Abstract
Pelvic inflammatory disease (PID) is a clinical syndrome caused by ascending spread of infection from the vagina and/or endocervix into the pelvis causing endometritis, salpingitis, parametritis, oophritis, tubovarian abscess and even peritonitis in severe cases.
Definition
Pelvic inflammatory disease (PID) is a clinical syndrome caused by ascending spread of infection from the vagina and/or endocervix into the pelvis causing endometritis, salpingitis, parametritis, oophritis, tubovarian abscess and even peritonitis in severe cases.1
Aetiology
PID is almost always a sexually transmitted infection disease.
The most common micro-organisms that have been implicated are Neisseria gonorrhoeae and Chlamydia trachomatis. Other organisms including vaginal anaerobes, Mycoplasma genitalium and Gardnerella vaginalis have also been implicated.
A large study of 315 123 Western Australian women found that gonorrhoeal infection conferred a higher risk than chlamydia for hospitalisation or presentation with PID. The emergence of gonorrhoea antimicrobial resistance may have a serious impact on rates of PID and its sequelae.2 [EL 2]
Incidence
The incidence of PID is unknown, mainly due to the difficulty in making a diagnosis.
First attack of PID is often unrecognised if it has atypical presentation or is asymptomatic.
In a large cohort historical follow-up study of women tested for Chlamydia trachomatis, Bakken et al. showed that PID was diagnosed in 1.7 per cent of primary care physician attendances by women 16–46 years of age.3
Approximately 125 000–150 000 hospitalisations occur yearly in the United States because of PID.
PID is a clinical syndrome and diagnosis is mainly clinical.
Expert opinion from the British Association for Sexual Health and HIV (BASHH) recommends making the diagnosis of PID based on history and clinical examination alone and having a low threshold for initiating treatment.4
Symptoms
Signs
Lower abdominal tenderness which is usually bilateral
Adnexal tenderness on bimanual vaginal examination
Cervical motion tenderness on bimanual vaginal examination
Fever (>38°C)
Risk Factors
1. Age less than 20 years poses a greater risk for development of PID
2. High number of sexual partners
3. Previously treated sexually transmitted infections (STIs) increase the risk of PID significantly
4. Commercial sex workers
5. Women who do not use condom contraception
6. Women in areas with a high prevalence of STIs
7. Young age at first intercourse is also a risk factor for PID
8. An intrauterine device (IUD) for contraception confers a relative risk of 2.0–3.0 for the first four weeks following insertion; this risk subsequently decreases to baseline. This risk is usually associated with sexually transmitted infection. However, the best evidence suggests that the risk of PID among IUD users is very low.5
Differential Diagnosis
1. Ectopic pregnancy is the most important differential diagnosis to exclude in young women presenting with acute abdominal pain.
2. Ovarian cyst accidents (ovarian cyst torsion or rupture or bleeding inside an ovarian cyst).
3. Appendicitis.
4. Urinary tract infection.
5. Mittelschmerz pain (painful ovulation, pain occurs during ovulation in the midpoint between menstrual periods, about two weeks before a period may begin. The discomfort can appear on either side of the lower abdomen depending on which ovary is producing the ovum.
6. Endometriosis.
7. Functional pain (that is of unknown physical origin).
Complications
1 Chronic Pelvic Pain
Chronic pelvic pain occurs in approximately 25 per cent of patients with a history of PID. The pain may be the result of adhesions or hydrosalpinx.
2 Infertility
According to one study, the risk of tubal infertility was 0.6 per cent after mild infection, and 21.4 per cent after severe infection.
3 Ectopic Pregnancy
The risk of ectopic pregnancy is increased 15–50 per cent in women with a history of PID.
4 Tubo-ovarian Abscess (TOA)
TOA can manifest as an adnexal mass, fever, elevated white blood cell count, lower abdominal–pelvic pain, and/or vaginal discharge.
PID may cause TOA and extend to produce pelvic peritonitis and Fitz-Hugh−Curtis syndrome (perihepatitis).
TOA occurred in as many as one-third of women hospitalised for PID.6
Acute rupture of a TOA with resultant diffuse peritonitis is a rare but life-threatening event that calls for urgent abdominal surgery.
MRI is superior in evaluating the extent of disease, the characteristics of the lesion and to make the diagnosis of a TOA. However, due to high cost and more limited availability, MRI is not usually the first-line imaging used.
5 Pelvic Abscess
An abscess occurs when pus from the fallopian tube spills onto the ovary and infects it at the site of follicular rupture or by direct penetration.
Symptoms include abdominal and pelvic pain that may be bilateral and is aggravated by motion and intercourse. Fever with leucocytosis, tachycardia and prostration are the common symptoms of pelvic abscess.
Abdominal and pelvic examination may reveal a fluctuant mass, although the degree of pain and guarding may mask the diagnosis.
Rectal examination may provide a clue.
Imaging modalities (US, CT and MRI) help diagnoses and may elicit other causes of pain.
Pregnancy-Related Factors
•PID rarely occurs in pregnancy.
•Chorioamnionitis can occur in the first 12 weeks of gestation, before the mucous plug solidifies and seals off the uterus from ascending bacteria.
•Fetal loss may result if chorioamnionitis occurs.
•Pregnancy influences the choice of antibiotic therapy for PID.
•Uterine infection is usually limited to the endometrium but may be more invasive in a gravid or postpartum uterus.
•Pregnant women with suspected PID should be admitted to hospital, as intravenous (IV) antibiotics are required due to the increased risk of maternal and fetal morbidity and preterm delivery.
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