Pelvic inflammatory disease (PID) is a combination of the infection affecting the uterus, fallopian tubes, ovaries and the peritoneum that results from ascending infection by micro-organisms from the vagina or cervix and usually caused by many microorganisms most of which are sexually transmitted infections with few others being caused by other factors.
What is PID?
Pelvic inflammatory disease (PID) is a broad term that is used to refer to any upper genital tract infection such as Endometritis (Inflammation of the endometrium of the uterus), Parametritis (inflammation of the parametrium dividing fibrous tissue between the bladder and the cervix), Salpingitis (the inflammation of fallopian tube)andOophoritis (inflammation of the ovaries). PID infections usually spread from the vagina or cervix and ascends up through the uterine cavity, to the fallopian tubes and the ovaries.
Pelvic inflammatory disease is a disease of the reproductive years of a woman as about 75% of patients are young and under 25 years and are sexually active (90% of infections are sexually acquired).
Pelvic Inflammatory Disease Symptoms (PID Symptoms)
- PID may not even show any symptom (Asymptomatic)
- Low, bilateral pelvic pain with associated Fever
- Minimal or profuse Vaginal discharge that is purulent and offensive with or without blood stain
- Intermenstrual or post coital bleeding resulting from endometritis and cervicitis
- Deep dyspareunia (Pain on sexual intercourse)
- General malaise(feeling of sickness)
- Right upper abdominal pain and tenderness at the liver edge with or without a hepatic friction rub this is known as Fitz-Hugh Curtis syndrome (which is due to inflammation and infection of the liver capsule, causing peri-hepatitis and affects 1020% of women with gonococcal or chlamydial PID)
Pelvic Inflammatory Disease (PID) affects Females alone and does not occur in Men. PID caused by gonorrhoea presents more acutely and is more severe compared to chlamydial PID. It is worth of note that for every woman with clinical symptoms and signs of PID there are two others who are asymptomatic (not showing signs or symptoms).
PID Risk Factors
- Multiple sexual partners
- Use of intrauterine contraception devices
Pelvic Inflammatory Disease Causes (PID Causes)
- Sexually transmitted infections such as Gonorrhea and Chlamydia infection
- Post-partum infections occurring after giving birth
- Post-abortal infections occurring after an abortion
- Gynecological procedures such as insertion of the Intrauterine contraception device (IUCD) or hysterosalpingography make up 10% of the cases of PID
- Pelvic Surgeries predispose to having PID
- Genital Tuberculosis may cause PID too
PID without STD
PID may occur without sexually transmitted disease causing it. This may occur following instrumentation such as insertion of IUCD, pelvic surgeries, or infections from the bowel or blood affecting the pelvis or even genital tuberculosis. STD only cause about 80% of cases of PID.
PID is mainly transmitted sexually but other means of transmission may occur. Lymphatic spread of PID may occur along the Parametrium or along the surface of the Uterus. In fact, inflammation of fallopian tube (Salpingitis) has occurred in women who have been sterilized. PID can also be transmitted from the bowel or through the blood. Many organisms have been cultured from women with PID and about 80% have shown to be caused by Sexually transmitted diseases (especially Chlamydia infection or Gonorrhea). Mycoplasma genitalium is probably sexually transmitted and has been implicated in PID in women and as a cause of non-gonococcal urethritis (NGU) in men.
Types of PID
- Acute PID: this mostly occur as a life-threatening condition
- Chronic PID: this type may be disabling
These occurs within few days of infection and when it is symptomatic, it presents with the symptoms mentioned above. Acute PID should be treated completely to prevent development of chronic PID with associated complications.
This follows inadequately treated acute PID or may follow cases where low-grade symptoms in which the patient did not present to the hospital; there is usually adhesions, scarring or tubal obstruction. It can also occur even with good treatment of the first infection in the presence of tubal damage or reinfection with Streptococcus, Staphylococcus, anaerobes or Actinomyces. In Chronic PID, the patient complains of pelvic pain made worse during the menstrual periods, which are irregular and heavy. Dyspareunia is common.
Treatment of the infectious cause of chronic PID alone is often unsatisfactory as scarring causes inadequate blood supply with poor delivery of antibiotics to the affected area. Surgical clearance of the pelvis may be the final step in a long line of treatments.
How long does it take for PID to develop?
Onset of PID symptoms takes a few days to develop for acute PID and may take several weeks for chronic PID. The onset of PID is often (but not always) associated with menstruation.
