Pelvic Inflammatory Disease

INTRODUCTION

Background: Pelvic Inflammatory disease (PID) is an inflammatory disorder of the uterus, fallopian tubes, and adjacent pelvic structures. Risk factors for PID include young age at first intercourse, multiple sexual partners, intrauterine device (IUD) insertion, and tobacco smoking. A delay in diagnosis or treatment can result in long-term sequelae such as tubal infertility.

Pathophysiology: In pelvic inflammatory disease, the upper female genital tract is infected by direct spread of microorganisms ascending from the vagina and cervix. The cervix produces mucus that normally protects against upward spread, but bacteria may penetrate the cervical mucus and cause widespread extension of infection.

Frequency:
　

• In the US: PID affects 11% of women of reproductive age. Approximately 1 million women experience an episode of PID per year, and 20% of these women require hospitalization for treatment. The disease produces 2.5 million office visits and 125,000-150,000 hospitalizations yearly.

• Internationally: Public health efforts implemented in Scandinavia to decrease incidence of sexually transmitted disease (STD) have been quite effective.

Mortality/Morbidity: A delay in diagnosis or treatment can result in long-term reproductive sequelae, such as tubal infertility. Each repeat episode of PID doubles the risk for tubal factor infertility. Women with a history of PID have a 7- to- 10-fold increased risk for ectopic pregnancy (tubal pregnancy) compared with women with no history of PID. Chronic pelvic pain also can follow PID and occurs in 25-75% of women.

Sex: PID is an infection of the female genital tract.

CLINICAL

History: Patients can present with a variety of symptoms, ranging from lower abdominal pain to dysuria. A direct correlation exists between the incidence of STDs and PID in any given population.

• Pain is present in more than 90% of documented cases and is by far the most common presenting complaint.

• Usually, it is described as dull, aching, and constant; beginning a few days after the onset of the last menstrual period; and tending to be accentuated by motion, exercise, or coitus.

• Pain from PID usually lasts fewer than 7 days; if longer than 3 weeks in duration, the likelihood of the correct diagnosis being PID declines substantially.

• Abnormal vaginal discharge is present in approximately 75% of cases.

• Unanticipated vaginal bleeding coexists in about 40% of cases.

• Fever higher than 38蚓 (30%), nausea, and vomiting all present late in the clinical course of the disease.

Physical: Sensitivity of pelvic exam is only 60%. The Center for Disease Control and Prevention (CDC) recommends the following minimal clinical criteria for the diagnosis of PID:

• Lower abdominal tenderness

  　

• Adnexal tenderness

• Cervical motion tenderness

In addition to the preceding criteria, at least 1 of the following findings also should be present:

• Meets the case surveillance definition of chlamydial or gonorrheal infection

• Temperature higher than 100.4蚌 or 38蚓

• Leukocytosis greater than 10,000 WBC/mm³

• Purulent material in the peritoneal cavity obtained by culdocentesis or laparoscopy

• Pelvic abscess or inflammatory complex detected by bimanual exam or by sonography

• Patient is a sexual contact of a person known to have gonorrhea, Chlamydia, or nongonococcal urethritis

Causes: 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 high prevalence of STD. PID is also more prevalent among unmarried women and individuals who are young at first intercourse. The IUD confers a relative risk of 2.0-3.0 for the first 4 months following insertion, but then decreases to baseline thereafter. Women who are not sexually active have a very low incidence of upper genital tract infection, as do women who have undergone tubal sterilization.

• Chlamydia trachomatis: C trachomatis, an intracellular bacterial pathogen, is the predominant STD organism causing PID. Clinically, this obligate intracellular parasite may present as mucopurulent cervicitis.

• Cytomegalovirus (CMV): CMV has been found in the upper genital tracts of women with PID, suggesting a potential role of CMV in PID.

• Endogenous microflora: In iatrogenically induced infections the endogenous microflora of the vagina predominate.

• Gardnerella vaginalis

• Haemophilus influenzae

• Enteric gram-negative organisms (Escherichia coli)

• Peptococcus species

• Streptococcus agalactiae

• Bacteroides fragilis: This can cause tubal and epithelial destruction.

• Pregnancy: PID is rare in pregnancy.

• Neisseria gonorrhea: In the US, the role of N gonorrhea as the primary cause of PID has decreased.

WORKUP

Lab Studies:
　

• Additional criteria may be used to increase the specificity of the diagnosis as listed below.

• Vaginal wet mount - Increased amount of white cells

• Erythrocyte sedimentation rate (ESR) - Elevated, nonspecific

• C-reactive protein (CRP) - Elevated, nonspecific

• CBC - Elevated white blood cell count

• Gonorrhea cultures - Generally used to confirm diagnosis. Frequently negative in later stages.

• Chlamydial cultures - Generally used to confirm diagnosis. A large variability in recovery from cervix (5 to 56%)

Imaging Studies:
　

• Transvaginal sonography may not be useful in the diagnosis of PID. It has poor sensitivity (81%) and specificity (78%) with mild or atypical PID. It can be used to document an adnexal mass or demonstrate fluid-filled fallopian tubes.

• Although the specificity (95%) and sensitivity (95%) of MRI is relatively high, it is costly and rarely indicated in acute PID. If used in the management of PID, MRI can demonstrate thickened fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex.

Procedures:
　

• Culdocentesis: With the advent of transvaginal sonography, culdocentesis rarely is performed. In the absence of state of the art technology, insertion of an 18-gauge spinal needle attached to a syringe can be performed. The needle is inserted transvaginally into the cul-de-sac, yielding either purulent fluid or bloody fluid from the peritoneum.

