Pelvic Inflammatory Disease (PID) is an infection of the female upper genital tract, including the uterus, fallopian tubes, ovaries, and surrounding pelvic structures. It is a serious complication of sexually transmitted infections (STIs), mainly caused by Chlamydia trachomatis and Neisseria gonorrhoeae, though other microorganisms can be involved. If untreated, PID can lead to chronic pelvic pain, infertility, and ectopic pregnancy.
Pathophysiology
- Ascending Infection: PID typically results from an ascending infection that begins in the lower genital tract (vagina and cervix) and moves upwards through the uterus to the fallopian tubes and ovaries. The infection can spread to the surrounding pelvic tissues and even the peritoneum.
- Inflammatory Response: The body’s immune response to the infection causes inflammation of the affected organs, leading to tissue damage, scarring, and adhesions.
- Fallopian Tubes: Tubal inflammation (salpingitis) is common and can lead to tubal blockage or narrowing.
- Peritoneal Spread: The infection may extend to the peritoneum (peritonitis), leading to the formation of abscesses (tubo-ovarian abscess) or adhesions within the pelvis.
Etiology
- Sexually Transmitted Infections (STIs): Most cases are linked to Chlamydia and Gonorrhea, though bacterial vaginosis-associated organisms (e.g., Gardnerella vaginalis) and anaerobes may also be involved.
- Iatrogenic Factors: PID can also follow gynecologic procedures that breach the cervical barrier (e.g., intrauterine device (IUD) insertion, endometrial biopsy, or dilation and curettage).
- Other Causes: Postpartum infections, post-abortion complications, and rarely, hematogenous spread (from systemic infections like tuberculosis).
Clinical Presentation
- Lower Abdominal Pain: Typically bilateral and gradual in onset, worsening over time.
- Abnormal Vaginal Discharge: Purulent or mucopurulent discharge, often associated with cervicitis.
- Fever, Chills: May accompany more severe infection.
- Dyspareunia (Pain during intercourse): A common symptom of PID.
- Dysuria: May occur if the infection involves the urinary tract.
- Menstrual Irregularities: Abnormal bleeding or spotting, especially post-coital bleeding.
Physical Examination Findings
- Cervical Motion Tenderness (Chandelier Sign): Pain upon movement of the cervix during bimanual examination.
- Adnexal Tenderness: Tenderness in the areas of the ovaries and fallopian tubes.
- Uterine Tenderness: The uterus may be painful upon palpation.
Diagnosis
Clinical Diagnosis: Based primarily on history and physical exam findings, particularly cervical motion tenderness, uterine tenderness, and adnexal tenderness
- NAAT (Nucleic Acid Amplification Tests): Detect Chlamydia and Gonorrhea.
- Microscopy of Vaginal Discharge: May show an elevated number of white blood cells (WBCs), indicating infection.
- Elevated C-reactive protein (CRP) and Erythrocyte Sedimentation Rate (ESR): Indicate inflammation.
- Imaging: Pelvic ultrasound can help assess for tubo-ovarian abscess or other complications.
- Laparoscopy: Definitive but invasive, used in uncertain cases or if there is no response to treatment.
Treatment
- Empiric Antibiotic Therapy: Since delayed treatment can result in severe complications, broad-spectrum antibiotics targeting likely organisms are started immediately.
- Outpatient Treatment: A combination of Ceftriaxone (IM) plus oral Doxycycline (14 days) with or without Metronidazole for anaerobic coverage.
- Inpatient Treatment: Indicated for severe PID, abscess, or if the patient is pregnant. IV antibiotics like Cefoxitin/Cefotetan plus Doxycycline are commonly used.
- Surgical Intervention: Required in cases of ruptured tubo-ovarian abscess or lack of improvement with antibiotics.
Complications
- Tubal Factor Infertility: Due to scarring and adhesions in the fallopian tubes, leading to blocked or damaged tubes.
- Ectopic Pregnancy: The risk increases significantly in women with a history of PID.
- Chronic Pelvic Pain: Resulting from adhesions and chronic inflammation.
- Tubo-ovarian Abscess (TOA): A localized collection of pus in the ovary and fallopian tube, requiring drainage or surgery if unresponsive to antibiotics.
Prevention
- Safe Sex Practices: Use of condoms reduces the risk of STIs and PID.
- Regular STI Screening: Especially for sexually active women under 25 years or those with new/multiple sexual partners.
- Prompt Treatment of STIs: Early treatment of infections like chlamydia and gonorrhea can prevent progression to PID.
Prognosis
- Early Treatment: Most women recover without long-term complications if treated early.
- Delayed Treatment: Increases the risk of infertility, chronic pelvic pain, and ectopic pregnancy.
In summary, PID is a potentially serious reproductive tract infection that can have long-term reproductive consequences if not recognized and treated early. Effective prevention strategies include STI screening, safe sex practices, and prompt treatment of infections.
