PELVIC INFLAMMATORY

DISEASE (PID)
PAPM 231.3

INTRODUCTION
Bacterial infection of the female upper genital
tract
Inflammation of the uterus, fallopian tube,
or ovaries as it progresses to scar formation.
PID term can refer to viral, fungal, parasitic,
bacterial infections and should be classified by
affected organs, and the organism(s) causing it.

PID should be classified by affected

organs, the stage of the infection, and the
organism(s) causing it.
Although a sexually transmitted infection
(STI) is often the cause, many other routes
are possible, including lymphatic,
postpartum, postabortal (either
miscarriage or abortion) or intrauterine
device (IUD) related, and hematogenous
spread.

PID is initiated by infection that ascends

from the vagina and cervix into the
upper genital tract
The classic high-risk patient is a
menstruating woman younger than 25
years who has multiple sex partners,
does not use contraception, and lives in
an area with a high prevalence of
sexually transmitted disease (STD ).

SIGN AND SYMPTOMS OF

PELVIC INFLAMMATORY
DISEASE (PID)
Many women do not know they have PID
because they don't have any symptoms.
Symptoms can range from mild to severe,
including:

Abnormal vaginal
discharge, possibly
with an odor

Pain during
urination

More frequent
urination

pain in the upper

abdomen

Irregular menstrual
bleeding

Pain during intercourse

Low back pain

Fever, with a
temperature higher
than 101 F (38.3 C)

Vomiting

Nausea

Pain in the rectum

Pain in lower
abdomen
(stomach area)

CAUSES OF PELVIC
INFLAMMATORY DISEASE
(PID)

Normally, the cervix prevents bacteria that enter the vagina from
spreading to the internal reproductive organs.

If the cervix is exposed to a sexually transmitted disease such

as gonorrhea and/or chlamydia ; the cervix itself becomes
infected and less able to prevent the spread of organisms to the
internal organs.

PID occurs when the disease causing organisms travel from the
cervix to the upper genital tract.

It can take from a few days to a few months for an infection to

travel up from the vagina to the pelvic organs.

Untreated gonorrhea and chlamydia cause

about 90% of all cases of PID.

Unprotected sex with one or more partners

increase the risk of pelvic inflammatory
disease. Some forms of contraception may
affect the risk of developing pelvic
inflammatory disease.

A contraceptive intrauterine device (IUD) may

increase the risk of PID. Bacteria may also
enter our reproductive tract as a result of an
IUD insertion.

DIAGNOSIS

Your doctor will examine you for tenderness in your pelvic region and an
abnormal vaginal discharge.
a)

They will usually take sample from inside your vagina and cervix, which
will be sent to a laboratory to identify the type of bacteria causing the
infection.

Your doctor will take samples from your vagina and your cervix with a swab
(similar to a cotton bud). It usually takes a few days for the swab result to come
back.

A positive swab result confirms a diagnosis of PID and means you need
treatment.

A pelvic examination may show:

A cervix that bleeds easily
Cervical discharge
Pain with movement of the cervix
Tenderness in the uterus or ovaries

A laparoscopy

is a minor
operation where two small
cuts are made in the abdomen.
Laparoscopy

is direct
visualization of the ovaries,
outside of the tubes and
uterus.
The

laparoscopy is an
instrument somewhat like a
miniature telescope with a
fiber optic system which
brings light into the abdomen.

Laparoscopic instruments.

PROCEDURE

A surgeon makes a small cut

below the belly button (navel) and
inserts a needle into the area.

Carbon dioxide (CO2) is put into

the abdomen through a special
needle that is inserted just below
the navel.

