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{{Pelvic inflammatory disease}}
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==Overview==
==Overview==
'''Pelvic inflammatory disease''' (or disorder) (PID) is a generic term for [[infection]] of the female [[uterus]],[[fallopian tubes]], and/or [[ovaries]] as it progresses to scar formation with [[Adhesion (medicine)|adhesions]] to nearby tissues and organs.  This may lead to tissue [[necrosis]] with/or without [[abscess]] formation. [[Pus]] can be released into the peritoneum.  Two thirds of patients with [[laparoscopic]] evidence of previous PID were not aware they had had PID <ref name="titleSTD Facts -Pelvic inflammatory disease (PID)">{{cite web |url=http://www.cdc.gov/std/PID/STDFact-PID.htm |title=STD Facts - Pelvic inflammatory disease (PID) |accessdate=2007-11-23 |format= |work=}}</ref>  (Cecil's 5th ed). PID is often associated with [[sexually transmitted diseases]], as it is a common result of such infections. PID is a vague term and can refer to viral, fungal, parasitic, though most often bacterial infections. PID should be classified by affected organs, the stage of the infection, and the organism(s) causing it. Although an [[sexually transmitted disease|STD]] is often the cause, other routes are possible, including lymphatic, postpartum, postabortal (either miscarriage or abortion) or [[Intrauterine device|intrauterine device (IUD)]] related, and [[blood|hematogenous]]spread.
Pelvic inflammatory disease is a generic term for the [[infection]] of the female [[uterus]], [[fallopian tubes]], and/or [[ovaries]] as it progresses to [[scar]] formation with [[Adhesion (medicine)|adhesions]] to nearby tissues and organs.  This may lead to tissue [[necrosis]] (with or without [[abscess]] formation). [[Pus]] can be released into the [[peritoneum]].  Two-thirds of patients with [[laparoscopic]] evidence of previous PID were not aware they had ever had PID. PID is often associated with [[sexually transmitted diseases]], as it is a common result of such infections. PID is a vague term and can refer to [[viral]], [[fungal]], or [[parasitic]] infections, though it most often refers to [[bacterial infections]]. PID should be classified by affected organs, the stage of the infection, and the causative organism(s). Although an [[sexually transmitted disease|STD]] is often the cause, other routes are possible, including [[Lymphatic system|lymphatic]], [[postpartum]], post-abortal (either [[miscarriage]] or [[abortion]]) or [[Intrauterine device|intrauterine device (IUD)]]-related and [[blood|hematogenous]] spread.


==Epidemiology and Demographics==
==Causes==
In the [[United States]], more than one million women are affected by PID each year, and the rate is highest with teenagers. Approximately 50,000 women become [[infertile]] in the US each year from PID. [[gonorrhea|N. gonorrhoea]] is isolated in only 40-60% of women with acute salpingitis <ref name="isbn0-8385-1401-4">{{cite book |author=Lauren Nathan; DeCherney, Alan H.; Pernoll, Martin L. |title=Current obstetric & gynecologic diagnosis & treatment |publisher=Lange Medical Books/McGraw-Hill |location=New York|year=2003 |pages= |isbn=0-8385-1401-4 |oclc= |doi=}}</ref> .  [[chlamydia|C. trachomatis]] was estimated by current obgyn 9th ed to be the cause in about 60% of cases of[[salpingitis]], which may lead to PID.  It is unsure how much is due to a single organism and how much is due to multiple organisms; many other pathogens that are in normal[[vaginal flora]] become involved in PID.  10% of women in one study had asymptomatic [[Chlamydia trachomatis]] infection and 65% had asymptomatic infection with [[N. gonorrhoea|Neisseria gonorrhoeae]]<ref name="isbn0-8385-1401-4">{{cite book |author=Lauren Nathan; DeCherney, Alan H.; Pernoll, Martin L. |title=Current obstetric & gynecologic diagnosis & treatment |publisher=Lange Medical Books/McGraw-Hill|location=New York |year=2003 |pages= |isbn=0-8385-1401-4 |oclc= |doi=}}</ref>  It was noted in one study that 10-40% of untreated women with N. gonorrhoea develop PID and 20-40% of women infected with C. trachomitis developed PID. PID is the leading cause of infertility. "A single episode of PID results in infertility in 13% of women." This rate of infertility increases with each infection.
PID occurs when bacteria move upward from a woman's [[vagina]] or [[cervix]] (opening to the [[uterus]]) into her reproductive organs. Many different organisms can cause PID, but a majority of cases are associated with [[gonorrhea]] and/or [[chlamydia]], two very common [[Sexually transmitted disease|bacterial STDs]].


