Pelvic Inflammatory Disease

Pelvic Inflammatory DiseasePelvic Inflammatory Disease

Pelvic Inflammatory Disease – Introduction

Pelvic inflammatory disease (PID) is a disease very frequently seen both in emergency and outpatient gynecological consultations. It includes a wide range of symptoms; therefore, it should be considered in the differential diagnosis of acute abdominal pain, causes of infertility, or chronic pelvic pain, among others.

Due to the severe complications it generates, detecting and treating it as soon as possible is vital.

This article emphasizes the most important aspects to consider to arrive at a diagnosis and the different treatment options.

Definition

It is defined as the spectrum of inflammatory and infectious disorders of the upper genital tract, which include endometritis, salpingitis, purulent pelvic fluid collections, and pelvic peritonitis of genital origin. It is related to long-term sequelae, such as infertility and chronic pelvic pain. (1,2) It can be classified as uncomplicated, compatible with clinical treatment, or complicated by a tubo-ovarian abscess or pelvic peritonitis requiring surgical intervention. (3)

Epidemiology

More than a million women in the US are diagnosed with PID every year. (2) According to an analysis published by the CDC, approximately 2.5 million women aged between 18 and 44 nationwide have received a diagnosis of PID in their lifetime. (4)

Even though PID is not associated with high mortality, it is with high morbidity. It has been published that women diagnosed with PID between 20 to 24 years of age will develop long-term complications: 18% will suffer from chronic pain, 8.5% will develop ectopic pregnancies, and 16.8% will struggle with infertility. (5)

Over the past decade, the rates of PID have been decreasing, but its surveillance is difficult to estimate because a cheap, simple, and accurate diagnostic test does not exist. It represents a relevant healthcare issue in industrialized countries. Overall, the leading causes of PID, Chlamydia and Gonorrhea, are estimated to cost the US almost $1 billion yearly in direct medical expenses. (6)

Etiology

In 85% of cases, the infection is caused by sexually transmitted bacteria. Neisseria Gonorrhoeae and Chlamydia Trachomatis are the most common pathogens implicated, representing 50% of the cases. (7, 8) Neisseria Gonorrhoeae is associated with severe PID; in contrast, Chlamydia Trachomatis is usually asymptomatic and results in subclinical cases. The latter continues to be relevant since it can generate long-term consequences. (9)

In addition, some microorganisms that are part of the vaginal flora have been associated with PID, such as Gardnerella Vaginallis, Haemophilus Influenzae, Streptococcus Agalactieae, and enteric gram-negative rods. (8, 10) On the other hand, Cytomegalovirus, Trichomonas Vaginalis, Mycoplasma Hominis, Mycoplasma Genitalium, and Ureaplasma Urealyticum might be associated with PID. (11-13) Screening and treating sexually active women for Chlamydia and Gonorrhea reduces their risk of PID (14,15). Although bacterial vaginosis is associated with PID, whether its incidence can be reduced by identifying and treating women with vaginosis is unclear. The same happens with screening and treatment of Mycoplasma Genitalium. (10)

Risk Factors

PID is more frequent among sexually active and fertile women; other important factors to consider are age under 25-year-old, having multiple sexual partners, not using barrier contraception methods, or having a record of sexually transmitted infections. In addition, a relevant aspect to consider is a previous PID episode. (2)

Pathophysiology

It originates from ascending microorganisms from the vagina or cervix that cause inflammatory damage along the epithelial and peritoneal surface of the fallopian tubes and ovaries. This leads to scarring, adhesion, and possibly partial or total obstruction of the fallopian tube. The adaptive immune response plays a vital role in this disease and is associated with an increased risk of infertility after reinfection. The inflammatory response from this infection induces selective loss of ciliated epithelial cells along the fallopian tube epithelium, which can cause difficulties in ovum transportation resulting in infertility. In addition, the inflammatory response could generate adhesions within the pelvis resulting in pelvic pain. (16)

Diagnosis and Management

Because of the variety in symptoms and signs of PID, diagnosis is difficult and usually delayed. Laparoscopic exploration is considered the gold standard, but this tool is not always available and is not justified when symptoms are mild. As a result, clinical findings are the most frequent tool for diagnosis, with a positive predictive value of 65 to 90% versus laparoscopy. (17 )

Clinical Features

Symptoms Signs
Lower abdominal pain

Vaginal discharge, usually purulent

Intermenstrual or postcoital bleeding

Lower back pain

Dysmenorrhea

Deep dyspareunia

Urinary frequency

Nausea/vomiting

Lower abdominal tenderness

Adnexal tenderness (sometimes mass)

Cervical motion tenderness

Fever (>38°C /101F)

 

Complementary Studies

-Analysis of vaginal secretions: microscopy of vaginal secretions shows >1 leukocyte per epithelial cell, evaluation for bacterial vaginosis and trichomonas should be performed. If available, testing with nucleic acid amplification for Neisseria Gonorrhoeae and Chlamydia Trachomatis should be considered, but a negative result does not exclude PID diagnosis.

