Pelvic Inflammatory Disease

by Armando HF

Overview
Overview Pelvic inflammatory disease (PID) comprises a spectrum of inflammatory disorders of
the upper female genital tract, including any combination of endometritis, salpingitis, tubo-ovarian
abscess, and pelvic peritonitis. Causative organisms are either sexually transmitted (such as C
trachomatis, N gonorrhoeae, Mycoplasma genitalium) or endogenous vaginal organisms (for
example, Bacteroides species) that ascend into the pelvic area from the lower genital tract through
the cervix. Pelvic inflammatory disease is a major concern because it can result in longterm
reproductive disability, including infertility, ectopic pregnancy, and chronic pelvic pain.
Definition
Pelvic Inflammatory Disease: Inflammation and infection of the upper genital tract
in women, typically involving the uterus and adnexa
Mild to moderate PID: Absence of a tubo-ovarian abscess
Severe PID: Severe systemic symptoms or the presence of a tubo-ovarian abscess

Anatomy and Physiology

Vaginal Microbiology
The hydrogen peroxide-producing Lactobacillus species is the most dominant, non-pathogenic
organism living in the vagina. The vaginal flora of most normal, healthy women also includes a
variety of potentially pathogenic bacteria in low numbers:
Streptococci
Staphylococci
Enterobacteriaceae (most commonly Klebsiella spp, Escherichia coli, and Proteus spp)

Many factors influence the vaginal microflora including:

Hormonal changes (eg, pregnancy, menstrual cycle)

Contraceptive method
Sexual activity
Other unknown factors
Cervix

The endocervical canal functions as a barrier protecting the normally sterile upper genital tract
from the organisms of the dynamic vaginal ecosystem. Endocervical infection with sexually
transmitted pathogens can disrupt this barrier.

Risk Factors
Young age
Low socioeconomic status
Lower educational attainment
Recent new sex partner.
Prior STI
Young age at onset of sexual activity
Unprotected sexual intercourse with multiple partners
Sex during or just after menstruation
History of PID
Alcohol/Illicit drug use
 Genetic and Immunological factors

Signs and Symptoms

PID is mostly asymptomatic

Acute PID: characterized by the acute onset of lower abdominal or pelvic pain, pelvic organ
tenderness, and evidence of inflammation of the genital tract
Subclinical PID: Subclinical infection of the upper reproductive tract that does not prompt a
woman to present to medical care but is severe enough to produce significant sequelae appears to
be relatively common
Chronic PID: An indolent presentation of PID with low-grade fever, weight loss, and abdominal
pain has been reported with actinomycosis and tuberculosis

Differential Diagnosis
Condition Clinical Features

Ectopic pregnancy History of missed menses, positive pregnancy test

Ovarian cyst rupture/torsion Sudden onset of severe pain

Endometriosis Cyclical or chronic pain

Cystitis Urinary frequency and/or dysuria

Appendicitis Pain localized to the right iliac fossa, vomiting

Diverticulitis Bowel symptoms in older women

Irritable bowel syndrome Generalized abdominal pain, constipation, diarrhea

Functional pain Other causes have been excluded

Investigations
FBC
ESR
Nucleic acid amplification tests Chlamydia or Gonorrhoea
Saline microscopy Trichomonas vaginalis infection or bacterial vaginosis
Transvaginal ultrasound
CT
Endometrial biopsy
Laproscopy gold standard (invasive maybe only for severe cases)

Diagnosis
One or more of the following minimum criteria must be present on pelvic examination to diagnose
PID:

Cervical motion tenderness

Uterine tenderness
Adnexal tenderness
 The following criteria can improve the specificity of the diagnosis:

Fever
Abnormal Vaginal Discharge
Presence of abundant numbers of white blood cells on saline microscopy of vaginal fluid
Erythrocyte sedimentation rate
Laboratory documentation of cervical infection with gonorrhea or chlamydia

The following test results are the most specific criteria for diagnosing PID:

Endometrial biopsy endometritis

Transvaginal sonography or magnetic resonance imaging techniques showing thickened, fluid-
filled tubes +/- free pelvic fluid or tubo-ovarian complex
Doppler studies
Laparoscopy