==Risk Factors==
==Risk Factors==
Pelvic inflammatory disease is more likely to occur when there is a history of pelvic inflammatory disease, recent sexual contact, recent onset of menses, or an IUD in place or if the partner has a sexually transmitted disease. Acute pelvic inflammatory disease is highly unlikely when recent intercourse has not taken place or an IUD is not being used.
Pelvic inflammatory disease is more likely to occur in patients with a history of pelvic inflammatory disease, recent sexual contact, recent onset of menses, an [[IUD]] in place, or if a patient's partner has a [[sexually transmitted disease]]. Acute pelvic inflammatory disease is highly unlikely when recent intercourse has not taken place and an IUD is not being used.


==Natural History, Complications and Prognosis==
==Natural History, Complications and Prognosis==
PID itself may be cured, effects of the infection may be permanent. This makes early identification by someone who can prescribe appropriate curative treatment so important in the prevention of damage to the [[reproductive system]]. Since early gonococcal infection may be asymptomatic, regular screening of individuals at risk for common agents (history of multiple partners, history of any unprotected sex, or people with symptoms) or because of certain procedures (post pelvic operation, [[postpartum]], [[miscarriage]],or [[abortion]]). Prevention is also very important in maintaining viable reproduction capabilities. If the initial infection is mostly in the lower tract, after treatment the person may have few difficulties. If the infection is in the fallopian tubes or ovaries, more serious complications are more likely to occur.
While PID itself may be cured, effects of the infection can be permanent. This makes early identification by someone who can prescribe appropriate curative treatment critical for the prevention of damage to the [[reproductive system]]. Since early [[gonococcal infection]] may be asymptomatic, regular screening of high-risk individuals (e.g., though with a history of multiple partners, history of any unprotected sex, or people with symptoms) and patients who have undergone certain procedures (e.g., post pelvic operation, [[postpartum]], [[miscarriage]],or [[abortion]]). Prevention is also very important in maintaining viable reproductive capabilities. If the initial infection is mostly in the lower tract, a patient will likely not have reproductive difficulties after sufficient treatment. If the infection is in the [[fallopian tubes]] or [[ovaries]], serious complications are more likely to occur.


==History and Symptoms==
==Diagnosis==
There may be no actual symptoms of PID. If there are symptoms then [[fever]], [[cervix|cervical]] motion tenderness, lower [[abdominal pain]], new or different discharge, [[Pain and nociception|painful]] [[sexual intercourse|intercourse]], or irregular [[Menstrual cycle|menstrual]] bleeding may be noted. It is important to note that PID can occur and cause serious harm without causing any noticeable symptoms.
===History and Symptoms===
PID is difficult to diagnose because the symptoms are often subtle and mild. Many episodes of PID go undetected because the patient or her health care provider fails to recognize the implications of mild or non-specific symptoms. Because there are no precise tests for PID, a diagnosis is usually based on clinical findings. There may be no actual symptoms of PID for a given patient. If symptoms are present, then [[fever]], [[cervical motion tenderness]], lower [[abdominal pain]], new or different discharge, [[Dyspareunia|painful intercourse]], or irregular [[Menstrual cycle|menstrual]] bleeding may be noted. It is important to note that PID can occur and cause serious harm without causing any noticeable symptoms. Other signs and symptoms include unusual vaginal discharge that may have a foul odor, [[Dyspareunia|painful intercourse]], [[Dysuria|painful urination]], and [[Right upper quadrant pain|pain in the right upper abdomen]] (rare).


==Laboratory Findings==
===Laboratory Findings===
No single test has adequate [[sensitivity]] and [[specificity]] to diagnose pelvic inflammatory disease. Laboratory findings that look for signs of [[infection]] include [[C-reactive protein]] ([[CRP]]), [[erythrocyte sedimentation rate]] ([[ESR]]), and [[WBC]] count.
No single test has adequate [[sensitivity]] and [[specificity]] to diagnose pelvic inflammatory disease. Laboratory findings that look for signs of [[infection]] include [[C-reactive protein]] ([[CRP]]), [[erythrocyte sedimentation rate]] ([[ESR]]), and [[WBC]] count. A sensitive serum [[pregnancy test]] should be obtained to rule out ectopic pregnancy. [[Gram stain|Gram-stain]]/smear becomes important in identification of rare and possibly more serious [[Organism|organisms]].