If the cervix is normal and no white blood cells are noted, a differential diagnosis should be investigated since its negative predictive value for upper genital tract infection is almost 95%. Testing for Mycoplasma Genitalium is not routinely performed. (18)

-Blood test: high white blood cells count, and elevated levels of CRP or ESR can be detected. If these inflammatory markers are elevated, the specificity for PID increases. (19)

– Urinalysis: allows ruling out differential diagnosis.

– Pregnancy test: should be done to know the woman’s current situation, help with decision-making, and rule out an ectopic pregnancy.

-Ultrasound Scanning: it can be helpful if an adnexal mass is suspected, but it has limited value. Nevertheless, an increased fallopian-tube blood flow by Doppler studies is highly suggestive of infection. (20,21)

-MRI or CT scanning: helpful in ruling out differential diagnosis but is not mandatory. As with transvaginal ultrasound, MRI revealing thickened, fluid-filled tubes are highly specific for salpingitis. (22, 23)

-Laparoscopy: visual evidence of acute tubal inflammation (erythema, edema, and purulent exudate) could confirm approximately 65% of the acute cases of salpingitis. For patients with severe symptoms or signs of an adnexal mass, it is vital to rule out tubo-ovarian abscess by laparoscopic inspection. Examining the right upper quadrant for hepatic adhesions is mandatory during surgical diagnosis.

On the other hand, cases of acute endometritis may not be evident at the laparoscopic examination.

Differential Diagnosis

Some diagnoses that should be considered are ectopic pregnancy, ovarian torsion, ovarian cyst rupture, endometritis, pyelonephritis, cystitis, appendicitis, and diverticulitis, among others. (24)

Clinical Stages

Stage Clinical Features Treatment
I Salpingitis/ endometritis without peritonitis (absence of rebound tenderness) Medical

(oral antibiotics)

II Salpingitis/ endometritis with peritonitis Medical

(intravenous antibiotics)

III Tubo-ovarian abscess Surgical
IV Ruptured tubo-ovarian abscess or pelvic peritonitis Surgical

Medical Treatment

The CDC recommends empiric treatment for PID in sexually active women under 25 years old with risk factors for STI if they complain of pelvic or lower abdominal pain, no other cause is identified, and if one or more of the following is appreciated on bimanual pelvic examination: cervical motion tenderness, uterine tenderness, or adnexal tenderness. (1)

Pregnant patients, those unable to tolerate oral treatment or with severe symptoms that suggest the need for surgical treatment, should be hospitalized. (16)

Oral Treatment

It should be considered for patients with mild to moderate acute PID. Patients should receive intravenous therapy in the absence of clinical response after 72 hours.

Parental third-generation cephalosporin

+

Doxycycline 100 mg orally twice/day for 14 days

+

Metronidazole 500 mg orally twice/day for 14 days

Ceftriaxone IM 500 mg single dose

+

Doxycycline 100 mg orally twice/day for 14 days

+

Metronidazole 500 mg orally twice/day for 14 days

Cefoxitin 2 gr IM with Probenecid orally single dose

+

Doxycycline 100 mg orally twice/day for 14 days

+

Metronidazole 500 mg orally twice/day for 14 days

Intravenous Treatment

Ceftriaxone 1 gr IV every 24 hours

+

Doxycycline 100 mg orally  or IV twice/day

+

Metronidazole 500 mg orally or IV twice/day

Cefotetan 2 gr IV twice/day

+

Doxycycline 100 mg orally or IV twice/day

 

Cefoxitin 2 gr IV twice/day

+

Doxycycline 100 mg orally or IV twice/day

Ampicillin- sulbactam 3 gr every 6 hours

+

Doxycycline 100 mg orally or IV twice/day

Clindamycin 900 mg every 8 hours

+

Gentamicin loading dose (2 mg/kg) followed by maintenance (1,5 mg/kg) every 8 hours

Oral or intravenous doxycycline and metronidazole have similar bioavailability. Intravenous doxycycline is associated with pain during infusion, so it is recommended orally when possible.

The last two enumerated regimens are considered alternatives because they have fewer scientific records.

After 48 hours of clinical improvement with parenteral treatment, transition to oral therapy should be indicated.

It is vital to explain the importance of abstention from sexual intercourse and treatment of sexual partners to reduce disease transmission. (16)

Surgical Treatment

As mentioned, surgical treatment is indicated for PID grades 3 and 4. This indication is based on the clinical findings, complementary studies, and the lack of response to medical therapy. Some possible things that should be performed are, washed and vacuumed, abscess drainage, salpingectomy, oophorectomy, and adhesiolysis. (25) Laparoscopic approach should be preferred when possible.

