Pelvic Inflammatory Disease

Pathophysiology

Presumed to occur in two stages: acquisition of vaginal or cervical infection, followed by the direct ascent of the microorganism from the vagina or cervix to
the upper genital tract, with inflammation and infection of these structures.
The mechanism by which microorganisms ascend is unclear
PID rarely occurs in pregnancy
Variants in the genes that regulate toll-like receptors, an important component in the innate immune system, have been associated with an increased
progression of C trachomatis infection to PID

Etiology:

The organisms most commonly isolated in cases of acute PID are N gonorrhoeae and C trachomatis
In the United States, N gonorrhoeae is no longer the primary organism associated with PID, but gonorrhea remains the second most frequently reported
sexually transmitted disease, after chlamydial infection.

Epidemiology

From 1995 to 2001, 769,859 cases of PID were reported in the United States annually, though true incidence was probably much higher.
The CDC has estimated that more than 1 million women experience an episode of PID every year.

Risk Factors

Risk factors for PID include multiple sexual partners, a history of prior STIs, and a history of sexual abuse.
Gynecologic surgical procedures such as endometrial biopsy, curettage, and hysteroscopy break the cervical barrier, predisposing women to ascending
infections

Clinical Manifestations

The classic patient at high risk for pelvic inflammatory disease (PID) 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 infections
Depending on the severity of the infection, patients with PID may be minimally symptomatic or may present with toxic symptoms of fever (temperature 38
C [100.4 F] or higher), nausea, vomiting, and severe pelvic and abdominal pain
Lower abdominal pain is usually present. The pain is typically described as dull, aching or crampy, bilateral, and constant; it begins a few days after the
onset of the last menstrual period and tends to be accentuated by motion, exercise, or coitus.
Abnormal vaginal discharge is present in approximately 75% of cases. Unanticipated vaginal bleeding, often postcoital, is reported in about 40% of cases

Physical Exam

The CDC recommends instituting empiric treatment of PID when a sexually active young woman who is at risk for STI has pelvic or lower abdominal pain,
no identifiable cause for her illness other than PID, and, on pelvic examination, 1 or more of the following minimal criteria: cervical motion tenderness,
uterine tenderness, adnexal tenderness.
A temperature higher than 38.3 C (101 F) and the presence of an abnormal cervical or vaginal mucopurulent discharge enhance the specificity of the
minimum criteria, as do selected laboratory tests.

Diagnosis

Laparoscopy is the criterion standard for the diagnosis of PID.

Additional criteria that improve diagnostic specificity include: oral temperature higher than 101F, abnormal cervical or vaginal mucopurulent discharge,
abundant white blood cells (WBCs) on saline microscopy of vaginal secretions, elevated ESR, elevated CRP level, or laboratory evidence of cervical
infection.

Treatment

Most TOAs (60-80%) resolve with antibiotic administration.

The advantages of laparoscopy include direct visualization of the pelvis and more accurate bacteriologic diagnosis if cultures are obtained. However,
laparoscopy is not always available in acute PID; moreover, it is costly and requires general anesthesia.
Laparotomy is usually reserved for patients experiencing surgical emergencies and for patients who are not candidates for laparoscopic management.

Prognosis

PID has three principal complications: chronic pelvic pain, infertility, and ectopic pregnancy.
Chronic pelvic pain is thought to be related to cyclic menstrual changes, but it also may be the result of adhesions or hydrosalpinx.
The risk of ectopic pregnancy is increased 15-50% in women with a history of PID.
Infection and inflammation can lead to scarring and adhesions within tubal lumens leading to impaired fertility.

Patient Education

Patient education should focus on methods of preventing PID and STIs, including reducing the number of sexual partners, avoiding unsafe sexual practices,
and routinely using appropriate barrier protection.

After treatment, women should be counseled to abstain from sexual activity or educated to use barrier protection strictly and appropriately until their
symptoms have fully abated and they have completed their antibiotic regimen.
The womans sexual partner should also be treated for STI if necessary.

SuzanneMooreShepherd.PelvicInflammatoryDisease.http://emedicine.medscape.com/article/256448overview(accessed02February2014).