AN ACUTE INFECTION of the female upper genital tract structures involving any or all of the uterus, oviducts, and/or ovaries, pelvic inflammatory disease (PID) is most commonly a complication of sexually transmitted infections (STIs), especially Chlamydia trachomatis and Neisseriagonorrhoeae.1 Other organisms that have been implicated in PID include Gardnerella vaginalis, Haemophilus influenzae, and Streptococcus agalactiae.2,3 Along with causing severe lower abdominal and pelvic pain, PID may lead to complications such as infertility and ectopic pregnancy. In the short term, PID may cause abscess formation, requiring hospitalization and surgery.2,3
One million or more women in the United States develop PID each year.2 A woman's risk of developing PID increases with the number of sexual partners she has and/or a sexual partner who has multiple sexual partners. A woman who previously had PID is at risk for a repeat episode due to increased susceptibility from damage to the pelvic organs during the first infection. Women under age 25 have an increased risk of PID because the cervix, which can block the entrance of the offending organisms into the uterus, isn't fully developed until after age 25.2 Other risk factors include vaginal douching and the use of an intrauterine device during the first 3 weeks after insertion; the risk decreases if testing and treatment of any STIs is done before insertion.2
Signs and symptoms of PID vary depending upon the severity of the infection and the infectious organism. Chlamydia is often responsible for mild symptoms, even though the infection can cause severe damage to reproductive structures. Often, infections aren't recognized because chlamydial infections may be asymptomatic.2
When symptoms occur, they're most often in the form of lower abdominal and/or pelvic pain. Other signs and symptoms include:
- change in vaginal discharge including color, amount, and odor
- pain with intercourse
- irregular menses.2
Depending on the severity of the infection, fever and chills, nausea and vomiting, painful defecation, and dehydration may also occur.2-4
Complications of PID can include infertility from blocked fallopian tubes, ectopic pregnancy, tuboovarian abscess, chronic pelvic pain, and infection, including sepsis, of a vaginally delivered newborn.3,5
PID may go undiagnosed if symptoms are mild or unrecognized. A specific test for diagnosing PID doesn't exist and test results for STIs aren't immediately available, so PID is diagnosed on clinical presentation. Physical examination of the genitalia and STI testing are done first.3 Ultrasound may be ordered to rule out abscess or other abnormalities (tumors, fibroids, cysts, ectopic pregnancy, appendicitis) as well as to look for inflammation of the fallopian tubes. In some cases, laparoscopy may be done to examine the ovaries and fallopian tubes as well as to obtain bacterial samples.
PID should be suspected if cervical motion tenderness, uterine tenderness, and/or adnexal tenderness are present. Lower genital tract inflammation such as cervical friability, leukocytosis seen on microscopic examination of vaginal secretions, or cervical exudates along with the previous symptoms increase the likelihood of PID.2,3
Additional signs and symptoms that support a diagnosis of PID include:
- oral temperature over 101° F (38.3° C)
- abnormal cervical or vaginal discharge
- elevated erythrocyte sedimentation rate and C-reactive protein.4
PID is treated with antibiotics specifically aimed at the offending organism, most often chlamydia, gonorrhea, or a combination of infectious organisms. Antibiotics prescribed include cefoxitin, doxycycline, clindamycin, gentamicin, ampicillin/sulbactam, and ceftriaxone.3 Because of increasing resistance rates, fluoroquinolones are no longer recommended to treat PID.1
Because PID is most commonly caused by STIs, the patient's sex partners must be identified and treated as well to decrease not only reinfection in the patient but spread of the disease to others. Partners should be considered for treatment if they had sexual contact with the patient during the 60 days before the patient's onset of symptoms.1 In patients with no sexual partners within the preceding 60 days, treatment of the most recent partner is considered. While undergoing treatment, patients and partners should abstain from sexual relations until treatment is completed and symptoms have resolved.2,3
Mild infections can be managed on an outpatient basis. Patients who should be hospitalized and treated with I.V. antibiotics and fluids include those with more severe infections or complications, such as dehydration from fever and/or nausea and vomiting; those who fail to respond to oral antibiotics; those who have an abscess; and pregnant patients. Surgery may be needed in those with an unresolved abscess or an alternative diagnosis such as appendicitis.2,3
Patients with a diagnosis of PID should be followed closely to prevent complications. If the patient is being treated as an outpatient, the patient should return for reevaluation in 72 hours. If symptoms don't improve or if the patient's clinical status is worsening, hospitalization and I.V. therapy as well as further diagnostic studies such as ultrasound and laparoscopy may be indicated. Reinfection rates are high; all women diagnosed with chlamydia or gonorrhea should have repeat testing done in 3 to 6 months.3
Prevention of PID is based on safer sexual practices. Limiting partners, preferably in a mutually monogamous relationship, and using condoms correctly each and every time are effective ways to decrease the risk of infection. Testing for STIs before entering into a new sexual relationship and treating any STIs found are also helpful. The CDC recommends testing for chlamydia and gonorrhea yearly in all women under age 25, in women over age 25 if they have multiple partners or a new sexual partner, and in pregnant women.2
Help patients distinguish between normal and abnormal vaginal discharge and tell them to seek assistance when they note changes in color and odor that may indicate infection. Educate women on the proper use of condoms and encourage women to be sure to have their partners use them each and every time they have intercourse. Be sure that women, especially those under age 25, get tested yearly for chlamydia and gonorrhea. Remind women to refrain from sexual intercourse during STI therapy.
Encourage women who can't get pregnant to inquire with a gynecologist about potential infertility related to past PID infection; one in eight women with a history of PID has problems getting pregnant.2 Also educate women about the signs and symptoms of ectopic pregnancy, especially abdominal pain and vaginal bleeding, which can be fatal if not recognized and treated promptly.