Pelvic Inflammatory Disease

Summary

• Pelvic inflammatory disease (PID) is an infection of the female reproductive organs.
• It is a leading cause of infertility in women.
• Women with sexually transmitted diseases (STDs) are at greater risk of developing PID.
• In most cases of PID, bacteria enter the vagina during sexual intercourse and move up into the cervix, uterus, fallopian tubes and to the ovaries.
• Symptoms include pain in the lower abdomen, vaginal discharge, abnormal bleeding and fever.

What is pelvic inflammatory disease (PID)?

Pelvic inflammatory disease (PID) is an infection of the upper genital tract and can affect the uterus, fallopian tubes and ovaries. The disease usually occurs when sexually transmitted bacteria move up from the vagina through the cervix into the upper genital tract. Aside from Aids, PID is the most common – and most serious – complication arising from sexually transmitted diseases (STDs) among women.

What causes PID?

The most common causes of PID are sexually transmitted micro-organisms which can lead to diseases such as gonorrhoea and chlamydia. The micro-organisms that cause these STDs are passed on through the sexual organs from the male to the female partner by being transmitted to the vagina and cervix during intercourse. From there, they can travel into the female internal reproductive organs. Bacteria participating in the developing infection can also be those ones which are normally found in the large intestine (colon). This may happen when intestinal bacteria get access to the vagina, especially when vaginal intercourse occurs right after anal sex.

Less common, PID can be caused by other organisms such as TB, and rarely by those causing bilharzia (schistosomiasis) and leprosy.

Who gets PID and who is at risk?

PID is more common in women under the age of 35 who are sexually active. The following factors increase the risk of PID:

• High-risk sexual practices, such as having unprotected intercourse, multiple sex partners or having sex with a person who has (or has had) other sexual partners.
• Women with STDs of the lower genital tract (vagina, cervix) – especially gonorrhoea and chlamydia.
• A prior episode of PID increases the risk of another episode.
• Sexually active teenagers are more likely to develop PID than older women.
• The more sexual partners a woman has, the greater her risk of developing PID.
• Research has also shown that women who perform vaginal douching once or twice a month may be more likely to develop PID. This is because these women often try to treat their already existing discharge and vaginal infection by douching which may also promote bacteria to travel into the upper genital tract.

Symptoms and signs of PID

Acute PID often starts shortly after a period, with lower abdominal pain that becomes progressively worse. A woman with PID may experience vomiting, high fever and a copious, foul-smelling vaginal discharge. However, a low-grade fever, mild to moderate abdominal pain, irregular bleeding and vaginal discharge can also be symptoms of the disease. When examined by a doctor, the abdomen is tender and even rigid, and if the cervix is moved during the gynaecological examination, this will increase the pain.

After an acute attack, chronic PID may follow with chronic pelvic pain, irregular periods and possibly infertility, all signs of adhesion formation and scarring within and around the fallopian tubes and ovaries as well as other pelvic organs.

Flaring up of the disease may occur commonly with bowel organisms.

How is PID diagnosed?

Generally, a diagnosis of PID will be based on the presence of lower abdominal tenderness, a raised temperature and the clinical findings on gynaecological examination – vaginal and cervical discharge and
tenderness of the uterus, tubes and ovaries during palpation. While performing the speculum examination, the doctor will take swabs to test for chlamydia, gonorrhoea and other micro-organisms. While doing the palpation, the doctor may feel a swelling and resistance either on one or both sides of the uterus, indicating severe inflammation of the fallopian tubes and ovaries (adnexal mass). These findings may be confirmed, if necessary, by an abdominal or transvaginal ultrasound examination.

If the symptoms are only on one side, together with an unclear history, the differential diagnosis of an acute appendicitis or an ectopic pregnancy has to be taken into account and a laparoscopy may be performed. This is a surgical procedure under general anaesthesia during which an endoscope (a thin fibre-optic tube with light supply) is inserted through a small incision just below the navel. This procedure allows the gynaecologist to visually examine the uterus, fallopian tubes and ovaries as well as the appendix and other pelvic structures. During laparoscopy, the gynaecologist will take the decision whether the condition is due to PID which will be treated conservatively with antibiotics, or whether to proceed with surgery by removing an inflamed appendix
or an ectopic pregnancy.