TREATMENT

Medical Care: Most patients are now managed as outpatients, but physicians should consider hospitalization for patients with the following conditions, although no clear data suggests that these patients benefit from hospitalization:

• Uncertain diagnosis

• Pelvic abscess on ultrasound

• Pregnancy

• Failure to respond to outpatient management

• Inability to tolerate outpatient oral regimen

• Severe illness or nausea and vomiting precluding outpatient treatment

  　

• Immunodeficiency (HIV with low CD4 count, utilizing immunosuppressive medications)

  　

• Failure to improve clinically after 72 hours with outpatient therapy

Surgical Care: Laparoscopy: The advantage of laparoscopy is that it allows direct visualization of the pelvis and provides a more accurate and bacteriologic diagnosis if cultures are obtained. However, laparoscopy is not always available in acute PID. In addition, this procedure is costly and requires general anesthesia. It should be used if the diagnosis is in doubt. If operative laparoscopy is used early in the course of the disease however, copious irrigation and separation of thin adhesions by blunt dissection may prevent later sequelae.

Consultations:

• Obstetrics

• Gynecology

FOLLOW-UP

Further Inpatient Care:
　

• Most patients clinically respond within 48-72 hours after medical therapy. If the patient continues to have fever, chills, uterine tenderness, adnexal tenderness, and cervical motion tenderness, consider other possible causes.

Further Outpatient Care:
　

• Perform a follow-up examination 48-72 hours after prescribing outpatient therapy to ensure clinical improvement. If the patient continues to have fevers, chills, uterine, adnexal tenderness, and cervical motion tenderness, consider hospitalization.

• Male sex partners of women with PID should be examined and treated if they have had sexual contact with the patient during the 60 days preceding onset of symptoms in the patient.

In/Out Patient Meds:
　

• Regimen A: Administer cefoxitin, IV, or cefotetan, IV, plus doxycycline, IV or orally, every 12 hours. Continue this regimen for 48 hours after the patient remains clinically improved, then start doxycycline orally, twice daily for a total of 14 days. Administer doxycycline orally when possible because of pain associated with infusion. Bioavailability is similar with oral and IV administrations. IV antibiotics may be discontinued 24 hours after patient improves clinically and oral therapy with doxycycline continued for a total of 14 days. If tubo-ovarian abscess is present, use clindamycin or metronidazole with doxycycline for more effective anaerobic coverage.

• Regimen B: Administer clindamycin IV every 8 hours plus a loading dose of gentamicin IV or IM, followed by a maintenance dose every 8 hours. IV therapy may be discontinued 24 hours after patient improves clinically, and oral therapy of doxycycline should be continued for a total of 14 days of therapy.

• Outpatient treatment

• Regimen A: Cefoxitin plus probenecid should be taken orally in a single dose. Alternatively, ceftriaxone (less active against anaerobic bacteria compared to cefoxitin) can be taken once, IM, with doxycycline orally twice daily for 14 days. Cefoxitin has better anaerobic coverage, and ceftriaxone has better coverage against N gonorrhea.

• Regimen B: Ofloxacin should be taken orally for 14 days plus either clindamycin or metronidazole, also orally for 14 days. Oral ofloxacin lacks anaerobic coverage but is effective against N gonorrhea and C trachomatis

Deterrence/Prevention:
　

• Randomized controlled trials suggest that preventing chlamydial infection reduces the incidence of PID. Other methods of preventing PID and sexually transmitted diseases include reducing the number of sexual partners, avoiding unsafe sexual practices, and using condoms with spermicide. Use of mechanical barriers with spermicide also decreases the risk of acquiring sexually transmitted diseases.

• Notification of the female sex partners of men infected with Chlamydia trachomatis is recommended.

Complications:
　

• Tubo-ovarian abscess is one of the major complications of acute PID and occurs in up to 15-30% of women requiring hospitalization for treatment of PID.

Prognosis:
　

• Therapy using antibiotics alone is successful in 33-75% of cases. If surgical therapy is warranted, the current trend in therapy is conservation of reproductive potential with simple drainage, adhesiolysis, and copious irrigation; or unilateral adnexectomy, if at all possible. Further surgical therapy is needed in 15-20% of cases so managed.

• Chronic pelvic pain occurs in approximately 25% of patients with a history of pelvic inflammatory disease. This pain is thought to be related to cyclic menstrual changes, but also may be the result of adhesions or hydrosalpinx.

• Impaired fertility is a major concern in women with a history of pelvic inflammatory disease. The rate of infertility increases with the number of episodes of infection.

• The risk of ectopic pregnancy is increased in women with a history of pelvic inflammatory disease. Ectopic pregnancy is a direct result of damage to the fallopian tube.

Patient Education:
　

• It is important to ask women about high-risk sexual behavior.

• Encourage screening tests for those at risk.

• Ensure that male sex partners are evaluated and treated.

• Counsel women about safe sex practices.

MISCELLANEOUS

Medical/Legal Pitfalls:
　

• A frequent cause of litigation is failure to diagnose. The physician should always clearly document the patient's complaints, as well as the physical examination and results of laboratory and radiological studies. It is equally important to document the diagnosis, treatment plan, and disposition of the case. If the patient is referred to other services for consultation, a copy of the consulting physician's note should be attached to the medical record.

Special Concerns:
　

• Women with HIV infection who have PID have similar symptoms when compared to women who do not have HIV. However, women with HIV infection are more likely to have tubo-ovarian abscess.