Pelvic Inflammatory Disease
What is Pelvic Inflammatory Disease?
Pelvic inflammatory disease (PID) pertains to the infection of the reproductive organs in women. It is a common and serious complication arising from sexually transmitted diseases (STDs), especially chlamydia and gonorrhea. PID can damage the fallopian tubes as well as tissues in and around the uterus and ovaries. If left untreated for a long time, PID can lead to more serious problems like infertility, ectopic pregnancy (a pregnancy outside the womb), etc.
Symptoms of Pelvic Inflammatory Disease
Symptoms of PID may vary from negligible to severe. In a woman with PID, her reproductive organs are being severely damaged but she may experience mild symptoms or no symptoms at all. Therefore, PID goes unrecognized by women and their healthcare providers about two thirds of the time. Women who have symptoms of PID have problems like:
01) Lower abdominal pain
02) Pain in the right upper abdomen
03) Fever
04) Cervical motion tenderness
05) Unusual vaginal discharge with foul odor
06) Painful intercourse
07) Painful urination
08) Irregular menstrual bleeding
09) Tissue necrosis (premature or unnatural death of cells and living tissue)
10) Abscess formation
11) Pus formation in the peritoneum
12) Ectopic pregnancy (fetus grows in fallopian tubes).
Diagnosis of Pelvic Inflammatory Disease
It is important to note that pelvic inflammatory disease (PID) can occur and cause serious harm without showing any noticeable symptoms, hence diagnosing the disease as early as possible is very essential. No single test has the required sensitivity and specificity to diagnose PID. But research studies show that cervical motion tenderness could be a criterion for suggesting further investigations for PID.
Because there are no precise tests for PID, a diagnosis is usually based on clinical findings. If symptoms such as lower abdominal pain are present, a health care provider would perform a physical examination to determine the nature and location of the pain. A check for fever, abnormal vaginal or cervical discharge, for evidence of gonorrheal or chlamydial infection is carried out to determine whether PID treatment is necessary. Yet, various methods are used for diagnosis because PID occurs subsequent to other existing disease:
1) Medical history: The doctor needs to ask the patient detailed questions about her sex partners, frequency of sex, whether Intrauterine device (IUD) is inserted, previous incidents of PID, signs or history of STDs, etc. PID is more likely to occur when there is recent sexual contact, multiple sexual partners, recent onset of menses or an IUD in place or even if the sex partner has a sexually transmitted disease.
2) Pregnancy test: A sensitive serum pregnancy test should be carried out to rule out ectopic pregnancy, hemorrhagic ovarian cyst, etc which could cause PID.
3) Ultrasounds: Pelvic and vaginal ultrasounds are useful to identify PID caused by ectopic pregnancy of over six weeks. An ultrasound can view the pelvic area to see whether the fallopian tubes are enlarged or whether an abscess is present.
4) Laparoscopy: Laparoscopy is a minor surgical procedure. A thin, flexible tube with a lighted end (laparoscope) is inserted through a small incision in the lower abdomen. This helps to view the internal pelvic organs and to take specimens for laboratory studies, if necessary.
Laparoscopic identification is helpful in diagnosing disease of the fallopian tubes and the test gives almost 90% accurate test results in patients with suspected PID. Laparoscopy is absolutely essential if the diagnosis is not certain or if the patient has not responded to antibiotic therapy for pelvic pain for 48 hours.
5) Gram-stain/smear: This is done despite Laparoscopy because it is important in identifying any more serious organisms that might be present.
Causes of Pelvic Inflammatory Disease
Pelvic Inflammatory Disease is a broad term and can refer to viral, fungal, parasitic infections. But bacterial infections are the most common causes of PID. PID occurs when these organisms move upward from a woman’s vagina or cervical opening into her reproductive organs namely the fallopian tubes, uterus and ovaries. The women who are most at risk from PID are:
Prior episode of PID: Women who have experienced a prior episode of PID are at greater risk from another episode because the reproductive organs have already been damaged during the initial infection.
Young women under 25 years of age: Sexually active women in their childbearing years are most at risk from PID than sexually active older woman. They are more susceptible to STDs which cause PID because the cervix of young women is not fully matured.
More than one sex partner: If a woman has more than one sex partner; or if her partner indulges in sex with other women, she is at greater risk of developing PID. This is because of the greater exposure to potential infections.
Douching: Douching refers to vaginal irrigation or rinsing of the vagina. Women who douche may have a higher risk of developing PID compared with women who do not, especially if the douche bag is reused. Also, research has shown that douching changes the organisms that live in the vagina in harmful ways. This can force bacteria from the vagina into the upper reproductive organs.
Intrauterine device (IUD): An intrauterine device, also known as a coil, is a birth control device. Women who have the device inserted in the uterus are slightly more at risk from PID in the areas around the insertion in comparison with women using oral contraceptives or no contraceptive at all. However, this risk is greatly reduced if a woman is tested for STDs before an IUD is inserted.
