Pelvic inflammatory disease

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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 adhesions to nearby tissues and organs. This may lead to tissue necrosis with/or without abscess formation. Pus can be released into the peritoneum. 2/3 of patients with laparoscopic evidence of previous PID were not aware they had had PID (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 a sexually transmitted infection is often the cause, other routes are possible, including lymphatic, postpartum, postabortal (either miscarriage or abortion) or IUD related, and hematogenous spread.

Epidemiology

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 [1]. N. gonorrhoea is isolated in only 40-60% of women with acute salpingitis (current obgyn 9th ed 2003). 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 Neisseria gonorrhoeae (current obgyn 9th ed.) 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.(Cecil's essentials of medicine 5th ed.). "PID is the leading cause of infertility. A single episode of PID results in infertility in 13% of women." (Cecil's 5th ed.) This rate of infertility increases with each infection

Diagnosis

There may be no actual symptoms of PID. If there are symptoms, 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. Laparoscopic idenitification is helpful in diagnosing tubal disease, 65-90% positive predictive value in patients with presumed PID (current obgyn 9th ed 2003). Regular STD testing is important for prevention. Treatment is usually started 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 (cecil's 5th ed.).

Prognosis

Although the PID infection 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 little difficulties. If the infection is in the fallopian tubes or ovaries, more serious complications are more likely to occur.

Complications

PID can cause scarring inside the reproductive organs, which can later cause serious complications, including chronic pelvic pain, infertility (difficulty becoming pregnant), ectopic pregnancy (the leading cause of pregnancy-related deaths in adult females), and other dangerous complications of pregnancy. Multiple infections and infections that are treated later are more likely to result in complications.

Persons with infertility may wish to see a specialist, because there may be a possibility in restoring fertility after scarring. Traditionally tuboplastic surgery was the main approach to correct tubal obstruction or adhesion formation, however success rates tended to be very limited. In vitro fertilization (IVF) was developed to bypass tubal problems and has become the main treatment for patients who want to become pregnant.

Treatment

Treatment depends on the cause and generally involves use of antibiotic therapy. See specific diseases for treatment. Treatment may take longer than other infections especially if an abscess has developed. Insufficient dose, wrong drug or drug resistance, or too short duration of treatment may lead to continued symptoms/infection/complications. Treating partners for STD's is a very important part of treatment and prevention. 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. Anyone with PID and partners of patients with PID should be treated for N. gonorrhoea and C. trachomatis.

Abstinence should be practiced for 7 days after a single dose treatment for chlamydia (not with PID) or until the 7 day course is completed or transmission to others could still occur (cecil's essentials of medicine 5th ed).

Prevention

  • Risk reduction against sexually transmitted diseases through abstinence or barrier methods such as condoms, see human sexual behavior for other listings.
  • Going to the doctor immediately if symptoms of PID, sexually transmitted diseases appear, or after learning that a current or former sex partner has, or might have had a sexually transmitted disease.
  • Getting regular gynecological (pelvic) exams with STD testing to screen for symptomless PID.
  • Discussing sexual history with a trusted physician in order to get properly screened for sexually transmitted diseases.
  • Regularly scheduling STD testing with a physician and discussing which tests will be performed that session.
  • Getting a STD history from your current partner and insisting they be tested and treated before intercourse.
  • Understanding when a partner says that they have been STD tested they usually mean chlamydia and gonorrhea in the US, but that those are not all of the sexually transmissible disease.
  • Treating partners so you don't become reinfected or they do not infect another.

Other diseases that can lead to or be involved in PID

  1. Salpingitis, any infection of the fallopian tubes.
  2. Tubo-ovarian abscess an abscess of the fallopian tube or ovary.
  3. Endometritis
  4. Pelvic peritonitis
  5. The Dalkon Shield (withdrawn from the market in 1975 for this reason)
  6. Avoiding multiple sexual partners.

External links

  • NIH/Medline
  • CDC
  • ISBN 0838514014 Current Obstetric & Gynecologic Diagnosis Treatment. Alan Decherney and Lauren Nathan. 9th Ed. 2003: pgs 729-731.
  • ISBN 0721681794 Carpenter, Griggs, Loscalzo. Cecil's essentials of medicine 5th ed. 2001: pages 623-625.
  • ISBN 0070072728 Harrison's Principles of Internal Medicine 15th ed.
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