Summary
Contents showPelvic inflammatory disease is a spectrum of inflammatory and infectious disorders affecting the upper female genital tract, which includes endometritis, salpingitis, purulent pelvic collections, and pelvic peritonitis. Pelvic inflammatory disease is diagnosed in more than a million women per year in the US, and is more frequently found in women of reproductive age.
Pelvic inflammatory disease is most frequently produced by sexually transmitted infections, such as Chlamydia Trachomatis, Neisseria gonorrheae, Gardnerella Vaginallis, Haemophilus influenzae, Streptococcus Agalactieae, enteric gram-negative rods, Cytomegalovirus, Trichomonas Vaginalis, Mycoplasma hominis, Mycoplasma genitalium, and Ureaplasma Urealyticum infections.
Symptoms of pelvic inflammatory disease include lower abdominal pain, vaginal discharge, usually purulent, intermenstrual or postcoital bleeding, lower back pain, dysmenorrhea, deep dyspareunia, urinary frequency, and nausea and vomiting. Some cases of the condition can present oligo or asymptomatic.
Diagnosis of pelvic inflammatory disease is based on anamnesis, gynecological examination, imaging studies, and laparoscopy in some cases. Treatment consists of antimicrobial therapy and surgical treatment of pelvic complications, if applicable.
Pelvic Inflammatory Disease – Introduction
Pelvic inflammatory disease (PID) is a disease very frequently seen both in emergency and outpatient gynecological consultations. It includes a wide range of symptoms; therefore, it should be considered in the differential diagnosis of acute abdominal pain, causes of infertility, or chronic pelvic pain, among others.
Due to the severe complications it generates, detecting and treating it as soon as possible is vital.
This article emphasizes the most important aspects to consider to arrive at a diagnosis and the different treatment options.
Definition of Pelvic Inflammatory Disease
It is defined as the spectrum of inflammatory and infectious disorders of the upper genital tract, which include endometritis, salpingitis, purulent pelvic fluid collections, and pelvic peritonitis of genital origin. It is related to long-term sequelae, such as infertility and chronic pelvic pain. (1,2)
PID can be classified as uncomplicated, compatible with medical treatment, or complicated by a tubo-ovarian abscess or pelvic peritonitis requiring surgical intervention. (3)
Epidemiology of Pelvic Inflammatory Disease
More than a million women in the US are diagnosed with PID every year. (2) According to an analysis published by the CDC, approximately 2.5 million women aged between 18 and 44 nationwide have received a diagnosis of PID in their lifetime. (4)
Even though PID is not associated with high mortality, it is with high morbidity. It has been published that women diagnosed with PID between 20 to 24 years of age will develop long-term complications: 18% will suffer from chronic pain, 8.5% will develop ectopic pregnancies, and 16.8% will struggle with infertility. (5)
Over the past decade, the rates of PID have been decreasing, but its surveillance is difficult to estimate because a cheap, simple, and accurate diagnostic test does not exist. It represents a relevant healthcare issue in industrialized countries. Overall, the leading causes of PID, Chlamydia Trachomatis and Neisseria gonorrheae infections, are estimated to cost the US almost $1 billion yearly in direct medical expenses. (6)
Etiology
In 85% of cases, the infection is caused by sexually transmitted bacteria. Neisseria Gonorrhoeae and Chlamydia Trachomatis are the most common pathogens implicated, representing 50% of the cases. (7, 8) Neisseria Gonorrhoeae is associated with severe PID; in contrast, Chlamydia Trachomatis is usually asymptomatic and results in subclinical cases. The latter continues to be relevant since it can generate long-term consequences. (9)
In addition, some microorganisms that are part of the vaginal flora have been associated with PID, such as Gardnerella Vaginallis, Haemophilus Influenzae, Streptococcus Agalactieae, and enteric gram-negative rods. (8, 10) On the other hand, Cytomegalovirus, Trichomonas Vaginalis, Mycoplasma Hominis, Mycoplasma Genitalium, and Ureaplasma Urealyticum might be associated with PID. (11-13)
Screening and treating sexually active women for Chlamydia and Gonorrhea reduces their risk of PID (14,15). Although bacterial vaginosis is associated with PID, whether its incidence can be reduced by identifying and treating women with vaginosis is unclear. The same happens with screening and treatment of Mycoplasma Genitalium. (10)
Risk Factors
Risk factors for PID are relevant, especially when taking the patient’s history. The risk factors for PID include:
- Women of reproductive age,
- Age under 25 years old,
- Multiple sexual partners,
- Not using barrier contraception methods,
- Record of sexually transmitted infections.