Types of Pelvic Inflammatory Disease
PID has to be classified by affected organs, the stage of the infection, and the organism/organisms causing it. Other diseases that are involved in PID are:
1) Salpingitis – Any infection of the fallopian tubes
2) Tubo-ovarian abscess – An abscess of the fallopian tube and ovary
3) Endometritis – Inflammation of the inner lining of the uterus
4) Pelvic Peritonitis – Infective scar tissue in the external surface of the liver. This is also called Fitz-Hugh-Curtis Syndrome
5) Bacterial Vaginosis – An imbalance of naturally occurring bacterial flora in the vagina
Treatment of Pelvic Inflammatory Disease
Treatment of PID is carried out empirically because of the various complications. The criteria for type of treatment would depend on evidence of Endometritis, thickened fallopian tubes or other laparoscopic findings.
Antibiotics: Treatment depends on the cause of PID and is treated by the use of suitable antibiotics. These drugs can be administered orally and consumed at home as prescribed by the attending gynecologist. Sometimes, more than one organism may be responsible for PID, in which case at least two broad-spectrum antibiotics are used. The symptoms may go away before the infection is cured, but the woman should finish taking all the prescribed medicine to completely cure the disease.
Antibiotic treatment does not reverse existent damage to the reproductive organs, but prompt antibiotic treatment can prevent further damage to reproductive organs. The longer a woman delays treatment of PID, the more likely she is to become infertile or to have a future ectopic pregnancy because of damage to the fallopian tubes.
Hospitalization: Evidence suggests that neither site nor route of antibiotic administration affects the short or long-term major outcome of women with mild or moderate PID. But if the condition has not improved within two to three days after beginning treatment with the antibiotics, they should return to the hospital for further treatment. Hospitalization to treat PID may be recommended if the patient shows severe symptoms of nausea, vomiting, high fever, and pregnancy or if she does not respond to oral antibiotics or if a life-threatening condition cannot be ruled out.
In this case, the antibiotics will be administered intravenously. This will help prevent the infection from returning. Women being treated for PID should be re-evaluated by their health care provider two to three days after starting treatment to be sure the antibiotics are working to cure the infection.
Partner’s treatment: In addition, a woman’s sex partner/partners should be treated to decrease the risk of re-infection. Although sex partners may have no symptoms, they may still be infected with the organisms that can cause PID.
Living with Pelvic Inflammatory Disease
Prompt and appropriate treatment can help prevent complications of PID. Delayed treatment can cause permanent damage to the female reproductive organs. If the initial infection is mostly in the lower tract, after treatment the person may have few difficulties. If the infection is in the fallopian tubes or ovaries, more serious complications are likely to occur.
The effects of neglecting PID are:
Infertility: When bacteria cause infection of the fallopian tubes, the healthy tissues become scar tissues. This scar tissue blocks or interrupts the normal movement of eggs into the uterus. When the scar tissues become excessive, they completely block the fallopian tubes. This prevents the sperm from fertilizing the egg, causing infertility. Slight scarring or a small blockage of the fallopian tubes can also cause infertility. If a woman has multiple episodes of PID she is even more at risk from infertility. In-vitro fertilization (IVF) then has to be used in order to bypass tubal problems if the patient wants to have a child.
Ectopic pregnancy: A fertilized egg may sometimes not move on to the uterus but start growing in the fallopian tubes because of some damage or blockage of the tubes. This is called an ectopic pregnancy. This ruptures the fallopian tubes resulting in internal bleeding, severe pain, and in some cases death.
Prevention of Pelvic Inflammatory Disease
Any genital symptoms like sores, unusual discharge with odor, bleeding out-of-schedule in the menstrual cycle or burning during urination would indicate an STD infection. If a woman has any of these symptoms, she must stop having sex and consult a health care provider immediately. Early treatment of STDs can prevent PID. Sexual activity should not resume until all sex partners too have been examined and treated if necessary.
There are various other preventive measures for PID:
1) Anyone with PID or partners of patients with PID since six months prior to diagnosis should be treated to prevent re-infection.
2) Psychotherapy is important for a patient to clarify any recurrent issues or uncertainties with a gynecologist and seek follow-up care.
3) Regular screening for STDs of women who are at risk like those who have multiple partners, who indulge in unprotected sex or people with STD symptoms should be carried out.
4) The surest way to avoid transmission of STDs is to abstain from sexual intercourse with the infected person.
5) Latex male condoms, when used consistently and correctly, can reduce the risk of transmission of STDs like chlamydia and gonorrhea which could lead to PID.
6) An appropriate sexual risk assessment by a health care provider should always be conducted and may indicate more frequent screening for sexually active women of 25 years of age and younger.
Each year in the United States alone it is estimated that more than 1 million women experience an episode of acute PID. PID is the major cause of the number of infertility cases in women and a large proportion of ectopic pregnancies in a year. Annually more than 150 women die from PID or its complications. Hence, treatment and prevention of PID is a major concern for health care providers globally.
