharge is usually white or gray in color. Burning with urination may occur. Itching is uncommon. Occasionally, there may be no symptoms. Having BV approximately doubles the risk of infection by a number of sexually transmitted infections, including HIV/AIDS. It also increases the risk of early delivery among pregnant women.

<span class="mw-page-title-main">Chlamydia</span> Sexually transmitted infection caused by the bacterium Chlamydia trachomatis

Chlamydia, or more specifically a chlamydia infection, is a sexually transmitted infection caused by the bacterium Chlamydia trachomatis. Most people who are infected have no symptoms. When symptoms do appear they may occur only several weeks after infection; the incubation period between exposure and being able to infect others is thought to be on the order of two to six weeks. Symptoms in women may include vaginal discharge or burning with urination. Symptoms in men may include discharge from the penis, burning with urination, or pain and swelling of one or both testicles. The infection can spread to the upper genital tract in women, causing pelvic inflammatory disease, which may result in future infertility or ectopic pregnancy.

Urethritis is the inflammation of the urethra. The most common symptoms include painful or difficult urination and urethral discharge. It is a commonly treatable condition usually caused by infection with bacteria. This bacterial infection is often sexually transmitted, but not in every instance; it can be idiopathic, for example. Some incidence of urethritis can appear asymptomatic as well.

<span class="mw-page-title-main">Ectopic pregnancy</span> Female reproductive system health issue

Ectopic pregnancy is a complication of pregnancy in which the embryo attaches outside the uterus. Signs and symptoms classically include abdominal pain and vaginal bleeding, but fewer than 50 percent of affected women have both of these symptoms. The pain may be described as sharp, dull, or crampy. Pain may also spread to the shoulder if bleeding into the abdomen has occurred. Severe bleeding may result in a fast heart rate, fainting, or shock. With very rare exceptions, the fetus is unable to survive.

<i>Neisseria gonorrhoeae</i> Species of bacterium

Neisseria gonorrhoeae, also known as gonococcus (singular) or gonococci (plural), is a species of Gram-negative diplococci bacteria first isolated by Albert Neisser in 1879. As an obligate human pathogen, it primarily colonizes the mucosal lining of the urogenital tract; however, it is also capable of adhering to the mucosa of the nose, pharynx and rectum, and the eyes. It causes the sexually transmitted genitourinary infection gonorrhea as well as other forms of gonococcal disease including disseminated gonococcemia, septic arthritis, and gonococcal ophthalmia neonatorum.

<span class="mw-page-title-main">Trichomoniasis</span> Medical condition

Trichomoniasis (trich) is an infectious disease caused by the parasite Trichomonas vaginalis. About 70% of affected people do not have symptoms when infected. When symptoms occur, they typically begin 5 to 28 days after exposure. Symptoms can include itching in the genital area, a bad smelling thin vaginal discharge, burning with urination, and pain with sex. Having trichomoniasis increases the risk of getting HIV/AIDS. It may also cause complications during pregnancy.

Nongonococcal urethritis (NGU) is inflammation of the urethra that is not caused by gonorrheal infection.

<span class="mw-page-title-main">Cervicitis</span> Inflammation of the uterine cervix

Cervicitis is inflammation of the uterine cervix. Cervicitis in women has many features in common with urethritis in men and many cases are caused by sexually transmitted infections. Non-infectious causes of cervicitis can include intrauterine devices, contraceptive diaphragms, and allergic reactions to spermicides or latex condoms. Cervicitis affects over half of all women during their adult life.

<span class="mw-page-title-main">Fitz-Hugh–Curtis syndrome</span> Medical condition

Fitz-Hugh–Curtis syndrome is a rare complication of pelvic inflammatory disease (PID) involving liver capsule inflammation leading to the formation of adhesions presenting with the clinical syndrome of right upper quadrant (RUQ) pain.

<span class="mw-page-title-main">Mycoplasmataceae</span> Family of bacteria

Mycoplasmataceae is a family of bacteria in the order Mycoplasmatales. This family consists of the genera Mycoplasma and Ureaplasma.

<span class="mw-page-title-main">Endometritis</span> Medical condition

Endometritis is inflammation of the inner lining of the uterus (endometrium). Symptoms may include fever, lower abdominal pain, and abnormal vaginal bleeding or discharge. It is the most common cause of infection after childbirth. It is also part of spectrum of diseases that make up pelvic inflammatory disease.

<span class="mw-page-title-main">Salpingitis</span> Inflammation of the fallopian tubes due to infection

Salpingitis is an infection causing inflammation in the fallopian tubes. It is often included in the umbrella term of pelvic inflammatory disease (PID), along with endometritis, oophoritis, myometritis, parametritis, and peritonitis.

