Pelvic Inflammatory Disease

Original Editor - Khloud Shreif
Top Contributors - Khloud Shreif and Kim Jackson

Description

Overview-of-the-Female-Reproductive-Tract.jpg

The female reproductive system/ genital tract consists of the upper and lower genital tract. The lower genital tract consists of ( mons pubis, labia majora, labia minora, clitoris, vestibule, hymen, bartholin's glands, external urethra meatus, and skene's gland). The upper or internal genitalia is the reproductive system and consists of ( the vagina, cervix, uterus, fallopian tubes, and ovaries), and it is related to pelvic inflammatory disease.

Pelvic inflammatory disease (PID) is an inflammation of the female upper genital tract due to infection that is usually an ascending infection from vagina and cervix to uterine body, fallopian tubes, and may spread to ovaries, it is most common between young, sexually active women, having more than one partner from 15-25 years old. It happens in the case of untreated bacterial infection such as gonorrhea, or chlamydia associated with symptoms varying from mild symptoms need an antibiotic course to severe symptoms that need urgent hospital administration[1]. In other words, it is named as a polymicrobial infection.

Etiology

Sexually transmitted infection STI is the most common bacterial infection for pelvic inflammatory disease such as neisseria gonorrhea and chlamydia trachomatise bacteria. The natural useful bacteria that normally exist in the vagina and cervix may be a source for PID if there was a previous history of PID, damage to the cervix after childbirth, abortion[2], intrauterine contraceptive device IUCD,
GIT inflammatory conditions like; appendicitis, colitis can spread through the lymphatic extension causing perisalpingitis.

Epidemiology

There was about 750,000 female diagnosed with PID in 2001 in the united state[3], and from 2013-2014 according to self-reporting lifetime 4,4% between sexually, reproductive women aged 18-44 that is about 2,5 million [4]

Clinical Presentation

PID symptoms vary from mild in most cases to sever in others, symptoms with chlamydia infection less in severity than those with N gonorrhoea. Majority of women with mild PID symptoms (silent PID) may develop one or more of the following symptoms, these symptoms are general and not specific for pelvic inflammatory disease:

  • Lower abdominal pain is the most common symptom.
  • Heavy, painful periods.
  • Pain or discomfort during sex that is felt deep in the pelvis.
  • Increase in vaginal discharge especially if it is yellow or green.
  • Bleeding between two menstrual cycles and after sex.
  • Headache, fever, malaysia.

Sever symptoms presented in :

  • Increase in temperature.
  • Severe abdominal pain.
  • Being sick.

Complications

Tubo-ovarian abscess
  • Salpingitis, if the infection spreads to the fallopian tube that makes it difficult to transmit the ovaries to the womb.
  • Ectopic pregnancy, when the fertilized egg grows outside the uterine cavity and the fallopian tube is the most common site. Increase 7 folds in women with PID than others.
  • Infertility, repeated PID increases the possibility of infertility
  • Tubo-ovarian abscess TOA is a short term complication of PID that happens due to the collection of infected fluid that develops an abscess, not found in all women but it may happen[5].
  • Hydrosalpinx, water accumulation in the scar tissue that is built in the tube.
  • Chronic pelvic pain a long term sequelae that sometimes happens and leads to depression and anxiety[6].

Risk factors

  • Young, sexually active woman, having more than one sexual partner.
  • Previous history of sexually transmitted infection, or pelvic inflammatory disease.
  • Having a new sexual partner with chlamydia bacteria, it is common in young men, and it is asymptomatic in common. Using a male condom decreases the risk of STI and PID[7][8].
  • Intrauterine contraceptive device IUCD increases the risk of PID infection, oral contraceptive pills associated with a low incidence of PID
  • Retrograde menstruation.
[9]

Diagnostic Procedures

  • Pelvic examination to examine and check if there is tenderness or any other vaginal discharge especially green or yellow. Patients with PID will feel discomfort during examination.
  • Laboratory examination: vaginal or cervical swabs, positive swaps will show antibodies for chlamydia or gonorrhoea that confirm the diagnosis of PID, on the other hand, negative swaps for chlamydia or gonorrhoea don't role out PID.
  • Blood test: we will find an increase in WBC’S, C-RP, and ESR they support but they aren’t specific to PID and aren’t an accurate diagnosis.
  • Ultrasound: through the transvaginal U.S. used to exclude ectopic pregnancy, ovarian swelling, findings may be normal[10].
  • Laparoscopy is the gold standard to confirm PID diagnosis when the antibiotic course treatment fails.

