Pelvic inflammatory disease, or PID, is a general term for infection in the upper genital tract (uterus, fallopian tubes and ovaries).
Endometritis implies involvement of the lining of the uterus, the endometrium and salpingitis refers to inflammation of the fallopian tubes.
Chronic PID is a long term sequela of acute or subacute infection.
The prevalence of PID is underreported, though is estimated at 1 - 3% of sexually active women. The incidence of PID is increasing. PID is most commonly caused by ascending infection from the vagina or endocervix, but can also occur from descending infection from organs such as the appendix.
The microorganisms invade the columnar cells of the crypts of the cervix and can spread via lymphatics, veins, or may even travel on spermatozoa. The endometrium is first infected, and from here the infection may spread to the myometrium or to the fallopian tubes, causing acute or subacute salpingitis. Ovaries and the pelvic peritoneum may be involved in some cases.
Risk Factors for PID:
No specific signs or lab tests are diagnostic. A full gynaecological history including sexual history should be taken. An abdominal examination should be carried out to assess sites of tenderness. Speculum and vaginal examination are necessary to assess adnexal masses, vaginal discharge and tenderness.
Analgesia as appropriate.
Antibiotics. Treat as soon as PID is clinically suspected. Early treatment is likely to reduce risk of long term complications. Women should be admitted if there is diagnostic uncertainty, severe symptoms or signs, or if they fail to respond to oral therapy.
Referral to GUM clinic. Consider referral for full STI screen, contact tracing and treatment of sexual partners.
Contact tracing. C. trachomatis and N. gonorrhoeae are easily transmitted, though they may not show symptoms, especially in men. Advise patients to avoid unprotected sexual contact until treated fully. All sexual partners within the last 6 months, (or the most recent if more than 6 months ago) should be screened. Sexual partners should be treated for chlamydial infection even if not identified on testing, but treatment for gonorrhoeal infection need only be given if N. gonorrhoeae found in patient or the partner.
Review. Women with moderate or severe clinical findings should be reviewed after 2-3 days to ensure they are improving. Lack of response may require further investigations, IV antibiotics and/or surgical intervention.
Subfertility: The risk is related to the number of episodes and their severity. Tubal infertility occurs in 10-12% of women after 1 episode of PID, 20-30% after two episodes and 50-60% after three episodes.
Ectopic pregnancy: Risk is increased six to ten-fold.
Chronic pelvic pain (>6months): in 18% of women. This is thought to be related to the number of episodes and severity and the extent of pelvic adhesions.
Fitz-Hugh-Curtis Syndrome: In 5-15% of women with salpingitis, the infection spreads from the pelvis to the liver capsule, causing perihepatitis.
Repeated infections: Relapse occurs in around one third.
Pregnancy: PID is associated with increased risk of pre-term delivery and increased foetal and maternal morbidity.
Neonate: Untreated infection of chlamydia or gonorrhoea risks ophthalmia neonatorum. Chlamydial transmission to the neonate can cause chlamydial pneumonitis.
Pelvic inflammatory disease can also lead to:
Avoidance of risk:
Drife, J., and Magowan, B., Clinical Obstetrics and Gynaecology, 2004. Elsevier Saunders Science.
Oats, J., and Abraham, S., Fundamentals of Obstetrics and Gynaecology, 9th Edition (2010), Mosby Elsevier.
Collins, S., Arulkumaran, S., Hayes, K., Jackson, S., and Impey, L., Oxford Handbook of Obstetrics and Gynaecology, 2nd Edition, 2008. Oxford University Press.
Article by Patient UK: http://www.patient.co.uk/doctor/Pelvic-Inflammatory-Disease-(PID).htm
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