Aetiology
Pelvic inflammatory disease (PID) is a polymicrobial infection of the upper genital tract that
primarily affects young, sexually active women. In most cases, the precise microbial etiology
of PID is unknown. When known:
STI pathogens or bacterial vaginosis (85% of cases)
Neisseria gonorrhoeae (Most common)
Chlamydia trachomatis (Most common)
Mycoplasma genitalium
Bacterial Vaginosis (gardenlla vaginalis)
Respiratory or enteric organisms that have colonized the lower genital tract (15%)
Streptococci
Staphylococci
Enterobacteriaceae (most commonly Klebsiella spp, Escherichia coli, and Proteus spp)
Rare: Mycobacterium tuberculosis and the agents of actinomycosis

Pathophysiology
Ascending infection from the cervix is often due to sexually acquired infections
Infection moves from cervix fallopian tubes peritoneal surface of the fallopian tubes
ovaries
Infection results in fibrinous or suppurative inflammatory damage along the epithelial surface of
the reproductive tract
This leads to scarring, adhesions, and possibly partial or total obstruction of the fallopian tubes.
Reinfection substantially increases the risk of tubalfactor infertility
The inability to conceive because of structural or functional damage to the fallopian tubes
The adaptive immune response thought to play a role in this
Infection-induced selective loss of ciliated epithelial cells along the fallopian tube epithelium can
cause impaired ovum transport
This results in tubal-factor infertility or ectopic pregnancy
Peritoneal adhesions along the fallopian tubes may prevent pregnancy, and adhesions within the
pelvis are related to pelvic pain.
Side note PID can occur after instrumentation of the uterus, such as during D & C for
termination of pregnancy or miscarriage, or insertion of an PID.

Side note PID can be caused by polyps, fibroids and neoplasms, which prevent
closure of the uterine cavity and allow endogenous organisms to colonise the upper
genital tract
 The microorganisms that are implicated in PID are thought to spread in three ways:

1. Intra-abdominally, traveling from the cervix to the endometrium, through the salpinx, and into the
peritoneal cavity (causing endometritis, salpingitis, tubo-ovarian abscess, or pelvic peritonitis)
2. Through the lymphatic systems, such as infection of the parametrium from an intrauterine device
(IUD)
3. Through hematogenous routes, such as with tuberculosis (rare)

Management
Empiric antibiotic treatment should be initiated at the time of presentation in patients with
symptoms suspicious for PID, even if the diagnosis has not been confirmed. Antibiotics can be
any of the following depending on severity and situation:

Parenteral Antibiotics
Oral Antibiotics
IV Antibiotics

Remember to test and treat the partner if necessary. Partners should be instructed to abstain from
sexual intercourse until they and their sex partners have been adequately treated.

Mild to moderate (outpatient) Oral antibiotics

Ceftriaxone PLUS Doxycycline PLUS Metronidazole PLUS Azythromycin
Severe (Inpatient) IV Antibiotics
Ceftriaxone PLUS Cefotaxime PLUS Metronidazole PLUS Azythromycin
Follow up
If no improvements after 3 days reassess +/- hospitalisation
Remove intrauterine device (IUD) if no response to treatment in 48-72 hours.
If Chlamydia or gonococcal infection retest in 3 months
Indications for hospitalzation

Inability to follow or tolerate an outpatient oral medication regimen

Pregnancy

No clinical response to oral antimicrobial therapy

Severe illness, nausea and vomiting, or high fever

Severe illness, nausea and vomiting, or high fever

Surgical emergencies (e.g., appendicitis) cannot be excluded

Tubo-ovarian abscess

Remember Pregnant women suspected to have PID are at high risk for maternal
morbidity and preterm delivery. These women should be hospitalized and treated with
intravenous antibiotics.

Side note Screening for lower genital tract chlamydial infection in younger and high-
risk populations is recommended to reduce the incidence of PID. Asymptomatic
 disease should be treated.

Complication and Prognosis

Complications (I-FACE-PID)
Infertility
Fitz-Hugh-Curtis syndrome
Abscesses
Chronic pelvic pain
Ectopic pregnancy
Peritonitis
Intestinal obstruction
Disseminated infection (sepsis, endocarditis, arthritis, meningitis)
Prognosis Patients who have co-existent conditions (HIV infection, pregnancy, IUD, prior PID or
tubo-ovarian abscess) require close observation and may require hospitalisation.
20% of women with PID become infertile
40% develop chronic pain,
1% of those who conceive have an ectopic pregnancy
Spontaneous resolution of symptoms may occur in some women.