Complications

Infertility rates following PID can be high, such as in the USA, where rates may vary from 21.3% to 55.6%. (9, 26) It is more likely to occur if Chlamydia is related, treatment is delayed, the patient has recurrent episodes of PID, or in severe cases. (5)

PID increases the risk of ectopic pregnancy since this infection affects the fallopian tubes. The latter was shown in a cohort study that included 2501 women who underwent laparoscopic examination for acute salpingitis, and it concluded that fallopian tube infection was a major risk factor for first ectopic pregnancy. (27) In addition, a retrospective cohort study using the Taiwan National Health Insurance Database examined 30450 patients with PID, concluding that patients between 12 and 19 years have the highest risk of developing ectopic pregnancy and preterm labor than other age groups. (28)

Chronic pelvic pain is evident in one-third of women. As mentioned above, it is related to inflammation, scarring, and adhesions generated by this infection. The most important predictor for developing this type of pain is associated with recurrent PID. (5)

Perihepatitis, or Fitz-Hugh-Curtis syndrome, is a chronic manifestation of PID. It is an inflammation of the liver capsule with adhesion formation that generates right upper quadrant pain. The pain usually worsens with movement and breathing, mimicking other acute abdominal pathologies. Diagnosis can be made through laparoscopy or laparotomy with direct visualization of violin string-like adhesions or through hepatic capsular biopsy and culture. (29)

Disclosures

The author does not report any conflict of interest.

Disclaimer

This information is for educational purposes and is not intended to treat disease or supplant professional medical judgment. Physicians should follow local policy regarding the diagnosis and management of medical conditions.

References

1- Workowski KA; Bachmann LH; Chan PA.; Johnston,  CM;  Muzny, CA; Park, I; et al. Sexually Transmitted Infections Treatment Guidelines, 2021. Centers for disease control and prevention. MMWR. Vol 70, Num.4, Jul 2021.

2-Lee A. Learman, MD, PhD, and Katherine W. McHugh, MD. American College of Obstetricians and Gynecologists’ on Practice Bulletins–Gynecology. Vol. 135, Num. 3, March 2020.

3- Jean-Luc Brun, Bernard Castan, Bertille de Barbeyrac, Charles Cazanave, Amélie Charvériat, Karine Faure, Stéphanie Mignot, Renaud Verdon, Xavier Fritel, Olivier Graesslin. Pelvic inflammatory diseases: updated French guidelines. https://www.sciencedirect.com/science/article/pii/S2468784720300441.

4- Kristen Kreisel, Elizabeth Torrone, Kyle Bernstein, Jaeyoung Hong, Rachel Gorwitz. Prevalence of Pelvic Inflammatory Disease in Sexually Experienced Women of Reproductive Age -United States, 2013–2014. MMWR Morb Mortal Wkly Rep 2017;66:80–83.

5-Lindsey K. Jennings; Diann M. Krywko. Pelvic Inflammatory Disease. https://www.ncbi.nlm.nih.gov/books/NBK499959/#_NBK499959_pubdet.

6- Kumar S, Chesson H, Gift TL. Estimating the Direct Medical Costs and Productivity Loss of Outpatient Chlamydia and Gonorrhea Treatment. Sex Transm Dis. 2021 Feb 1;48(2):e18-e21.

7- Darville T. Pelvic Inflammatory Disease Workshop Proceedings Committee. Pelvic inflammatory disease: identifying research gaps— proceedings of a workshop sponsored by Department of Health and Human Services/National Institutes of Health/National Institute of Allergy and Infectious Diseases. Sex Transm Dis 2013;40:761–7.

8- Wiesenfeld HC, Meyn LA, Darville T, Macio IS, Hillier SL. A randomized controlled trial of ceftriaxone and doxycycline, with or without metronidazole, for the treatment of acute pelvic inflammatory disease. Clin Infect Dis 2021;72:1181–9.

9- Jennings LK, Krywko DM. Pelvic Inflammatory Disease. [Updated 2022 Jun 5]. Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499959/.

10- Ness RB, Kip KE, Hillier SL, et al. A cluster analysis of bacterial vaginosis-associated microflora and pelvic inflammatory disease. Am J Epidemiol 2005;162:585–90.

11- Smith KJ, Ness RB, Wiesenfeld HC, Roberts MS. Cost-effectiveness of alternative outpatient pelvic inflammatory disease treatment strategies.SexTransmDis2007;34:960–6.

12- Lillis RA, Martin DH, Nsuami MJ. Mycoplasma genitalium infections in women attending a sexually transmitted disease clinic in New Orleans. Clin Infect Dis 2019;69:459–65.

