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PELVIC INFLAMMATORY DISEASE (PID)

Pelvic inflammatory disease (PID) is an ascending infection of the upper female genital tract involving the endometrium, Fallopian tubes, ovaries and pelvic peritoneum.

It is a major public health problem very common in sexually active women of all ages. PID results from multiple bacterial infection from the vagina and cervix upwards especially if not treated properly. Sources of these infections can include

  • Sexually Transmitted Infections from introduction of foreign body like intrauterine contraceptive devices, hysterosalpingogram, tubal insufflation, dilatation and curettage, and pregnancy interruption.
  • Pelvic infection following major gynaecological surgeries.
  • Puerperal (after birth) and post arbotal infections.
  • Septic pelvic thrombophlebitis.
  • Primary pathology in the gastrointestinal tract spreading to the pelvis
  • Tuberculosis can also spread to the genital tract to cause PID.

What are the risk factors for developing PID?

  • All sexually active women especially below age 25
  • Women with multiple sex partners
  • Young nulliparous (have never given birth)
  • Women who use intrauterine contraceptive devices
  • Women of lower socioeconomic class
  • Vaginal douching (irrigation)
  • Sex during menstruation
  • Preexisting infection like bacterial vaginosis

What are the causes of PID?

The aetiological causes of PID include both aerobic and anaerobic bacterial spectrum. The most common pathogens responsible for over 75% – 90% of all PID cases are N. Gonorrhoea and C. Trachomatis. Others include

  • Gardnerella Vaginalis
  • Gram -ve enterobacteriae
  • E. Coli
  • Proteus
  • Klebseilla
  • Group B Streptococcus
  • Peptostreptococcus
  • Mycoplasma Hominis and Mycoplasma Genitalis
  • Ureaplasma
  • Mycobacterium Tuberculosis

Clinical features of PID

  • Can be subtle or asymptomatic
  • May present with fever 38 degrees Celsius or more
  • Foul vaginal discharge
  • Dyspaurenia
  • Irregular menses
  • Unilateral or bilateral abdominal tenderness and /or rebound tenderness
  • Cervical motion or excitation tenderness
  • Adnexal or uterine tenderness

How PID is diagnosed

It is important to first rule out other differential diagnoses of PID including, cervicitis, UTI, Appendicitis, endometriosis, ectopic pregnancy, adnexal tumours, hemorrhagic or ruptured ovarian cyst, ovarian torsion, gastroenteritis, peritonitis and bacterial vaginosis.

The gold standard for diagnosing PID is laparoscopy following clinical signs and symptoms. Other lab investigations used for the diagnosis of PID are

  • Ultrasound scan may show pus in pouch of douglas or adnexal masses which may be unilateral or bilateral.
  • FBC showing leucocytosis
  • Cervical exudates tested C. Trachomatis and Gram -ve intracellular dibococci.
  • VDRL test for syphilis
  • ESR and C-Reactive protein
  • CT and MRI can also be done

How PID is treated

PID is treated with a combination of antibiotics for both in-patient and out-patient cases. Treatment is often started without confirmation of infection because of the serious complications that can follow delayed treatment.

Regimen combination for in-patients can be one of the following :

  • Cefotetan or cefoxitin plus doxycycline for 14days
  • Clindamycin plus gentamycin for 14 days
  • Ampicillin plus gentamycin plus clindamycin for 14days

Out-patient regimen combination can be one of the following

  • Ciprofloxacin plus doxycycline plus metronidazole/clindamycin for 14days
  • Ceftriaxone or cefoxitin plus doxycycline for 14days
  • Ofloxacin plus metronidazole for 14days

Complications of PID

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Tubal abscess resulting from pelvic inflammatory disease

  • Tubo ovarian abscess
  • Fitz Hugh Curtis syndrome (perihepatitis)
  • Septic abortion
  • Intrauterine growth retardation
  • Premature rupture of membrane
  • Preterm delivery
  • Infertility
  • Ectopic pregnancy
  • Pelvic peritonitis

How to prevent PID

  • Abstinence from sex or reducing sex partners or have on sex partner (sexual monogamy)
  • Using barriers like condoms
  • Regular screening for chlamydia infection and others in women of high risk
  • Treating women’s sexual partners

 

REFERENCE

wikipedia : “pelvic inflammatory disease ”

S. Campbell, A. Monga (2006), “pelvic inflammatory disease ” Gynaecology by Ten Teachers, 18th edition.

P. Chan, S. Johnson (2008), “pelvic inflammatory disease ” Gynaecology and Obstetrics, 2008 edition.

 

 

 

 

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