==Ultrasound==
===Ultrasound===
Pelvic and vaginal ultrasounds are helpful in the differential diagnosis of ectopic pregnancy of over six weeks. Laparoscopy is often utilized to diagnose pelvic inflammatory disease, and it is imperative if the diagnosis is not certain or if the patient has not responded to antibiotic therapy after 48 hours.
A [[pelvic ultrasound]] is a helpful procedure for diagnosing PID. An [[ultrasound]] can view the pelvic area to see whether the [[fallopian tube]]s are enlarged or whether an [[abscess]] is present. Pelvic and vaginal ultrasounds are helpful in the differential diagnosis of [[ectopic pregnancy]] of over six weeks.


==Other Diagnostic Studies==
===Other Diagnostic Studies===
Laparoscopic identification is helpful in diagnosing tubal disease, 65-90% [[positive predictive value]] in patients with presumed PID. Regular[[Sexually Transmitted Disease|Sexually transmitted disease (STD)]] testing is important for prevention.  Treatment is usually started [[empirical|empirically]] because of the terrible complications.  Definitive criteria include:  [[histopathologic]] evidence of [[endometritis]], thickened filled fallopian tubes, or laparoscopic findings.  Gram-stain/smear becomes important in identification of rare and possibly more serious organisms. A sensitive serum pregnancy test should be obtained to rule out ectopic pregnancy. Culdocentesis will differentiate hemoperitoneum (ruptured [[ectopic pregnancy]] or hemorrhagic [[cyst]]) from pelvic sepsis ([[salpingitis]], ruptured [[pelvic abscess]], or ruptured [[appendix]]).
[[Culdocentesis]] will differentiate [[hemoperitoneum]] (ruptured [[ectopic pregnancy]] or hemorrhagic [[cyst]]) from pelvic sepsis ([[salpingitis]], ruptured [[pelvic abscess]], or ruptured [[appendix]]).


==Medical Therapy==
==Treatment==
Treatment depends on the cause and generally involves use of [[antibiotic]] therapy. If the patient has not improved within two to three days after beginning treatment with the antibiotics, they should return to the hospital for further treatment. Drugs should also be given orally and/or intravaneously to the patient while in the hospital to begin treatment immediately to increase the effectiveness of antibiotic treatment.   Hospitalization may be necessary if Tubo-ovarian abscess, very ill, immunodeficient, pregnancy, incompetence, or because this or something else life threatening can not be ruled out.  Treating partners for STD's is a very important part of treatment and prevention. Anyone with PID and partners of patients with PID since six months prior to diagnosis should be treated to prevent reinfection. Psychotherapy is highly recommended to women diagnosed with PID as the fear of redeveloping the disease after being cured may exist. It is important for a patient to communicate any issues and/or uncertainties they may have to a doctor, especially a specialist such as a gynecologist, and in doing so, to seek follow-up care.
===Medical Therapy===
Treatment depends on the cause and generally involves use of [[antibiotic]] therapy. If the patient has not improved within two to three days after beginning treatment with the antibiotics, they should return to the hospital for further treatment. Drugs should also be given orally and/or intravaneously to the patient while in the hospital to begin treatment immediately to increase the effectiveness of antibiotic treatment. Hospitalization may be necessary if there is a [[tubo-ovarian abscess]], the patient is very ill, [[immunodeficiency]] exists, the patient is [[pregnant]], there is [[cervical incompetence]], or because this or something else life threatening can not be ruled out.  Treating partners for [[STD]]s is a very important part of treatment and prevention. Anyone with PID and partners of patients with PID since six months prior to diagnosis should be treated to prevent reinfection. [[Psychotherapy]] is highly recommended to women diagnosed with PID as the fear of redeveloping the disease after being cured may exist. It is important for a patient to communicate any issues and/or uncertainties they may have to a doctor, especially a specialist such as a gynecologist, and in doing so, to seek follow-up care.
 
===Surgery===
If symptoms continue or if an [[abscess]] does not go away, surgery may be needed. Complications of PID, which can include [[chronic pelvic pain]] and [[scarring]], tend to be difficult to treat, though they sometimes improve with surgery.