13- Wiesenfeld HC, Manhart LE. Mycoplasma genitalium in women: current knowledge and research priorities for this recently emerged pathogen. J Infect Dis 2017;216(suppl_2):S389–95.

14- Scholes D, Stergachis A, Heidrich FE, Andrilla H, Holmes KK, Stamm WE. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. N Engl J Med 1996;334:1362–6.

15-. Oakeshott P, Kerry S, Aghaizu A, et al. Randomised controlled trial of screening for Chlamydia trachomatis to prevent pelvic inflammatory disease: the POPI (Prevention of Pelvic Infection) trial. BMJ 2010 Apr 8;340:c1642.

16- Brunham R.C., M.D., Gottlieb S.L., M.D., M.S.P.H., Paavonen J., M.D. Pelvic Inflammatory Disease. Review article. The New England Journal of Medicine. May 21, 2015. N Engl J Med.

17- Das B.B, Ronda J., M.,Trent M.. Pelvic inflammatory disease: improving awareness, prevention, and treatment. Infection and Drug Resistance 2016:9 191–197.

18- S.Ona, R.L. Molina, K. Diouf. Mycoplasma genitalium: An Overlooked Sexually Transmitted Pathogen in Women? Infect Dis Obstet Gynecol. 2016; 2016: 4513089.

19- Peipert JF, Boardman L, Hogan JW, Sung J, Mayer KH. Laboratory evaluation of acute upper genital tract infection. Obstet Gynecol 1996;87:730-736

20- Molander P, Sjoberg J, Paavonen J, Cacciatore B. Transvaginal power Doppler findings in laparoscopically proven acute pelvic inflammatory disease. Ultrasound Obstet Gynecol 2001;17:233-238

21- Sakhel K, Benson CB, Platt LD, Goldstein SR, Benacerraf BR. Begin with the basics: role of 3-dimensional sonography as a first-line imaging technique in the cost-effective evaluation of gynecologic pelvic disease. J Ultrasound Med

22- Molander P, Sjoberg J, Paavonen J, Cacciatore B. Transvaginal power Doppler findings in laparoscopically proven acute pelvic inflammatory disease. Ultrasound Obstet Gynecol 2001;17:233-238

23- Tukeva TA, Aronen HJ, Karjalainen PT, Molander P, Paavonen T, Paavonen J. MR imaging in pelvic inflammatory disease: comparison with laparoscopy and US. Radiology 1999;210:209-216

24- Jennings L., Krywko D.M. Pelvic Inflammatory Disease. NCBI Bookshelf. National Library of Medicine, National Institutes of Health. June 5, 2022.

25- Chaparral C; Wiesenfeld H. Pathogenesis, Diagnosis, and Management of Severe Pelvic Inflammatory Disease and Tuboovarian Abscess. Clinical Obstetrics and Gynecology: December 2012 – Volume 55 – Issue 4 – p 893-903.

26- Gremeau A., Girard A., Lambert C. , Chauvet P. , Bourdel N., Canis M. ,  Pouly J. Benefits of second-look laparoscopy in the management of pelvic inflammatory disease. J Gynecol Obstet Hum Reprod. 2019 Jun;48(6):413-417.

27- Joesoef MR, Westrom L, Reynolds G, Marchbanks P, Cates W (1991) Recurrence of ectopic pregnancy: the role of salpingitis. American journal of obstetrics and gynecology 165: 46–50. 10.1016/0002-9378(91)90221-c

28- Huang C-C, Huang C-C, Lin S-Y, Chang CY-Y, Lin W-C, Chung C-H, et al. (2019) Association of pelvic inflammatory disease (PID) with ectopic pregnancy and preterm labor in Taiwan: A nationwide population-based retrospective cohort study. PLoS ONE 14(8): e0219351.

29- Basit H, Pop A, Malik A, Sharma S. Fitz-Hugh-Curtis Syndrome. 2022 Jul 4. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 29763125

See Also

Nephrolithiasis in Adults

Distal Radius Fractures in Adults

Diagnosis and Management of Vulvovaginitis

Diagnosis and Management of Anaphylaxis in Adults

Acute Uncomplicated Pyelonephritis in Adults

Initial Management of Hip Fractures in Adults

Community Acquired Pneumonia in Adults

About the Author

Dr. Florencia Virili
Dr. Florencia Virili graduated with honors from Favaloro’s University School of Medicine in Buenos Aires, Argentina. She completed her specialty training in Obstetrics and Gynecology at Bernardo Houssay Hospital and Santa Rosa Maternity. She is a lifelong learner including as a researcher in multi-centric, double-blind, studies on vaccine efficacy. In addition, she is passionate about creating accurate, consistent medical content to ensure physicians have access to relevant information for their daily practice.

Follow us

Leave a comment

Your email address will not be published.


*