Pelvic Inflammatory Disease

Definition

Pelvic Inflammatory Disease (PID) refers to an infection of the female reproductive organs, including the uterus, fallopian tubes, ovaries, and surrounding pelvic structures, most commonly caused by sexually transmitted infections (STIs) like Chlamydia trachomatis and Neisseria gonorrhoeae.

Etiology

• Sexually transmitted infections (STIs):
  • Chlamydia trachomatis (most common)
  • Neisseria gonorrhoeae
• Endogenous flora:
  • Escherichia coli
  • Streptococcus species
  • Gardnerella vaginalis
• Post-surgical or post-abortion infections
• IUD-related infections (particularly in the first 3 weeks after insertion)
• Bacterial vaginosis (BV) and other vaginal infections may predispose to PID.

Risk Factors

• Sexually active women, particularly those under 25 years
• Multiple sexual partners
• History of STIs or previous PID
• Lack of consistent condom use
• Douching
• Recent gynecological surgery or abortion
• IUD insertion within the last 3 weeks

Clinical Features

Symptoms

• Lower abdominal/pelvic pain (most common)
• Abnormal vaginal discharge (often foul-smelling)
• Dysuria (painful urination)
• Dyspareunia (painful intercourse)
• Fever
• Irregular menstrual bleeding or postcoital bleeding
• Nausea and vomiting (in severe cases)

Signs

• Tenderness on pelvic examination:
  • Cervical motion tenderness (CMT)
  • Adnexal tenderness
  • Lower abdominal tenderness
• Abnormal vaginal discharge (purulent, yellow-green in color)
• Fever (low-grade), especially in acute cases
• Tachycardia
• Signs of peritonitis (in severe cases)

Investigations

1. Blood Tests

• Full blood count (FBC):
  • Leukocytosis (elevated white blood cell count) suggests infection
  • Neutrophilia may be seen in acute infections
• C-reactive protein (CRP): Elevated CRP indicates inflammation/infection.
• Erythrocyte sedimentation rate (ESR): Elevated in active infection.
• Liver function tests: Elevated in cases of tubo-ovarian abscess (TOA) or perihepatitis (Fitz-Hugh-Curtis syndrome).
• Serological tests for STIs:
  • Chlamydia trachomatis and Neisseria gonorrhoeae (urine or cervical swab testing).
  • HIV, Syphilis, and Hepatitis B/C testing may be considered.

2. Urine Test

• Urine analysis: Rule out urinary tract infection (UTI) and provide general health status.
• Urine PCR (Polymerase Chain Reaction) for Chlamydia trachomatis and Neisseria gonorrhoeae.

3. Microscopy & Cultures

• Endocervical or vaginal swab: Microscopic examination and culture of discharge can help identify the causative organisms.
  • Gram stain can help identify Neisseria gonorrhoeae.
  • PCR-based testing for Chlamydia and Gonorrhea.
  • Culture for other pathogens (e.g., E. coli, Streptococcus, Gardnerella).

4. Imaging

• Ultrasound (first-line imaging modality):
  • Transabdominal or transvaginal ultrasound: Useful in detecting complications like tubo-ovarian abscess (TOA), free pelvic fluid, and uterine enlargement.
  • Color Doppler ultrasound may show increased blood flow to inflamed areas.

• CT scan or MRI (in severe cases or to evaluate complications):
  • May help identify tubo-ovarian abscesses (TOA) and pelvic collections.

Diagnosis

• Diagnosis is largely clinical, supplemented by laboratory and imaging findings.
• Key diagnostic criteria include:
  • Pelvic pain (abdominal and/or adnexal)
  • Cervical motion tenderness, uterine tenderness, and/or adnexal tenderness on pelvic exam
  • Laboratory evidence of infection (positive STI tests or elevated inflammatory markers like CRP or ESR)
  • Imaging findings (e.g., ultrasound showing TOA or free fluid).

Differential Diagnosis

Ectopic pregnancy

Urinary tract infection (UTI)

Ovarian cyst or rupture

Appendicitis

Endometriosis

Ovarian torsion

Urinary tract stones

Pelvic tumors

Gastrointestinal conditions (e.g., diverticulitis)

Management

1. Antibiotic Therapy

• Empiric antibiotics should be started as soon as PID is suspected, even before definitive diagnosis is confirmed.
• Outpatient treatment: For mild to moderate cases, and when the patient can tolerate oral medication.
• Inpatient treatment: For severe cases, complications (e.g., TOA), or inability to tolerate oral antibiotics.

Outpatient regimen (based on RCOG, ACOG, RANZCOG, and British guidelines):

• Ceftriaxone 500 mg IM single dose +
• Doxycycline 100 mg orally twice a day for 14 days +
• Metronidazole 400 mg orally twice a day for 14 days (for anaerobic coverage).

Inpatient regimen (severe cases):

• IV Cefotetan or Cefoxitin + Doxycycline IV
• Transition to oral antibiotics once clinical improvement is observed.
• Consider Broad-spectrum coverage for anaerobes and Gram-negative organisms.
• Adjust treatment based on culture results: After obtaining culture and sensitivity, modify the antibiotic regimen to narrow-spectrum treatment.

2. Surgical Management

• Tubo-ovarian abscess (TOA):
  • If large or complicated, abscess drainage may be required (either percutaneously or surgically).
  • Surgical intervention is considered if the abscess does not respond to antibiotic therapy.
• Emergency surgery in cases of rupture or peritonitis.

3. Pain Management

• Analgesics (NSAIDs such as ibuprofen) and paracetamol.
• Opioids for severe pain (as needed).

4. Management of Sexual Partners

• All recent sexual partners (within 60 days prior to diagnosis) should be tested and treated for STIs, regardless of their symptoms.

5. Follow-up

• Re-evaluate in 72 hours: If symptoms do not improve or worsen, the patient should return for reassessment, including considering hospital admission or alternative diagnoses.
• Repeat STI testing: In cases of reinfection or if symptoms persist.

6. Prevention

• Consistent condom use to reduce STI transmission.
• Regular screening for Chlamydia and Gonorrhea for sexually active women under 25 or those with risk factors.
• Prompt treatment of any STIs to prevent PID.

Complications of PID

• Tubo-ovarian abscess (TOA)
• Chronic pelvic pain
• Infertility (due to fallopian tube scarring)
• Ectopic pregnancy
• Peritonitis
• Sepsis
• Adhesions and chronic inflammation

Prognosis

• Early diagnosis and appropriate treatment lead to good outcomes in most cases.
• Chronic complications (such as infertility or chronic pelvic pain) are more common in cases of delayed treatment or recurrent PID.

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