This gas helps to separate the

organs inside the abdominal
cavity, making it easier for the
physician to see the reproductive
organs during laparoscopy. The
gas is removed at the end of the
procedure

The uterus is lined by a special type of

tissue known as the endometrium.
Endometrial biopsy is a technique of

removing a piece of tissue from the inner

lining of the uterus. The sample of tissue is
analyzed under a microscope in the
laboratory by a pathologist

This procedure may be done with or

without anesthesia. You will lie on your
back with your feet.
The health care provider will do a pelvic
examination, and will insert an
instrument (speculum) into the vagina
to hold it open and see the cervix.
The cervix is cleaned with an antiseptic
liquid and then grasped with an
instrument (tenaculum) to hold the
uterus steady.
A device called a cervical dilator may be
needed to stretch the cervical canal if
there is tightness (stenosis). Then a
small, hollow plastic tube is gently
passed into the uterine cavity.
Gentle suction removes a sample of the
lining. The tissue sample and
instruments are removed. A specialist
called a pathologist examines the
sample under a microscope.

Tests that are not specific for PID may also be

done to detect and evaluate associated
inflammation and immune response. They
include:
ESR (Erythrocyte Sedimentation Rate) nonspecific

indicator of inflammation
The sedimentation rate blood test measures how quickly

red blood cells (erythrocytes) settle in a test tube in one

hour. The more red cells that fall to the bottom of the test
tube in one hour, the higher the sedimention rate.
When inflammation is present in the body, certain proteins
cause red blood cells to stick together and fall more
quickly than normal to the bottom of the tube.
These proteins are produced by the liver and the immune
system under many abnormal conditions, such as an
infection

CBC (Complete Blood Count) an increased

white blood cell count may indicate the
presence of an infection.
White blood cells protect the body against

infection. If an infection develops, white blood

cells attack and destroy the bacteria, virus, or
other organism causing it. White blood cells are
bigger than red blood cells but fewer in number.
When a person has a bacterial infection, the
number of white cells rises very quickly.

Pelvic ultrasound or CT scan to look for

other abscesses or pockets of infection
around the tubes and ovaries

Mechanism of Pelvic Inflammatory

Disease
Pelvic inflammatory disease (PID) occurs when bacteria
move from the vagina or cervix into the uterus, fallopian
tubes, ovaries, or pelvis.
Pelvic inflammatory disease is usually caused by:

Chlamydia trachomatis
Neisseria gonorrhoeae

Also caused by other microorganism such as vaginal

microflora including anaerobic organisms, enteric gramnegative rods, streptococci, genital mycoplasmas, and
Gardnerella vaginalis, which is associated bacterial
vaginosis.

Mechanism of Chlamydia trachomatis :

Chlamydia trachomatis ability to grow and reproduce

inside the host contributes to its virulence. It is unclear
how the elementary bodies attach and penetrate the host
cells for entry, however, once they gain entrance into the
cell and are phagocytized they transform into reticulate
bodies that live in a membrane bound vacuole.
The vacuole prevents phagolysosome fusion, allowing
the reticulate bodies to replicate and eventually transform
back into the infectious elementary bodies in the
phagosome.
The elementary bodies are released by host cell lysis or
through fusion of the vacuoles plasma membrane with
the host cells plasma membrane.
This life cycle not only evades the hosts immune system,
but also uses the hosts immune system to proliferate.

Mechanism of Neisseria gonorrhoeae:

Gonococci invade nonciliated epithelial cells,
but are toxic to ciliated cells, due to
elaborated lipooligosaccharides and
peptidoglycan.
Certain gonococci stimulate chemotaxis of
polymorphonuclear leukocytes whose release
of toxic metabolites that may damage tissue.
Once the bacteria reach the subepithelial
layer and the blood stream they have to adapt
to these niches in order to disseminate to
other tissue.

Neisseria gonorrhoeae (green diplococci)

invading epithelial cells.

TREATMENT

If the findings of your exam or tests suggest PID,

treatment is started immediately.

Antibiotics. The initial treatment for mild cases of PID

usually consists of one or more
antibiotic medications taken by mouth. More
significant cases can be treated with a combination of
intravenous and oral antibiotics. If treatment is not
effective, if you cannot take antibiotics by mouth, or if
the infection is severe, you may need to be
hospitalized to receive medication intravenously
(directly into a vein).

If you are diagnosed with PID, your

sexual partner(s) also must be treated
even if they do not have any symptoms.
Otherwise, the infection will likely recur
when you have sex again.

