Pelvic inflammatory disease is an ascending pelvic infection, which may produce a combination of endometritis, salpingitis, oophoritis and parametritis. It may be complicated by tubo-ovarian abscess, pelvic peritonitis and peri-hepatitis. It is usually related to cervical infection with N. gonorrhoeae or C. trachomatis. The latter is responsible for most cases, although the bacteria may coexist. Anaerobic bacteria associated with bacterial vaginosis (bacteroides, anaerobic cocci) may also be involved in the pathophysiology of pelvic inflammatory disease. Other microorganisms found in patients with pelvic inflammatory disease include E. coli, Mycoplasma hominis and ureaplasma.

pelvic inflammatory disease is more common in women under 35 years old and in those with multiple partners or an STL It is rare in pregnancy, before menarche or after menopause. Hormonal and barrier (condoms, diaphragm) methods of contraception appear to be protective. pelvic inflammatory disease is not always due to an sexually transmitted infection and can occur after a gynecologic procedure in the absence of either chlamydia or gonorrhea. The risk of pelvic inflammatory disease after termination of pregnancy is approximately 5-15% and less than 1% following IUD insertion. These rates are highest if there is a pre-existing cervical sexually transmitted infection. The risk of pelvic infection with an IUD in situ is only raised above the background risk for 20 days after insertion. It has been demonstrated that the rate of postabortal pelvic inflammatory disease can be approximately halved when prophylactic antibiotics are used at the time of termination of pregnancy. The Royal College of Obstetricians and Gynaecologists’ Guidelines recommend that selected women are tested for sexually transmitted infections and/or given prophylaxis before an intrauterine procedure (see page 59 for reducing the risk of pelvic inflammatory disease in women having an IUD fitted).

Pelvic inflammatory disease: Diagnosis

Women may be asymptomatic, but it is more common that pelvic inflammatory disease presents with lower abdominal pain, deep dyspareunia, vaginal discharge and intermenstrual bleeding. The diagnosis of pelvic inflammatory disease is usually made on clinical findings, as the gold standard, laparoscopy, is rarely used. The only findings on examination required to make a diagnosis of pelvic inflammatory disease are cervical, uterine or adnexal excitation (cervical motion tenderness) and adnexal tenderness. In addition, the patient may also be pyrexial and/or have abdominal tenderness, signs of peritonism or a pelvic mass. Right upper abdominal pain suggests the presence of peri-hepatitis, a rare condition associated with both chlamydial and gonococcal pelvic inflammatory disease, known as the Fitz-Hugh-Curtis syndrome. Other complications of pelvic inflammatory disease are tubo-ovarian abscess, pyosalpinx and hydrosalpinx. A raised white blood cell count, C-reactive protein or erythrocyte sedimentation rate supports the clinical diagnosis of pelvic inflammatory disease, retrospectively. Because of the need to carry out effective contact tracing, testing for sexually transmitted infections is important. A pregnancy test may be required to exclude ectopic pregnancy. Other differential diagnoses to consider include acute appendicitis, torted or ruptured ovarian cyst and endometriosis. Additional criteria supporting a diagnosis of pelvic inflammatory disease are listed in Table Findings supporting a diagnosis of pelvic inflammatory disease.

Table Findings supporting a diagnosis of pelvic inflammatory disease

Oral temperature > 38.3°C (> 101°F)
Cervical and/or vaginal mucopurulent discharge
Presence of WBC on microscopy of vaginal secretions
Elevated ESR
Elevated CRP
Laboratory diagnosis of N. gonorrhoeae or C. trachomatis

WBC, white blood cells; ESR, erythrocyte sedimentation rate; CRP, C-reactive protein

Pelvic inflammatory disease: Treatment

Early treatment of pelvic inflammatory disease reduces the risk of developing long-term sequelae such as ectopic pregnancy, infertility, chronic pelvic pain and dyspareunia. The risk of developing subfertility is approximately 9% after one episode of pelvic inflammatory disease and approximately doubles with each subsequent episode. The risk of ectopic pregnancy for women with a history of pelvic inflammatory disease is 10%. Therefore, there should be a low threshold for treatment. As pelvic inflammatory disease is polymicrobial, combination antibiotic therapy is required to cover gonorrhea, chlamydia and anaerobic infection.

Treatment depends upon local patterns of antibiotic resistance but usually consists of oral doxycycline 100 mg twice daily for 14 days plus oral metronidazole 400 mg twice daily for 14 days and ciprofloxacin 500 mg stat. Hospital admission and parenteral treatment is indicated for more severe clinical disease, particularly in the presence of HIV infection (Table Indications for hospital admission). One in-patient regimen is cefoxitin 2.0 g IV every 6 h plus doxycycline 100 mg orally or IV every 12 h. Analgesia may be required. WhenPID is diagnosed in a patient with an IUD, it is advised to leave the device in place unless the condition has not improved 48 h after starting treatment.

Table Indications for hospital admission

Diagnostic uncertainty
Clinical failure with oral therapy
Presence of a tubo-ovarian abscess
Inability to tolerate oral therapy
Immunodeficiency

Patients should be advised to avoid inter-course until they, and their partner (s), have completed treatment and follow-up. Clear verbal and written information should be provided. Pelvic examination should be performed at follow-up visits, 2 days and 2 weeks after commencing treatment.

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