PELVIC INFLAMMATORY DISEASE

Pelvic inflammatory disease (PID) is an infectious and inflammatory disorder of the upper female
genital tract, including the uterus, fallopian tubes, and adjacent pelvic structures. Infection and
inflammation may spread to the abdomen, including perihepatic structures (Fitz-HughCurtis
syndrome). 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 a high prevalence of
sexually transmitted disease (STD).
PID is initiated by infection that ascends from the vagina and cervix into the upper genital
tract. Chlamydia trachomatis is the predominant sexually transmitted organism associated with PID.
Other organisms implicated in the pathogenesis of PID include Neisseria gonorrhoeae, Gardnerella
vaginalis, Haemophilus influenzae, and anaerobes such as Peptococcus and Bacteroides species.
Laparoscopic studies have shown that in 30-40% of cases, PID is polymicrobial
The diagnosis of acute PID is primarily based on historical and clinical findings. Clinical manifestations
of PID vary widely, however: Many patients exhibit few or no symptoms, whereas others have acute,
serious illness. The most common presenting complaint is lower abdominal pain. Many women report
an abnormal vaginal discharge.

The differential diagnosis includes appendicitis, cervicitis, urinary tract infection, endometriosis, and
adnexal tumors. Ectopic pregnancy can be mistaken for PID; indeed, PID is the most common
incorrect diagnosis in cases of ectopic pregnancy. Consequently, a pregnancy test is mandatory in the
workup of women of childbearing age who have lower abdominal pain.
PID may produce tubo-ovarian abscess (TOA) and may progress to peritonitis and Fitz-HughCurtis
syndrome (perihepatitis; see the image below). Subclinical PID or a delay in diagnosis or treatment of
PID can result in long-term sequelae, such as chronic pelvic pain and tubal infertility.

"Violin-string" adhesions of chronic Fitz-Hugh-Curtis syndrome.

Laparoscopy is the current criterion standard for the diagnosis of PID. No single laboratory test is
highly specific or sensitive for the disease, but studies that can be used to support the diagnosis
include the erythrocyte sedimentation rate (ESR), the C-reactive protein (CRP) level, and chlamydial
and gonococcal DNA probes and cultures. Imaging studies (eg, ultrasonography, computed
tomography [CT], and magnetic resonance imaging [MRI]) may be helpful in unclear cases.
Most patients with PID are treated in an outpatient setting. In selected cases, however, physicians
should consider hospitalization.
Empirical antibiotic treatment is recommended for patients with otherwise unexplained uterine or
adnexal tenderness and cervical motion tenderness, according to guidelines from the Centers for
Disease Control and Prevention (CDC). Antibiotic regimens for PID must be effective against C
trachomatis andN gonorrhoeae, as well as against gram-negative facultative organisms, anaerobes,
and streptococci.

Pathophysiology
Most cases of PID are presumed to occur in 2 stages. The first stage is acquisition of a vaginal or
cervical infection. This infection is often sexually transmitted and may be asymptomatic. The second
stage is direct ascent of microorganisms from the vagina or cervix to the upper genital tract, with
infection and inflammation of these structures.
The mechanism (or mechanisms) by which microorganisms ascend from the lower genital tract is
unclear. Studies suggest that multiple factors may be involved. Although cervical mucus provides a
functional barrier against upward spread, the efficacy of this barrier may be decreased by vaginal
inflammation and by hormonal changes that occur during ovulation and menstruation.
In addition, antibiotic treatment of sexually transmitted infections can disrupt the balance of
endogenous flora in the lower genital tract, causing normally nonpathogenic organisms to overgrow
and ascend. Opening of the cervix during menstruation, along with retrograde menstrual flow, may
also facilitate ascent of microorganisms.
Intercourse may contribute to the ascent of infection through rhythmic uterine contractions occurring
during orgasm. Bacteria may also be carried along with sperm into the uterus and fallopian tubes.
In the upper tract, a number of microbial and host factors appear to influence the degree of
inflammation that occurs and, thus, the amount of subsequent scarring that develops. Infection of the
fallopian tubes initially affects the mucosa, but inflammation may rapidly become transmural. This
inflammation, which appears to be mediated by complement, may increase in intensity with
subsequent infections.
Inflammation may extend to uninfected parametrial structures, including the bowel. Infection may
extend via spillage of purulent materials from the fallopian tubes or via lymphatic spread beyond the
pelvis to produce acute peritonitis and acute perihepatitis (Fitz-HughCurtis syndrome).

