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Pelvic Inflammatory Disease (PID)

“Infection of the female upper genital tract including the uterus, fallopian tubes, and ovaries”

Risk Factors
  • Ages 14-25
  • Sexually active
  • Having multiple sexual partners (or one partner who has other sexual partners)
  • Sex without a condom
  • Douching regularly which upsets the microbial balance
  • History of STIs or PID
  • Slight increased risk in the first three weeks after IUD insertion
Aetiology
  • Chlamydia trachomatis and Neisseria gonorrhoeae are the main causes of PID. Evidence suggests that it is usually polymicrobial
Pathophysiology
  1. Bacteria enter the female lower genital tract
  2. Infection in the vagina and cervix
  3. Ascends into the upper genital tract
  4. Pathogens travel through the infundibulum to the pelvic cavity
  5. PIDIn about ¼ of cases, an STI is a cause
  • In most cases, the cause of infection is unknown
Clinical Presentation
  • Presentations range from asymptomatic to severe.
  • The most common symptom is pain in the lower abdomen.
  • Other symptoms include pain in the upper abdomen, pyrexia, dyspareunia, dysuria, irregular bleeding, increased or foul-smelling vaginal discharge, tiredness, cervical motion tenderness, uterine tenderness and adnexal tenderness.
  • Severe symptoms include a sharp pain in the abdomen, vomiting, fainting and a fever > 38oC
Investigations
  • Diagnosis is based on symptoms and a gynaecological examination.
  • Medical and sexual history
    • a diagnosis may be made after a history is taken but in most cases, other investigations are needed.
  • Pelvic examination
    • to check for cervical motion, uterine and adnexal tenderness, swelling, and abnormal vaginal discharge.
    • Those with PID will find this examination particularly uncomfortable.
  • Vaginal and cervical swabs
    • for MC&S (a positive test for chlamydia, gonorrhoea, or mycoplasma genitalium supports the diagnosis of PID. However, a negative swab doesn’t rule out the diagnosis
  • Blood and urine tests
    • to test for pregnancy, HIV or other STIs, haematuria, cancer, or other diseases
  • Ultrasound
    • usually transvaginal ultrasound to image the reproductive organs.
    • Often only demonstrates ascitic fluid in the peritoneal cavity or non-specific thickening and increased vascularity of the endometrium but in severe cases, may show adnexal masses.
    • May show signs of tubal inflammation including thickened/dilated fallopian tubes, cogwheel sign (thickening loops of the Fallopian tube seen on cross-section), and beads on a string sign.
  • Laparoscopy
    • for visualisation of the internal organs and tissue samples can be taken if necessary.
    • Laparoscopy can visualize “violin-string” adhesions, characteristic of Fitz-Hugh–Curtis perihepatitis and other abscesses that may be present.
    • Definitive criteria include histopathologic evidence of endometritis, thickened filled Fallopian tubes, or laparoscopic findings.
  • CT
    • shows thickening of uterosacral ligaments, complex free fluid in the pouch of Douglas, pelvic fat stranding or haziness, indistinct uterine border, fallopian tube thickening of >5mm, and reactive lymphadenopathy
Management
  • If diagnosed early, PID can be treated easily and effectively with antibiotics.
  • Antibiotics
    • must be started quickly before the results of the swabs are available.
    • A mixture of antibiotics is given to cover common causative organisms.
    • They are usually taken for 14 days and the course must be finished.
    • For severe cases, IV antibiotics may be given in hospital.
    • NICE recommendations example: Ceftriaxone 1 g as a single intramuscular (IM) dose, followed by oral doxycycline 100 mg twice daily plus oral metronidazole 400 mg twice daily for 14 days.
  • Sexual partners that the patient has been with in the 6 months before their symptoms started should be tested and treated.
    • Sexual intercourse should be avoided until treatment is completed and symptoms are resolved.
  • Prevention includes practicing safe sex with barrier methods, getting tested for STIs and requesting partner does, avoiding douching, and wiping from front to back
Complications
  • Repeated episodes of PID – a recurrent pelvic inflammatory disease. PID can return if the initial infection isn’t cleared completely, or if there is damage to the uterus and fallopian tubes as this makes it easier for bacteria to infect these areas in the future
  • Abscesses can form, most commonly in the fallopian tubes and ovaries.
  • Chronic pain can develop around the pelvis and lower abdomen. This can lead to further problems such as depression and insomnia.
  • Scarring in the fallopian tubes can lead to ectopic pregnancy or even infertility as the fertilised embryo or egg /sperm cannot pass through the fallopian tube

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