- Previous PID episode. (2)
Pathophysiology
- PID originates from ascending microorganisms from the vagina or cervix that cause inflammatory damage along the epithelial and peritoneal surface of the fallopian tubes and ovaries. This leads to scarring, adhesion, and possibly partial or total obstruction of the fallopian tube.
- The inflammatory response from PID induces selective loss of ciliated epithelial cells along the fallopian tube epithelium, which can cause difficulties in ovum transportation resulting in infertility.
- The adaptive immune response plays a vital role in this disease and is associated with an increased risk of infertility after reinfection.
- The inflammatory response produced by PID could generate adhesions within the pelvis resulting in pelvic pain. (16)
Diagnosis and Management
Because of the variety in symptoms and signs of PID, diagnosis is difficult and usually delayed. Laparoscopic exploration is considered the gold standard, but this tool is not always available and is not justified when symptoms are mild. As a result, clinical findings are the most frequent tool for diagnosis, with a positive predictive value of 65 to 90% versus laparoscopy. (17 )
Clinical Features of Pelvic Inflammatory Disease
| Symptoms | Signs |
|---|---|
| Lower abdominal pain Vaginal discharge, usually purulent Intermenstrual or postcoital bleeding Lower back pain Dysmenorrhea Deep dyspareunia Urinary frequency Nausea/vomiting | Lower abdominal tenderness Adnexal tenderness (sometimes mass) Cervical motion tenderness Fever (>38°C /101F) |
Complementary Studies
Analysis of Vaginal Secretions
Microscopy of vaginal secretions shows >1 leukocyte per epithelial cell. Evaluation for bacterial vaginosis and trichomonas should be performed. If available, testing with nucleic acid amplification for Neisseria Gonorrhoeae and Chlamydia Trachomatis should be considered, but a negative result does not exclude PID diagnosis.
If the cervix is normal and no white blood cells are noted, a differential diagnosis should be investigated since its negative predictive value for upper genital tract infection is almost 95%. Testing for Mycoplasma Genitalium is not routinely performed. (18)
Blood tests
High white blood cells count and elevated levels of CRP or ESR can be detected. If these inflammatory markers are elevated, the specificity for PID increases. (19)
Urinalysis
It allows for ruling out differential diagnoses, such as nephrolithiasis and urinary tract infections.
Pregnancy Test
It should be done to know the woman’s current situation, help with decision-making, and rule out an ectopic pregnancy.
Ultrasound Scanning
It can be helpful if an adnexal mass is suspected, but it has limited value. Nevertheless, an increased fallopian-tube blood flow by Doppler studies is highly suggestive of infection. (20, 21)
MRI or CT scanning
They are helpful in ruling out differential diagnoses but are not mandatory. As with transvaginal ultrasound, MRI revealing thickened, fluid-filled tubes are highly specific for salpingitis. (22, 23)
Laparoscopy
Visual evidence of acute tubal inflammation (erythema, edema, and purulent exudate) could confirm approximately 65% of the acute cases of salpingitis. For patients with severe symptoms or signs of an adnexal mass, it is vital to rule out tubo-ovarian abscess by laparoscopic inspection. Examining the right upper quadrant for hepatic adhesions is mandatory during surgical diagnosis.
On the other hand, cases of acute endometritis may not be evident at the laparoscopic examination.
Differential Diagnosis
Some diagnoses that should be considered include:
- Ectopic pregnancy,
- Ovarian torsion,
- Ovarian cyst rupture,
- Endometritis,
- Pyelonephritis,
- Cystitis,
- Appendicitis,
- And diverticulitis, among others. (24)
Clinical Stages
| Stage | Clinical Features | Treatment |
|---|---|---|
| I | Salpingitis/ endometritis without peritonitis (absence of rebound tenderness) | Medical (oral antibiotics) |
| II | Salpingitis/ endometritis with peritonitis | Medical (intravenous antibiotics) |
| III | Tubo-ovarian abscess | Surgical |
| IV | Ruptured tubo-ovarian abscess or pelvic peritonitis | Surgical |
Medical Treatment for Pelvic Inflammatory Disease
The CDC recommends empiric treatment for PID in sexually active women under 25 years old with risk factors for STI if they complain of pelvic or lower abdominal pain, no other cause is identified, and if one or more of the following is appreciated on bimanual pelvic examination:
- Cervical motion tenderness,
- Uterine tenderness,
- Or adnexal tenderness. (1)
Pregnant patients, those unable to tolerate oral treatment or with severe symptoms that suggest the need for surgical treatment, should be hospitalized. (16)
Oral Treatment
It should be considered for patients with mild to moderate acute PID. Patients should receive intravenous therapy in the absence of clinical response after 72 hours.
