| Pelvic inflammatory disease | |
|---|---|
| Other names | Pelvic inflammatory disorder |
 | |
| 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] |
| Causes | Bacteria 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, usingcondoms[6] |
| Treatment | Antibiotics[7] |
| Frequency | 1.5 percent of young women yearly[8] |
Pelvic inflammatory disease (PID), also known aspelvic inflammatory disorder, is aninfection of the upper part of thefemale reproductive system, mainly theuterus,fallopian tubes, andovaries, and inside of thepelvis.[2][5] 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, orirregular menstruation.[1] Untreated PID can result in long-term complications includinginfertility,ectopic pregnancy,chronic pelvic pain, andcancer.[2][3][4]
The disease is caused by bacteria that spread from the vagina and cervix.[5] It has been reported that infections byNeisseria gonorrhoeae orChlamydia trachomatis are present in 75 to 90 percent of cases.[2] However, in the UK it is reported by the NHS that infections byNeisseria gonorrhoeae andChlamydia 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 achlamydial infection and 40 percent of those with agonorrhea infection will develop PID.[2][10] Risk factors are generally similar to those ofsexually transmitted infections and include ahigh number of sexual partners anddrug 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 findingpus involving the fallopian tubes duringsurgery.[2]Ultrasound may also be useful in diagnosis.[2]
Efforts to prevent the disease includenot having sex or having few sexual partners and usingcondoms.[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 theantibioticceftriaxone along with two weeks ofdoxycycline and possiblymetronidazole 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 ofintrauterine device (IUD) known as theDalkon shield led to increased rates of PID in the 1970s.[2] Current IUDs are not associated with this problem after the first month.[2]
Symptoms in PID range from none to severe. If there are symptoms,fever,cervical motion tenderness, lowerabdominal pain, new or different discharge,painful intercourse,uterine tenderness,adnexal tenderness, or irregular menstruation may be noted.[2][1][13][14]
Other complications includeendometritis,salpingitis,tubo-ovarian abscess, pelvicperitonitis, periappendicitis, andperihepatitis.[15]
PID can causescarring 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 theperitoneum causing inflammation and the formation of scar tissue on the external surface of theliver (Fitz-Hugh–Curtis syndrome).[17]
Chlamydia trachomatis andNeisseria 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] Isolatedanaerobes andfacultative 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 theinfundibulum. The disturbance of the naturally occurring vaginalmicrobiota associated withbacterial vaginosis increases the risk of PID.[19]
N. gonorrhoea andC. 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 whomChlamydia andNeisseria 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, andtubal 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]
Upon apelvic examination,cervical motion,uterine, or adnexal tenderness will be experienced.[5] Mucopurulentcervicitis and orurethritis may be observed. In severe cases, more testing may be required, such aslaparoscopy, intra-abdominal bacteria sampling and culturing, or tissue biopsy.[15][23]
Laparoscopy can visualize "violin-string"adhesions, characteristic ofFitz-Hugh–Curtis perihepatitis and other abscesses that may be present.[23]
Other imaging methods, such as ultrasonography, computed tomography (CT), and magnetic resonance 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 includehistopathologic evidence of endometritis, thickened, filledfallopian tubes, orlaparoscopic 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 percentpositive predictive value exists in patients with presumed PID.[25]
Upongynecologic ultrasound, a potential finding istubo-ovarian complex, which isedematous and dilated pelvic structures as evidenced by vague margins, but withoutabscess formation.[26]
Several other causes may produce similar symptoms, including appendicitis, ectopic pregnancy, hemorrhagic or rupturedovarian cysts,ovarian torsion, endometriosis andgastroenteritis, peritonitis, and bacterial vaginosis, among others.[2]
Pelvic inflammatory disease is more likely to recur when there is a prior history of the infection, recent sexual contact, recent onset ofmenses, or anIUD (intrauterine device) in place, or if the partner has asexually 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 serumpregnancy test is typically obtained to rule out ectopic pregnancy.Culdocentesis will differentiatehemoperitoneum (ruptured ectopic pregnancy orhemorrhagic cyst) from pelvicsepsis (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 correlate 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 adequatesensitivity andspecificity 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 theCDC diagnostic criteria from 83 percent to 95 percent. However, even the modified 2002 CDC criteria do not identify women with subclinical disease.[30]
Regular testing forsexually transmitted infections is encouraged for prevention.[31] The risk of contracting pelvic inflammatory disease can be reduced by the following:
Treatment is often started without confirmation of infection because of the serious complications that may result from delayed treatment. Treatment depends on theinfectious agent and generally involves the use ofantibiotic therapy although there is no clear evidence of which antibiotic regimen is more effective and safe in the management of PID.[35] 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 the risk of infertility.[36]
For women with PID of mild to moderate severity, parenteral and oral therapies appear to be effective.[37][38] It does not matter to their short- or long-term outcome whether antibiotics are administered to them as inpatients or outpatients.[39] Typical regimens includecefoxitin orcefotetan plusdoxycycline, andclindamycin plusgentamicin. An alternative parenteral regimen isampicillin/sulbactam plus doxycycline.Erythromycin-based medications can also be used.[40] A single study suggests superiority of azithromycin over doxycycline.[35] Another alternative is to use a parenteral regimen withceftriaxone 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]
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, the 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.[41] Treatment resulting in cure is very important in the prevention of damage to thereproductive system. Around 20 percent of women with PID develop infertility.[41] Even women who do not experience intense symptoms or are asymptomatic can become infertile.[42] 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.[41] Chronic pelvic/abdominal pain develops post PID 40% of the time.[41] Certain occurrences such as a post pelvic operation, the period of time immediately after childbirth (postpartum),miscarriage orabortion increase the risk of acquiring another infection leading to PID.[27]
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.[41] 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 among teenagers and first-time mothers. PID causes over 100,000 women to becomeinfertile in the US each year.[27][43]
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.[36]
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.[44]
The results:
Source:[45]
| International | |
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| National | |