PID is difficult to detect because it requires special culture medium to grow the microorganisms or use of a polymerase chain reaction (PCR) test.
PID Laboratory Investigations
- FBC (full blood count) there will be raised white blood cell count as response to infection
- ESR > 15 mm/hour
- Temperature – raised in response to infection
- Triple swabs – from high vagina, endocervix, urethra
- Diagnostic laparoscopy this may be considered for a definitive diagnosis, investigation of a pelvic mass, or failure to respond to treatment
PID diagnosis may be difficult because even endogenous anaerobes, such as Bacteroides spp. or Mycoplasma hominis, often complicate the disease by causing tubal abscess formation. There are criteria for diagnosis of PID which are stated below.
Criteria for PID Diagnosis
- Abdominal tenderness
- Cervical excitation
- Adnexal tenderness
The three signs above should all be present with at least one of the following
- Temperature > 38C
- WBC > 10 x 10e9/L
- ESR > 15 mm/hour
PID Treatment (How to treat PID)
Treatment of PID depends on the type as Acute PID treatment is different from Chronic PID treatment. For acute PID treatment, there is the outpatient PID treatment regimen and inpatient regimen. The in-patient antibiotic treatment should be based on intravenous therapy, which should be continued until 24 hours after clinical improvement and followed by oral therapy.
Acute PID Treatment regimen for in-patients
- Ceftriaxone 2 g intravenously daily + doxycycline 100 mg intravenously twice a day (oral doxycycline may be used if tolerated), followed by doxycycline 100 mg orally twice a day + metronidazole 400 mg orally twice a day for a total of 14 days
- OR Clindamycin 900mg intravenously three times a day + gentamicin 2 mg/kg loading dose followed by 1.5 mg/kg intravenously three times a day (a single daily dose of 7 mg/kg may be substituted), followed by clindamycin 450 mg orally four times a day to complete 14 days
- OR Doxycycline 100 mg orally twice a day + metronidazole 400 mg orally twice a day to complete 14 days
Acute PID Treatment for Outpatients
- Oral Ofloxacin 400 mg twice daily plus oral metronidazole 400 mg twice daily for 14 days
- Intramuscular ceftriaxone 250 mg single dose followed by oral doxycycline 100 mg twice daily plus metronidazole 400 mg twice daily for 14 days
These regimens were recommended by the Royal College of Obstetricians and Gynecologists, UK (Greentop Guideline 32, Management of Acute Pelvic Inflammatory Disease).
If acute signs and symptoms persist, an ultrasound should be carried out to search for abscess formation. Surgical intervention to drain abscesses may be required if after 48 hours of antibiotic therapy there is no improvement in the patient’s condition. Abstinence or the use of barrier contraception is advised until resolution of the condition on repeat testing. It is essential that sexual partners are screened for Chlamydia infections and gonorrhea and prescribed appropriate antibiotic treatment before intercourse is resumed.
Chronic PID Treatment
If a desire for fertility is not important for the patient, then removal of infected tissue may be the only way to get pain relief and may involve total abdominal hysterectomy with bilateral salpingo-oophorectomy (because leaving the ovaries behind at hysterectomy results in continuing pain in a number of patients)
Antibiotics for PID
- Ofloxacin 400mg BD plus Metronidazole 400mg BD for 14 days
- Ceftriaxone 250 mg intramuscularly stat (or cefoxitin 2g intramuscularly stat plus probenecid 1g orally stat) plus Doxycycline 100mg BD plus Metronidazole 400mg BD for 14 days
- Moxifloxacin 400mg Once daily
Criteria for Hospitalization or admission of Patients with Acute PID
- Surgical emergencies such as suspected Appendicitis
- When Patient is pregnant
- Non response to oral antimicrobial drugs
- Inability of patient to take out-patient therapy orally
- Severe illness with signs and symptoms such as vomiting and fever
- Tubo-ovarian abscess suspected
- Immunodeficiency ( such as in HIV with low CD4 cell count)
- Ectopic pregnancy
- Chronic pelvic pain
- Tubal abscess formation
- Tubo-ovarian abscess
- Fitz-Hugh Curtis syndrome
- Reiters syndrome
Differential diagnosis of Acute PID
- Ectopic pregnancy
- Threatened abortion
- Acute appendicitis
- Acute urinary tract infections
- Menstrual pain (dysmenorrhea)