| Parental third-generation cephalosporin
+ Doxycycline 100 mg orally twice/day for 14 days + Metronidazole 500 mg orally twice/day for 14 days |
| Ceftriaxone IM 500 mg single dose
+ Doxycycline 100 mg orally twice/day for 14 days + Metronidazole 500 mg orally twice/day for 14 days |
| Cefoxitin 2 gr IM with Probenecid orally single dose
+ Doxycycline 100 mg orally twice/day for 14 days + Metronidazole 500 mg orally twice/day for 14 days |
Intravenous Treatment
| Ceftriaxone 1 gr IV every 24 hours
+ Doxycycline 100 mg orally or IV twice/day + Metronidazole 500 mg orally or IV twice/day |
| Cefotetan 2 gr IV twice/day
+ Doxycycline 100 mg orally or IV twice/day
|
| Cefoxitin 2 gr IV twice/day
+ Doxycycline 100 mg orally or IV twice/day |
| Ampicillin- sulbactam 3 gr every 6 hours
+ Doxycycline 100 mg orally or IV twice/day |
| Clindamycin 900 mg every 8 hours
+ Gentamicin loading dose (2 mg/kg) followed by maintenance (1,5 mg/kg) every 8 hours |
Considerations for Medical Therapy for Pelvic Inflammatory Disease
- Oral or intravenous doxycycline and metronidazole have similar bioavailability. Intravenous doxycycline is associated with pain during infusion, so it is recommended orally when possible.
- The last two enumerated regimens are considered alternatives because they have fewer scientific records.
- After 48 hours of clinical improvement with parenteral treatment, a transition to oral therapy should be indicated.
- It is vital to explain the importance of abstention from sexual intercourse and treatment of sexual partners to reduce disease transmission. (16)
Surgical Treatment for Pelvic Inflammatory Disease
As mentioned, surgical treatment is indicated for PID grades 3 and 4. This indication is based on clinical findings, complementary studies, and the lack of response to medical therapy. Some possible things that should be performed are:
- Washing,
- Abscess drainage,
- Salpingectomy,
- Oophorectomy,
- And adhesiolysis. (25)
A laparoscopic approach should be preferred when possible.
Complications
- Infertility rates following PID can be high, such as in the USA, where rates may vary from 21.3% to 55.6%. (9, 26) It is more likely to occur if Chlamydia is related, treatment is delayed, the patient has recurrent episodes of PID, or in severe cases. (5)
- PID increases the risk of ectopic pregnancy since this infection affects the fallopian tubes. The latter was shown in a cohort study that included 2501 women who underwent laparoscopic examination for acute salpingitis, and it concluded that fallopian tube infection was a major risk factor for first ectopic pregnancy. (27) In addition, a retrospective cohort study using the Taiwan National Health Insurance Database examined 30450 patients with PID, concluding that patients between 12 and 19 years have the highest risk of developing ectopic pregnancy and preterm labor than other age groups. (28)
- Chronic pelvic pain is evident in one-third of women. As mentioned above, it is related to inflammation, scarring, and adhesions generated by this infection. The most important predictor for developing this type of pain is associated with recurrent PID. (5)
- Perihepatitis, or Fitz-Hugh-Curtis syndrome, is a chronic manifestation of PID. It is an inflammation of the liver capsule with adhesion formation that generates right upper quadrant pain. The pain usually worsens with movement and breathing, mimicking other acute abdominal pathologies. Diagnosis can be made through laparoscopy or laparotomy with direct visualization of violin string-like adhesions or through hepatic capsular biopsy and culture. (29)
Disclosures
The author does not report any conflict of interest.
Disclaimer
This information is for educational purposes and is not intended to treat disease or supplant professional medical judgment. Physicians should follow local policy regarding the diagnosis and management of medical conditions.
See Also
Distal Radius Fractures in Adults
Diagnosis and Management of Vulvovaginitis
Diagnosis and Management of Anaphylaxis in Adults
Acute Uncomplicated Pyelonephritis in Adults
Initial Management of Hip Fractures in Adults
Community Acquired Pneumonia in Adults
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