Pelvic Inflammatory Disease

Pelvic Inflammatory Disease (PID) is a clinical syndrome associated with ascending spread of microorganisms from the vagina and endocervix to the upper genital tract. It primarily affects young, sexually active women.

Causes

  • Infection: Most cases of PID are caused by sexually transmitted infections (STIs), with the most common isolates being Chlamydia trachomatis and Neisseria gonorrhoeae.
  • Microbial Invasion: Following procedures like childbirth, miscarriage, endometrial biopsy, or insertion of intrauterine devices (IUD), there’s a risk of microbial invasion leading to PID.

Diagnosis

  • History:
    • Symptoms: Lower abdominal pain, abnormal vaginal discharge, irregular menstrual bleeding, dyspareunia (pain during intercourse), fever.
    • Sexual History: Multiple sexual partners, recent partner change, unprotected intercourse.
    • Past Medical History: Previous episodes of PID, STIs.
  • Physical Examination:
    • Abdominal Exam: Lower abdominal tenderness.
    • Pelvic Exam: Cervical motion tenderness, uterine tenderness, adnexal tenderness.
  • Investigations:
    • Laboratory Tests: Elevated white blood cell count, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR).
    • STI Screening: Chlamydia and gonorrhea testing.
    • Imaging: Pelvic ultrasound may be used to detect signs of upper genital tract infection or complications like tubo-ovarian abscess.
    • Endometrial Biopsy: In some cases, to confirm diagnosis.

Differential Diagnosis

  • Ectopic Pregnancy: Must be excluded in sexually active women of childbearing age presenting with pelvic pain.
  • Appendicitis, Ovarian Torsion, and Urinary Tract Infection: Present with similar abdominal pain.
  • Endometriosis: Chronic pelvic pain, often associated with menstrual cycle.
  • Gastrointestinal Disorders: Irritable bowel syndrome, inflammatory bowel disease.

Management

  • Antibiotic Therapy: Empirical broad-spectrum antibiotics as soon as the diagnosis is suspected. eTG says ceftriaxone+metronidazole+doxycycline
    • Ceftriaxone 500mg IM or IV stat
    • Metronidazole 400mg oral BD 14/7
    • Doxycycline 100mg oral BD 14/7
  • Pain Management: NSAIDs for symptomatic relief of pain and inflammation.
  • Follow-Up: Reassessment in 48-72 hours to ensure clinical improvement.
  • Sexual Partners: Evaluation, testing, and treatment of sexual partners.
  • Education and Prevention: Safe sex practices, regular STI screening.
  • Vaccination for HPV if this has not already been done
  • Surgery: In rare cases, surgical intervention may be necessary, especially for complications like tubo-ovarian abscess.
  • Fertility Assessment: As PID can affect fertility, it’s important to discuss future fertility and family planning.

Monitoring and Long-Term Care

  • Regular follow-up to monitor for potential complications such as
    • chronic pelvic pain,
    • ectopic pregnancy, and
    • infertility.
  • Education regarding the importance of completion of antibiotic therapy, even if symptoms resolve earlier.

Referral

  • If the patient is not responding to treatment or if there are complications, referral to a gynecologist is warranted.

Prompt recognition and treatment of PID are crucial to prevent serious complications and preserve fertility. A high degree of suspicion is necessary in sexually active women presenting with pelvic pain.