Pelvic Inflammatory Disease: Symptoms, Causes, Treatment

What are the symptoms of pelvic inflammatory disease?

Pelvic inflammatory disease (PID) is an infection of the female reproductive organs, including the uterus, fallopian tubes, and ovaries. The symptoms of PID can vary widely; some women may have mild or no symptoms, while others may experience severe symptoms. Common symptoms of PID include:

1. Pelvic Pain:

• Lower Abdominal Pain: Often described as a dull or aching pain in the lower abdomen and pelvic area.
• Pain During Intercourse: Discomfort or pain during sexual intercourse (dyspareunia).

2. Abnormal Vaginal Discharge:

• Unusual Discharge: Increased vaginal discharge that may have an unusual color (yellow, green, or gray) or odor.

3. Menstrual Irregularities:

• Irregular Periods: Changes in the menstrual cycle, such as spotting or bleeding between periods.
• Heavier or Longer Menstrual Bleeding: Menorrhagia, or abnormally heavy or prolonged menstrual bleeding.

4. Urinary Symptoms:

• Painful Urination: Dysuria, or discomfort during urination.

5. Systemic Symptoms:

• Fever and Chills: Elevated body temperature and chills, indicating infection.
• Nausea and Vomiting: Some women may experience gastrointestinal symptoms.

6. Other Symptoms:

• Painful Bowel Movements: Discomfort during defecation.
• Fatigue: General feeling of tiredness or malaise.

7. Severe Symptoms (in advanced cases):

• Severe Lower Abdominal Pain: Intense pain that may require immediate medical attention.
• Signs of Sepsis: In rare and severe cases, PID can lead to sepsis, characterized by symptoms like rapid heartbeat, rapid breathing, low blood pressure, and confusion.

Asymptomatic Cases:

• It’s important to note that some women with PID may not exhibit any symptoms, particularly in the early stages. Asymptomatic PID can still cause damage to the reproductive organs and lead to complications such as infertility, chronic pelvic pain, and ectopic pregnancy.

When to Seek Medical Attention:

• Women experiencing any of the above symptoms, especially pelvic pain, abnormal discharge, or fever, should seek medical attention promptly. Early diagnosis and treatment are crucial to prevent long-term complications.

What are the causes of pelvic inflammatory disease?

Pelvic inflammatory disease (PID) is primarily caused by bacterial infections that ascend from the lower genital tract (vagina and cervix) to the upper genital tract (uterus, fallopian tubes, and ovaries). The main causes include:

1. Sexually Transmitted Infections (STIs):

• Chlamydia trachomatis: One of the most common causes of PID. Chlamydia often has no symptoms, which can lead to undiagnosed and untreated infections that result in PID.
• Neisseria gonorrhoeae: Another common STI that can cause PID. Gonorrhea can also be asymptomatic in many cases.

2. Non-Sexually Transmitted Infections:

• Normal Vaginal Flora: Bacteria normally present in the vagina, such as Gardnerella vaginalis, Haemophilus influenzae, and anaerobes, can sometimes cause PID, especially after procedures that disturb the cervical barrier.

3. Medical and Surgical Procedures:

• Endometrial Biopsy: A procedure to remove a small tissue sample from the lining of the uterus.
• Insertion of Intrauterine Device (IUD): The process of placing an IUD can occasionally introduce bacteria into the upper genital tract.
• Dilation and Curettage (D&C): A procedure to remove tissue from the inside of the uterus.
• Abortion: Either spontaneous (miscarriage) or induced, can be a risk factor if an infection develops.

4. Postpartum Infections:

• Postpartum Endometritis: Inflammation of the endometrium after childbirth can lead to PID, especially if there is a retained placenta or if the delivery was complicated.

5. Risk Factors:

• Multiple Sexual Partners: Having multiple partners increases the risk of acquiring STIs that can lead to PID.
• History of STIs or PID: Previous infections increase the risk of recurrent PID.
• Douching: Douching can alter the normal vaginal flora and increase the risk of infection.
• Young Age: Younger women, particularly teenagers, are at higher risk due to behavioral and biological factors.
• Inconsistent Condom Use: Lack of barrier protection increases the risk of acquiring STIs.

6. Bacterial Vaginosis (BV):

• BV, characterized by an imbalance in the normal vaginal flora, can increase the risk of PID.

Summary:

PID is most commonly associated with STIs, particularly chlamydia and gonorrhea. However, other bacteria, medical procedures, and certain risk factors can also contribute to the development of PID. Preventative measures, such as practicing safe sex, regular STI screenings, and proper hygiene, are important for reducing the risk of PID.

How is the diagnosis of pelvic inflammatory disease made?

The diagnosis of pelvic inflammatory disease (PID) involves a combination of clinical evaluation, laboratory tests, and imaging studies. The diagnosis is often based on clinical criteria because there is no single definitive test for PID. The process typically includes:

1. Medical History and Physical Examination:

• Medical History: The healthcare provider will ask about symptoms (such as pelvic pain, abnormal vaginal discharge, fever), sexual history, contraceptive use, history of STIs, and previous episodes of PID.
• Physical Examination: A pelvic exam is conducted to assess for tenderness in the lower abdomen, cervix, uterus, and adnexa (ovaries and fallopian tubes). Key findings suggestive of PID include:
  • Cervical Motion Tenderness: Pain when the cervix is moved during the pelvic exam.
  • Uterine Tenderness: Pain upon palpation of the uterus.
  • Adnexal Tenderness: Pain upon palpation of the ovaries and fallopian tubes.