<span class="mw-page-title-main">Vaginal discharge</span> Medical condition

Vaginal discharge is a mixture of liquid, cells, and bacteria that lubricate and protect the vagina. This mixture is constantly produced by the cells of the vagina and cervix, and it exits the body through the vaginal opening. The composition, amount, and quality of discharge varies between individuals and can vary throughout the menstrual cycle and throughout the stages of sexual and reproductive development. Normal vaginal discharge may have a thin, watery consistency or a thick, sticky consistency, and it may be clear or white in color. Normal vaginal discharge may be large in volume but typically does not have a strong odor, nor is it typically associated with itching or pain. While most discharge is considered physiologic or represents normal functioning of the body, some changes in discharge can reflect infection or other pathological processes. Infections that may cause changes in vaginal discharge include vaginal yeast infections, bacterial vaginosis, and sexually transmitted infections. The characteristics of abnormal vaginal discharge vary depending on the cause, but common features include a change in color, a foul odor, and associated symptoms such as itching, burning, pelvic pain, or pain during sexual intercourse.

<span class="mw-page-title-main">Hydrosalpinx</span> Medical condition

A hydrosalpinx is a condition that occurs when a fallopian tube is blocked and fills with serous or clear fluid near the ovary. The blocked tube may become substantially distended giving the tube a characteristic sausage-like or retort-like shape. The condition is often bilateral and the affected tubes may reach several centimeters in diameter. The blocked tubes cause infertility. A fallopian tube filled with blood is a hematosalpinx, and with pus a pyosalpinx.

<span class="mw-page-title-main">Fallopian tube obstruction</span> Medical condition

Fallopian tube obstruction, also known as fallopian tube occlusion, is a major cause of female infertility. Blocked fallopian tubes are unable to let the ovum and the sperm converge, thus making fertilization impossible.

<span class="mw-page-title-main">Gonorrhea</span> Sexually transmitted infection

Gonorrhoea or gonorrhea, colloquially known as the clap, is a sexually transmitted infection (STI) caused by the bacterium Neisseria gonorrhoeae. Infection may involve the genitals, mouth, or rectum. Infected males may experience pain or burning with urination, discharge from the penis, or testicular pain. Infected females may experience burning with urination, vaginal discharge, vaginal bleeding between periods, or pelvic pain. Complications in females include pelvic inflammatory disease and in males include inflammation of the epididymis. Many of those infected, however, have no symptoms. If untreated, gonorrhea can spread to joints or heart valves.

<span class="mw-page-title-main">Sexually transmitted infection</span> Infection transmitted through human sexual behavior

A sexually transmitted infection (STI), also referred to as a sexually transmitted disease (STD) and the older term venereal disease (VD), is an infection that is spread by sexual activity, especially vaginal intercourse, anal sex, oral sex, or sometimes manual sex. STIs often do not initially cause symptoms, which results in a risk of transmitting them on to others. The term sexually transmitted infection is generally preferred over sexually transmitted disease or venereal disease, as it includes cases with no symptomatic disease. Symptoms and signs of STIs may include vaginal discharge, penile discharge, ulcers on or around the genitals, and pelvic pain. Some STIs can cause infertility.

Female genital disease is a disorder of the structure or function of the female reproductive system that has a known cause and a distinctive group of symptoms, signs, or anatomical changes. The female reproductive system consists of the ovaries, fallopian tubes, uterus, vagina, and vulva. Female genital diseases can be classified by affected location or by type of disease, such as malformation, inflammation, or infection.

<span class="mw-page-title-main">Tubal factor infertility</span> Medical condition

Tubal factor infertility (TFI) is female infertility caused by diseases, obstructions, damage, scarring, congenital malformations or other factors which impede the descent of a fertilized or unfertilized ovum into the uterus through the fallopian tubes and prevents a normal pregnancy and full term birth. Tubal factors cause 25-30% of infertility cases. Tubal factor is one complication of chlamydia trachomatis infection in women.

<span class="mw-page-title-main">Tubo-ovarian abscess</span> One of the late complications of pelvic inflammatory disease

A tubo-ovarian abscess (TOA) is one of the late complications of pelvic inflammatory disease (PID) and can be life-threatening if the abscess ruptures and results in sepsis. It consists of an encapsulated or confined pocket of pus with defined boundaries that forms during an infection of a fallopian tube and ovary. These abscesses are found most commonly in reproductive age women and typically result from upper genital tract infection. It is an inflammatory mass involving the fallopian tube, ovary and, occasionally, other adjacent pelvic organs. A TOA can also develop as a complication of a hysterectomy.

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  31. ↑ Smith, KJ; Cook, RL; Roberts, MS (2007). "Time from sexually transmitted infection acquisition to pelvic inflammatory disease development: influence on the cost-effectiveness of different screening intervals". Value in Health. 10 (5): 358–66. doi: 10.1111/j.1524-4733.2007.00189.x . PMID   17888100.
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