==References==
==References==
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Latest revision as of 17:26, 21 May 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

Overview

Pelvic inflammatory disease is a generic term for the infection of the female uterus, fallopian tubes, and/or ovaries as it progresses to scar formation with adhesions to nearby tissues and organs. This may lead to tissue necrosis (with or without abscess formation). Pus can be released into the peritoneum. Two-thirds of patients with laparoscopic evidence of previous PID were not aware they had ever had PID. PID is often associated with sexually transmitted diseases, as it is a common result of such infections. PID is a vague term and can refer to viral, fungal, or parasitic infections, though it most often refers to bacterial infections. PID should be classified by affected organs, the stage of the infection, and the causative organism(s). Although an STD is often the cause, other routes are possible, including lymphatic, postpartum, post-abortal (either miscarriage or abortion) or intrauterine device (IUD)-related and hematogenous spread.

Causes

PID occurs when bacteria move upward from a woman's vagina or cervix (opening to the uterus) into her reproductive organs. Many different organisms can cause PID, but a majority of cases are associated with gonorrhea and/or chlamydia, two very common bacterial STDs.

Risk Factors

Pelvic inflammatory disease is more likely to occur in patients with a history of pelvic inflammatory disease, recent sexual contact, recent onset of menses, an IUD in place, or if a patient's partner has a sexually transmitted disease. Acute pelvic inflammatory disease is highly unlikely when recent intercourse has not taken place and an IUD is not being used.

Natural History, Complications and Prognosis

While PID itself may be cured, effects of the infection can be permanent. This makes early identification by someone who can prescribe appropriate curative treatment critical for the prevention of damage to the reproductive system. Since early gonococcal infection may be asymptomatic, regular screening of high-risk individuals (e.g., though with a history of multiple partners, history of any unprotected sex, or people with symptoms) and patients who have undergone certain procedures (e.g., post pelvic operation, postpartum, miscarriage,or abortion). Prevention is also very important in maintaining viable reproductive capabilities. If the initial infection is mostly in the lower tract, a patient will likely not have reproductive difficulties after sufficient treatment. If the infection is in the fallopian tubes or ovaries, serious complications are more likely to occur.

Diagnosis

History and Symptoms

PID is difficult to diagnose because the symptoms are often subtle and mild. Many episodes of PID go undetected because the patient or her health care provider fails to recognize the implications of mild or non-specific symptoms. Because there are no precise tests for PID, a diagnosis is usually based on clinical findings. There may be no actual symptoms of PID for a given patient. If symptoms are present, then fever, cervical motion tenderness, lower abdominal pain, new or different discharge, painful intercourse, or irregular menstrual bleeding may be noted. It is important to note that PID can occur and cause serious harm without causing any noticeable symptoms. Other signs and symptoms include unusual vaginal discharge that may have a foul odor, painful intercourse, painful urination, and pain in the right upper abdomen (rare).

Laboratory Findings

No single test has adequate sensitivity and specificity to diagnose pelvic inflammatory disease. Laboratory findings that look for signs of infection include C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and WBC count. A sensitive serum pregnancy test should be obtained to rule out ectopic pregnancy. Gram-stain/smear becomes important in identification of rare and possibly more serious organisms.

Ultrasound

A pelvic ultrasound is a helpful procedure for diagnosing PID. An ultrasound can view the pelvic area to see whether the fallopian tubes are enlarged or whether an abscess is present. Pelvic and vaginal ultrasounds are helpful in the differential diagnosis of ectopic pregnancy of over six weeks.

Other Diagnostic Studies

Culdocentesis will differentiate hemoperitoneum (ruptured ectopic pregnancy or hemorrhagic cyst) from pelvic sepsis (salpingitis, ruptured pelvic abscess, or ruptured appendix).

Treatment

Medical Therapy

Treatment depends on the cause and generally involves use of antibiotic therapy. If the patient has not improved within two to three days after beginning treatment with the antibiotics, they should return to the hospital for further treatment. Drugs should also be given orally and/or intravaneously to the patient while in the hospital to begin treatment immediately to increase the effectiveness of antibiotic treatment. Hospitalization may be necessary if there is a tubo-ovarian abscess, the patient is very ill, immunodeficiency exists, the patient is pregnant, there is cervical incompetence, or because this or something else life threatening can not be ruled out. Treating partners for STDs is a very important part of treatment and prevention. Anyone with PID and partners of patients with PID since six months prior to diagnosis should be treated to prevent reinfection. Psychotherapy is highly recommended to women diagnosed with PID as the fear of redeveloping the disease after being cured may exist. It is important for a patient to communicate any issues and/or uncertainties they may have to a doctor, especially a specialist such as a gynecologist, and in doing so, to seek follow-up care.

Surgery

If symptoms continue or if an abscess does not go away, surgery may be needed. Complications of PID, which can include chronic pelvic pain and scarring, tend to be difficult to treat, though they sometimes improve with surgery.

References

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