EXAMPLE OF DRUG USED FOR

THE TREATMENT
Doxycycline
Doxycycline is indicated for use in
respiratory tract infections. It is also used
for prophylaxis of malaria. Doxycycline is
indicated for a variety of bacterial
infections, from Mycobacterium fortuitum
and M. marinum, to susceptible E. coli and
Brucella spp. It can be used as an
alternative to treating plague, tetanus,
Campylobacter fetus

Moa

Doxycycline, like minocycline, is lipophilic

and can pass through the lipid bilayer of
bacteria. Doxycycline reversibly binds to
the 30 S ribosomal subunits and possibly
the 50S ribosomal subunit(s), blocking the
binding of aminoacyl tRNA to the mRNA
and inhibiting bacterial protein synthesis.
Doxycycline prevents the normal function
of the apicoplast of Plasmodium
falciparum, a malaria causing organism.

Absorption
Completely absorbed following oral
administration.
Protein binding
>90%
Route of elimination
They are concentrated by the liver in the bile
and excreted in the urine and feces at high
concentrations in a biologically active form.
Half life

L8-22hrs

Toxicity

Symptoms of overdose include anorexia,

nausea, diarrhoea, glossitis, dysphagia,
enterocolitis and inflammatory lesions in
the anogenital region, skin reactions such
as maculopapular and rashes, exfoliative
dermatitis, photosensitivity and
hypersensitivity

Surgery

When PID causes an abscess (when the inflamed

tissue forms a collection of pus), antibiotics are no
longer as effective.
Surgery is often needed to remove the abscesses (or
the organ with the abscess) to prevent them from
rupturing and causing widespread infection
throughout the pelvis and abdomen.
Depending on the conditions, this may be done with a
laparoscope (a thin, lighted instrument) or with a
procedure in which the doctor opens the abdomen to
view the internal organs (laparotomy).
Both techniques are major surgical procedures and
are performed under general anesthesia (you are put
to sleep).

If abscesses have formed on the uterus or

ovaries, your doctor may recommend
hysterectomy (removal of the uterus) or
oophorectomy (removal of the ovaries).
Another surgical procedure that could be
recommended to treat chronic pain when there
is no infection, inflammation, or abscess
present are those that involve nerve ablation
(destruction) surgeries.
In these types of surgeries the nerves which
provide sensation to the organs in the pelvis are
removed or destroyed. In the hands of an
experienced surgeon, these procedures can be
effective in eliminating pain.

PREVENTION
PID is completely preventable. The number
one cause of PID is untreated STDs (also
called STIs, sexually transmitted infections).
Steps you can take to prevent PID include:

Avoid multiple sexual partners.

Use barrier methods of birth control (condoms
and birth control pills).
Avoid IUDs if you have multiple sexual
partners.

Seek treatment immediately if you

notice signs of PID or any sexually
transmitted disease, including
unusual vaginal discharge, pelvic
pain, or bleeding between periods.
Have regular gynecologic check-ups
and screenings since many cervical
infections can be identified and
treated before they spread to the
internal reproductive organs

CONCLUSION
Pelvis

inflammatory disease is term applied

infection in any part of the upper female genital
tract. Any invasive gynaecological may also cause
PID, as may spread from an intra-abdominal focus
infection, but these causes are infrequent. Early
treatment is necessary in order to obviate the risk
of sequelae, and investigation and treatment of
sexual partners is advised. We should identifying,
testing, and treating women at increased risk for
cervical chlamydial infection was associated with a
reduced incidence of pelvis inflammatory disease.

REFERENCES
Websites:
http://www.austincc.edu/microbio/2704t/
ct
http://www.uptodate.com/contents/tre
atment-of-pelvic-inflammatorydisease/abstract/2-5
http://www.mayoclinic.com/health/pelvicinflammatorydisease/DS00402/DSECTION=causes

http://women.webmd.com/guide/sexual-hea
lth-your-guide-to-pelvic-inflammatory-d
isease

http://emedicine.medscape.com/article/2
56448-overview