Pregnancy-related factors
PID rarely occurs in pregnancy; however, chorioamnionitis can occur in the first 12 weeks of
gestation, before the mucous plug solidifies and seals off the uterus from ascending bacteria. Fetal
loss may result. Concurrent pregnancy influences the choice of antibiotic therapy for PID and
demands that an alternative diagnosis of ectopic pregnancy be excluded. Uterine infection is usually
limited to the endometrium but may be more invasive in a gravid or postpartum uterus.
Genetic factors
Genetically mediated variation in immune response plays an important role in susceptibility to
PID. Variants in the genes that regulate toll-like receptors (TLRs), an important component in the
innate immune system, have been associated with an increased progression of C
trachomatis infection to PID.
Den Hartog et al found a possible contributing role of 5 single-nucleoside polymorphisms (SNPs) in 4
genes encoding pattern recognition receptors in local tubal cells and circulating immune cells (eg,
macrophages). The presence of 2 or more SNPs appeared to correlate with increased
laparoscopically identifiable tubal pathology.
PID has 3 principal complications, as follows:

Chronic pelvic pain

Infertility
Ectopic pregnancy
Chronic pelvic pain occurs in approximately 25% of patients with a history of PID. This pain is thought
to be related to cyclic menstrual changes, but it also may be the result of adhesions or hydrosalpinx.
Impaired fertility is a major concern in women with a history of PID. Infection and inflammation can
lead to scarring and adhesions within tubal lumens. Of women with tubal factor infertility, 50% have no
history of PID but have scarring of the fallopian tubes and exhibit antibodies to C trachomatis. The
rate of infertility increases with the number of episodes of infection.
The risk of ectopic pregnancy is increased 15-50% in women with a history of PID. Ectopic pregnancy
is a direct result of damage to the fallopian tube.
PID may produce TOA and extend to produce pelvic peritonitis and Fitz-HughCurtis syndrome
(perihepatitis). TOA is reported in as many as one third of women hospitalized for PID.
Approximately 125,000-150,000 hospitalizations occur yearly in the United States because of PID.
[37]
Women in resource-poor countries, especially those in sub-Saharan Africa and Southeast Asia,
experience an increased rate of complications and sequelae; reasons for these higher rates include
lack of access to care and inability to afford optimal care.
Studies of Taiwanese databases that included more than 60,000 women diagnosed with PID found
that PID was an independent risk factor for myocardial infarction in patients older than 55 year.and
that risk of stroke was increased in the 3 years following PID. Another large-scale study from Taiwan
found that the risk of ovarian cancer is also increased, particularly in women who have had at least 5
episodes of PID

Complications of pelvic inflammatory disease

Pelvic inflammatory disease (PID) can sometimes lead to serious and long-term problems, particularly
if the condition is not treated promptly with antibiotics.
However, most women with PID who complete their course of antibiotics have no long-term problems.
Recurrent pelvic inflammatory disease
Some women will experience repeated episodes of PID. This is known as recurrent pelvic
inflammatory disease.
The condition can return if the initial infection is not entirely cleared, often because the course of
antibiotics was not completed, or because a sexual partner has not been tested and treated.
If an episode of PID damages the womb or fallopian tubes, it can become easier for bacteria to infect
these areas in the future, making you more susceptible to developing the condition again.
Repeated episodes of PID are associated with an increased risk of infertility (see below).

Abscesses

PID can sometimes cause collections of infected fluid called abscessesto develop, most commonly in
the fallopian tubes and ovaries.
Abscesses may be treated with antibiotics, but sometimes laparoscopic surgery (keyhole surgery)
may be needed to drain the fluid away. The fluid can also sometimes be drained using a needle that's
guided into place using an ultrasound scan.
Long-term pelvic pain
Some women with PID develop long-term (chronic) pain around their pelvis and lower abdomen,
which can be difficult to live with and can lead to further problems such as depression and difficulty
sleeping (insomnia).

If you develop chronic pelvic pain, you may be given painkillers to help control your symptoms and
tests to determine the cause may be carried out. If painkillers do not help control your pain, you may
be referred to a pain management team or a specialist pelvic pain clinic.

Ectopic pregnancy

An ectopic pregnancy is when a fertilised egg implants itself outside of the womb, usually in one of the
fallopian tubes.
If PID infects the fallopian tubes, it can scar the lining of the tubes, making it more difficult for eggs to
pass through. If a fertilised egg gets stuck and begins to grow inside the tube, it can cause the tube to
burst, which can sometimes lead to severe and life-threatening internal bleeding.
Therefore, medication to stop the egg growing or surgery to remove it may be recommended if you
are diagnosed with an ectopic pregnancy.

Infertility

As well as increasing your risk of having an ectopic pregnancy, scarring or abscesses in the fallopian
tubes can make it difficult for you to get pregnant if eggs cannot pass easily into the womb.
It's estimated that about one in every 10 women with PID becomesinfertile as a result of the condition,
with the highest risk in women who had delayed treatment or repeated episodes of PID. However, a
long term study in the US showed that women who had been successfully treated for PID had the
same pregnancy rates as the rest of the population.
Blocked or damaged fallopian tubes can sometimes be treated with surgery, but if this is not possible
and you want to have children, you may want to consider an assisted conception technique such
as in-vitro fertilisation (IVF).
IVF involves surgically removing eggs from a woman's ovaries and fertilising them with sperm in a
laboratory, before planting the fertilised eggs are into the woman's womb. This technique can help you
get pregnant if you cannot have children naturally, but it's important to be aware that it does not have
a high success rate.