Pelvic inflammatory disease (PID)

كلية الطب ? جامعة بابل المرحلة الخامسة
د-نسرين مالك
Gynaecology

Pelvic inflammatory disease (PID)
Is an infection and inflammatory disorder of the upper female genital tract, including the uterus, fallopian tubes, and adjacent pelvic structures. Infection and inflammation may spread to the abdomen, including perihepatic structures (Fitz-Hugh?Curtis syndrome).

Risk factors of pelvic inflammatory disease include:-
1-Having sex and being under the age of 25.
2-Sex with more than one person.
3-Having sex without a condom.
4-Using an intrauterine device (IUD).
5-Vaginal douching. A clear association can be seen between vaginal douching and PID but more recent longitudinal studies suggest that douching does not cause PID
6-Smooking.
7-History of pelvic inflammatory disease.

PID is initiated by infection that ascends from the vagina and cervix into the uterus, fallopian tubes, and adjacent pelvic structures, leading to cervisitis, endometritis , pyometra ,hydrosalpinx ,pyosalpinx ,perioophoritis , oophoritis, tubo-ovarain abscess and peritonitis. Chlamydia trachomatis is the predominant sexually transmitted organism associated with PID and less frequently of gonorrhoea. Other organisms Aerobic/facultative anaerobic , Anaerobic and viruses are implicated in the pathogenesis of PID include., Mycobacterium tuberculosis, Ureaplasma urealyticum,Mycoplasm genitalium, Gardnerella vaginalis, mStreptococcus pyogene , Bacteroides sp, Peptostreptococcus sp,Clostridium bifermentans,Herpes simplex virus, Echovirus, Coxsackievirus, and Respiratory syncytial virus. Laparoscopic studies have shown that in 30-40% of cases PID is polymicrobial.



Clinical features:- Clinical manifestations of PID vary widely,
Some women with pelvic inflammatory disease don’t have symptoms. For the women who do have symptoms, these can include:-
1- Bilateral lower abdominal pain (the most common symptoms).
2-Pain in the upper abdomen.
3-Fever and tiredness.
4-Dyspareunia.
5-Painful urination.
6-Irregular uterine bleeding and\or post coital bleeding.
7-Increased or foul-smelling vaginal discharge(altered vaginal discharge).

Some women have severe pain and symptoms, such as
1-Sharp pain in the abdomen. 2-Vomiting.
3-Fainting. 4- High fever.

If there are severe symptoms, the patient should be refer to the emergency department. The infection may have spread to the blood stream or other parts of the body. Once again, this can be a life-threatening. PID may produce tubo-ovarian abscess (TOA) and may progress to peritonitis and Fitz-Hugh?Curtis syndrome (perihepatitis) is a rare but life-threatening complication. The acute rupture of a TOA may result in diffuse peritonitis and necessitate urgent abdominal surgery.

On physical examination:-There may be vaginal or cervical discharge, cervical motion tenderness
( often called cervical excitation) with or without uterine and adnexal tenderness.

The differential diagnosis :-includes
1-Ovarian cyst torsion or rupture. 6- Adnexal tumors.
2-Ectopic pregnancy 7- Appendicitis
3- Urinary tract infection 8-Irritable bowel syndrome
9-Inflammatry bowel diseases. 4- Endometriosis.
5- Cervicitis. 10-Psuchosomatic pain. .


Diagnosis of PID :-
1-History by asking about the risk factor and symptoms, and pelvic exam to check pelvic organs.
2- Screen for all STIs. NAAT for Trichomonas vaginalis from a vulvo?vaginal sample endocervical swab for N. gonorrhoeae culture, and NAAT for chlamydia trachomatis.
3-Pregnancy test to exclude ectopic pregnancy , urine test to check for signs of infection.
4-Pelvic ultrasound.
5- computed tomography [CT], and magnetic resonance imaging [MRI].
6-Laparoscopy-Laparoscopy is the current criterion standard for the diagnosis of PID, which reveal scarring and adhesion formation between the structures of the pelvis and the development of hydrosalpinges of the tubes. Violin-string" adhesions of chronic Fitz-Hugh-Curtis syndrome can be seen by laparoscopy.
No single laboratory test is highly specific or sensitive for the disease, but studies that can be used to support the diagnosis include the erythrocyte sedimentation rate (ESR), the C-reactive protein (CRP) level, and chlamydial and gonococcal DNA probes and cultures. Imaging studies (eg, ultrasonography, computed tomography [CT], and magnetic resonance imaging [MRI]) may be helpful in unclear cases, and not use as a routine investigations in diagnosis of PID .Endometrial biopsy may be useful in cases of suspected tuberculosis,and it may have the risk of introducing infection during the procedure.

Treatment:-
Most patients with PID are treated in an outpatient setting in cases of mild presentation . In selected cases, however, physicians should consider hospitalization.
Antibiotics to treat PID:- usually give two different types of antibiotics to treat a variety of bacteria. they usually include a macrolide or tetracycline plus metronidazole with a parenteral third-generation cephalosporin at the start. Within a few days of starting treatment, symptoms may improve or go away. However, treatment course should completed 2 weeks, even if feeling better. Stopping the medication early may cause the infection to return.
Out patient antibiotic regimen :Ceftriaxone 500 mg intramuscularly, plus doxycycline 100 mg twice daily, plus metronidazole 400 mg twice daily.

Inpatient antibiotic regimen:-for those who are severely ill ,use one of the following regimens:-
I.v Ceftriaxone 2 g daily, plus i.v or oral doxycycline 100 mg twice daily, followed by oral doxycycline 100 mg twice daily plus metronidazole 400 mg twice daily.

For all regimens parenteral therapy should be continued until 24 h after clinical improvement. Oral therapy should be continue to complete 14 days of antibiotics in total.
If an intrauterine device (IUD) is in situ it is advisable to consider removing this although the risk of pregnancy if there has been unprotected sex in the last week should be considered.

Pelvic inflammatory disease may require surgery. This is rare and only necessary if an abscess in the pelvis ruptures or there is suspicion that an abscess will rupture. It can also be necessary if the infection does not respond to treatment.
Management of the male partners of women with pelvic infection:-
1-Test for gonorrhea and Chlamydia.
2- Give empirical therapy for gonorrhea and Chlamydia if testing is not available .
3-Advice to avoid intercourse until index patient and male partner have both completed antibiotic therapy.

Prevention:-Ways to Prevent Pelvic Inflammatory Disease:-
1-Practicing safe sex.
2-Getting tested for sexually transmitted infections.
3-Avoiding vaginal douches.
4-Wiping from front to back after using the bathroom or after defecation to stop bacteria from entering the vagina.
Complications:- Long-term complications of pelvic inflammatory disease are:-
1-Infertility. 2-Ectopic pregnancy.
3-Chronic pelvic pain: pain in the lower abdomen caused by scarring of the fallopian tubes and other pelvic organs.
4-The infection can also spread to other parts of the body if it spreads to the blood. Right upper quadrant pain due to perihepatitis is an unusual complication called Fitz-Hugh–Curtis syndrome


References:-1-Margaret Kingston, Genitourinary problems Gynecology by Ten Teachers, 2 0th Edition ,9,177-195.
2-Jonathan D.C. Ross, Acute Pelvic Infection,Dewhurst’s Textbook of Obstetrics & Gynaecology Ninth Edition ,2018;45: 611-620.