2. Laboratory Tests:

• Tests for STIs: Swabs are taken from the cervix or vagina to test for chlamydia and gonorrhea. Nucleic acid amplification tests (NAATs) are commonly used for their high sensitivity.
• Complete Blood Count (CBC): To assess for signs of infection, such as elevated white blood cell count.
• Erythrocyte Sedimentation Rate (ESR) or C-Reactive Protein (CRP): Elevated levels may indicate inflammation or infection.
• Pregnancy Test: To rule out ectopic pregnancy, which can present with similar symptoms.
• Microscopy of Vaginal Discharge: To assess for the presence of white blood cells, which may indicate infection.

3. Imaging Studies:

• Transvaginal Ultrasound: Used to evaluate the pelvic organs for signs of PID, such as thickened, fluid-filled fallopian tubes (hydrosalpinx), tubo-ovarian abscesses, or free pelvic fluid.
• MRI or CT Scan: Occasionally used to provide more detailed images or in complicated cases, such as when an abscess is suspected.

4. Laparoscopy:

• Laparoscopy: A surgical procedure involving the insertion of a camera into the pelvic cavity through a small incision in the abdomen. It is considered the gold standard for diagnosing PID because it allows direct visualization of the pelvic organs. However, it is typically reserved for uncertain cases or when complications such as abscess formation are suspected.

5. Endometrial Biopsy:

• Endometrial Biopsy: In some cases, a biopsy of the endometrium (lining of the uterus) may be performed to detect endometritis, which can be associated with PID.

Clinical Diagnosis:

Given the potential variability of symptoms and the lack of a specific test for PID, the Centers for Disease Control and Prevention (CDC) suggest that clinicians should have a low threshold for diagnosing PID. The minimum clinical criteria for diagnosing PID include the presence of lower abdominal or pelvic pain along with one or more of the following on pelvic examination:

• Cervical motion tenderness
• Uterine tenderness
• Adnexal tenderness

Additional criteria, such as the presence of fever, abnormal cervical or vaginal discharge, or elevated inflammatory markers, can increase the specificity of the diagnosis.

Summary:

Diagnosis of PID is primarily clinical, based on symptoms, physical examination findings, and laboratory tests. Imaging and, in certain cases, laparoscopy may be used to confirm the diagnosis or assess for complications. Early diagnosis and treatment are crucial to prevent long-term complications such as infertility and chronic pelvic pain.

What is the treatment for pelvic inflammatory disease?

The treatment of pelvic inflammatory disease (PID) typically involves the use of antibiotics to eliminate the infection, relieve symptoms, and prevent complications. The choice of antibiotics and treatment duration may vary depending on the severity of the infection, the specific organisms involved, and whether the patient is pregnant. In some cases, hospitalization or surgical intervention may be necessary. Here’s an overview of the treatment approaches:

1. Antibiotic Therapy:

• Empirical Antibiotic Regimen: Treatment is often initiated empirically, without waiting for test results, because of the potential for serious complications if treatment is delayed. The antibiotic regimen should cover the most common pathogens, including Neisseria gonorrhoeae, Chlamydia trachomatis, anaerobes, Gram-negative facultative bacteria, and streptococci.
• Oral Antibiotics: For mild to moderate cases, oral antibiotics are usually sufficient. Common regimens include:
  • Ceftriaxone (single intramuscular dose) plus doxycycline (oral, typically for 14 days), with or without metronidazole (oral, typically for 14 days).
• Intravenous (IV) Antibiotics: For severe cases, patients who are pregnant, or those who cannot tolerate oral medications, IV antibiotics may be necessary. A common regimen includes:
  • Cefoxitin or cefotetan (IV) plus doxycycline (oral or IV).
  • Alternatively, clindamycin plus gentamicin can be used, especially if anaerobic bacteria are suspected.

2. Hospitalization:

• Criteria for Hospitalization: Hospitalization may be recommended for patients with severe illness, suspected abscess, inability to tolerate oral medications, pregnancy, or lack of response to outpatient treatment.
• IV Antibiotic Therapy: In the hospital, IV antibiotics are administered, and the patient is closely monitored. The regimen may be adjusted based on clinical response and laboratory findings.

3. Follow-Up Care:

• Reevaluation: Patients should be reexamined within 48-72 hours after starting treatment to assess their response. If there is no clinical improvement, further evaluation and possible change in therapy are necessary.
• Test of Cure: For Chlamydia trachomatis and Neisseria gonorrhoeae infections, a test of cure may be performed several weeks after completion of treatment to ensure the infection has been eradicated.

4. Surgical Intervention:

• Tubo-Ovarian Abscess: If a tubo-ovarian abscess (TOA) is present and does not respond to antibiotics, drainage (via ultrasound-guided aspiration, laparoscopy, or laparotomy) may be necessary.
• Surgery for Complications: In rare cases, severe PID with complications such as abscess rupture may require surgical intervention.

5. Treatment of Sexual Partners:

• Partner Notification and Treatment: Sexual partners of women with PID should be notified, evaluated, and treated for STIs, especially if Neisseria gonorrhoeae or Chlamydia trachomatis is identified. This prevents reinfection and further transmission.

6. Prevention and Education:

• Safe Sex Practices: Educating patients about the use of condoms and the importance of regular STI screening can help prevent PID.
• Avoiding Douching: Patients should be advised against douching, as it can disrupt the normal vaginal flora and increase the risk of PID.

7. Management of Chronic Symptoms:

• Chronic Pelvic Pain: Some women may develop chronic pelvic pain after an episode of PID. Management may include pain relievers, physical therapy, and in some cases, surgical intervention.

Summary:

Prompt and appropriate antibiotic treatment is essential for PID to prevent complications such as chronic pelvic pain, infertility, and ectopic pregnancy. Patients should follow their healthcare provider’s recommendations closely and complete the full course of antibiotics. Follow-up care is important to ensure the infection has been fully treated.