How can PID be prevented?

Most cases of PID could be prevented if sexually active couples are mutually monogamous. If she has sexual intercourse only with him, and he has sexual intercourse only with her, there would be no third (possibly contaminated) person who would bring sexually transmissible micro-organisms into their intimate relationship.

Second choice of prevention is what is often referred to as safe sex which means trying to prevent contamination with micro-organisms (which are possibly present in the other partner) by using barrier contraception (condoms, spermicides with cervical caps or diaphragms).

However, the safety is variable and depends on several factors (consistency of use, slipping-off condoms, breakage etc). The safety factor of condom use, for example, has to be seen in the right perspective: if sperms manage to enter the genital tract when a condom breaks and cause a pregnancy, so can STD micro-organisms enter the genital tract and cause PID.

PID may develop due to particular circumstances and not every contamination with a STD will automatically lead to PID. Certain hygienic factors play a role and the following should be kept in mind:

• Vaginal contamination with intestinal bacteria should be avoided. Contamination may occur after anal intercourse or, after a bowel motion if the perineal area is wiped wrongly from back to front thereby promoting bacteria from the colon to enter the vagina.
• If tampons are used during menstruation, they should be changed regularly at appropriate intervals.
• Women should avoid regular vaginal douching. This may disturb the normal eco-system of the vaginal bacterial flora. If women become dependent on douching as part of their hygiene and aim to reduce vaginal discharge, they should rather see a gynaecologist for a thorough examination.
• Sexual intercourse should be avoided for at least two weeks after a miscarriage, a D&C or a termination of pregnancy (abortion). The cervix is dilated during these procedures and the cervical barrier is breached so that bacteria can enter the upper genital tract easier.
• After having an IUD inserted, a condom should be used for two weeks.
• Women at risk for PID should have an annual Pap smear and consult their doctor in the event of any vaginal discharge.

How is PID treated?

Acute PID requires immediate treatment with antibiotics, started as soon as specimens have been obtained to determine to which antibiotics the causative organism is sensitive. Treatment can be started before the results of these tests are back and the antibiotics changed later if necessary. A serious case is treated in hospital with intravenous antibiotics. Milder cases can be treated with oral antibiotics on an outpatient basis. Immediate treatment is essential since the risk of infertility increases with increasing inflammation. Many women with PID have sexual partners who have no symptoms, even though these partners may be infected with organisms that can cause PID. Because of the risk of reinfection, sexual partners should be examined, even if they do not exhibit symptoms, and treated whenever necessary.

What is the outcome of PID?

A woman who has had PID more than once is likely to suffer scarring of the fallopian tubes, which may partially or completely block the normal passage between the uterus and the ovaries. This can lead to an ectopic pregnancy and also increases the risk of infertility. If an ectopic pregnancy occurs, the fertilised egg implants in the fallopian tube rather than in the uterus. These pregnancies are not viable and can lead to serious complications if not diagnosed early.

Abscesses may develop in the tubes, ovaries and elsewhere in the pelvis during the acute or subacute stage of PID. If these do not respond to antibiotic treatment they often have to be removed surgically.

PID can also cause chronic pelvic pain and this condition may sometimes be improved with surgery. With each episode of reinfection and recurrence of PID, the risk of infertility is increased.

When to see a doctor

A doctor should be consulted if a woman suffers from abdominal pain or tenderness, a vaginal discharge with an offensive smell, menstrual cramps or a high fever. A doctor should also be called if an IUD was recently inserted and it is causing discomfort, or if a woman had unprotected sex with a partner who she thinks might have an STD.

(Reviewed by Prof Bert Schaetzing, University of Stellenbosch)

The information provided in this article was correct at the time of publishing. At Mediclinic we endeavour to provide our patients and readers with accurate and reliable information, which is why we continually review and update our content. However, due to the dynamic nature of clinical information and medicine, some information may from time to time become outdated prior to revision.