Management / Interventions

Patients with mild symptoms treated with an outpatient regimen and they advised stopping the sexual activity until they finish the course of treatment. The sexual partner should also be examined even if he is asymptomatic. An asymptomatic untreated partner will transmit STI.

Pregnant patient, suspected pelvic abscess, severe illness, patients who can tolerate the outpatient regimen, and patient with no improvement with 72 hours from starting the antibiotic course all those will need hospitalization.

Medical interventions

CDC guidelines for the treatment of PID:

The treatment starts with a broad spectrum of antibiotics. women who experience one or more of the following in examination will need t start the treatment; adnexal tenderness, uterine tenderness, and cervical motion tenderness.

Outpatient management:

Cefoxitin 2gm or ceftriaxone250mg IM plus doxycycline 100 mg orally 2 times/day for 14 days or tetracycline orally 4 times/ day for 10-14 days. Those who don't respond to doxycycline/tetracycline, erythromycin 500mg orally 4 times/ day.

Inpatient/or with severe symptoms management:
Pain med.jpg
  • Regimen A

Cefoxitin 2 gm IV every 6 hours or cefotetan 2gm IV every 12 hours plus doxycycline 100 mg orally or IV every 12 hours. This protocol for 48 hours after the patient clinically improves and after discharge from hospital, doxycycline 100 mg orally 2 times/ day should be continued for 10-14 days.

  • Regimen B

Clindamycin 900 mg IV every 8 hours plus gentamicin loading dose IV or IM (2 mg/kg of body weight) then followed by (1.5 mg/kg) every 8 hours.

This regimen is given for at least 48 hours after the patient improves and after discharge from hospital, doxycycline 100 mg orally 2 times/ day should be continued for 10-14 days total or clindamycin 450 mg orally 4 times/ day for 10-14 days may be an alternative.

Surgical intervention

In patients with TOA surgical excision combined with antibiotics, will be needed according to the size of the abscess, when the rupture of an abscess is suspected immediate intervention will be needed as this considers a cause of morbidity in this situation.

Physical Therapy Intervention

Chronic pelvic pain is a long term complication for PID or repeated episodes of PID for physical therapy intervention lookup for this page chronic pelvic pain,

Differential Diagnosis

Ectopic pregnancy.

Endometriosis.

Rupture ovarian cyst.

Inflammatory bowel disease.

Resources

CDC: Guidelines for Prevention and Management

CDCP: Pelvic inflammatory disease

NHS: Pelvic inflammatory disease

References

  1. Terzić M, Kocijančić D. Pelvic inflammatory disease: contemporary diagnostic and therapeutic approach. Srpski arhiv za celokupno lekarstvo. 2010;138(9-10):658-63.
  2. Penney GC. Preventing infective sequelae of abortion. Human reproduction (Oxford, England). 1997 Nov;12(11 Suppl):107.
  3. Jennings LK, Krywko DM. Pelvic Inflammatory Disease (PID).
  4. Kreisel K, Torrone E, Bernstein K, Hong J, Gorwitz R. Prevalence of pelvic inflammatory disease in sexually experienced women of reproductive age—United States, 2013–2014. MMWR. Morbidity and mortality weekly report. 2017 Jan 27;66(3):80.
  5. Krivak TC, Cooksey C, Propst AM. Tubo-ovarian abscess: diagnosis, medical and surgical management. Comprehensive therapy. 2004 Jun 1;30(2):93-100.
  6. Chappell CA, Wiesenfeld HC. Pathogenesis, diagnosis, and management of severe pelvic inflammatory disease and tuboovarian abscess. Clinical obstetrics and gynecology. 2012 Dec 1;55(4):893-903.
  7. Hiltabiddle SJ. Adolescent condom use, the health belief model, and the prevention of sexually transmitted disease. Journal of Obstetric, Gynecologic, & Neonatal Nursing. 1996 Jan;25(1):61-6.
  8. Ha MM, Belcher HM, Butz AM, Perin J, Matson PA, Trent M. Partner Notification, Treatment, and Subsequent Condom Use After Pelvic Inflammatory Disease: Implications for Dyadic Intervention With Urban Youth. Clinical pediatrics. 2019 Oct;58(11-12):1271-6.
  9. Osmosis. Pelvic inflammatory disease - causes, symptoms, diagnosis, treatment, pathology. Available from: http://www.youtube.com/watch?v=eYk3GdBw-28[last accessed 14/8/2020]
  10. Polena V, Huchon C, Ramos CV, Rouzier R, Dumont A, Fauconnier A. Non-invasive tools for the diagnosis of potentially life-threatening gynaecological emergencies: a systematic review. PloS one. 2015 Feb 27;10(2):e0114189.