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Pelvic Inflammatory Disease - Clinical Features - Management - TeachMeObGyn
Pelvic Inflammatory Disease - Clinical Features - Management - TeachMeObGyn
Pelvic inflammatory disease (PID) is an infection of the upper genital tract in females, which a ects the uterus, fallopian tubes and ovaries.
It is a relatively common condition, with a diagnosis rate in primary care of approximately 280/100,000 person-years. It has the highest prevalence
in sexually active women aged 15 to 24.
In this article we shall look at the pathophysiology, clinical features and management of pelvic inflammatory disease.
Pathophysiology
Pelvic inflammatory disease refers to an infective inflammation of the endometrium, uterus, fallopian tubes (salpingitis), ovaries and peritoneum. It is
caused by the spread of bacterial infection from the vagina or cervix to the upper genital tract.
Chlamydia trachomatis and Neisseria gonorrhoea are responsible for approximately 25% of cases, with other bacteria such as Streptococcus, bacteriodes
and anaerobes also implicated.
Fig 1 – Pelvic inflammatory disease refers to infection of the upper female genital tract.
Risk Factors
The risk factors for pelvic inflammatory disease include:
Sexually active
History of STIs
Pelvic inflammatory disease can also occur via instrumentation of the cervix – inadvertently introducing bacteria into the female reproductive tract.
Such procedures include gynaecological surgery, termination of pregnancy, and insertion of an intrauterine contraceptive device.
Clinical Features
The signs and symptoms of pelvic inflammatory disease are elicited from the medical and sexual history, and a gynaecological examination. Whilst it can
be asymptomatic, symptoms include:
Lower abdominal pain
Post-coital bleeding
In advanced cases, women can experience severe lower abdominal pain, fever (>38° C), and nausea and vomiting.
On vaginal examination, there may be tenderness of uterus/adnexae or cervical excitation (on bimanual palpation). There may be a palpable mass in
the lower abdomen, with an abnormal vaginal discharge noted.
Di erential Diagnosis
The di erential diagnoses for pelvic inflammatory disease include:
Endometriosis
Investigations
The initial investigations in suspected pelvic inflammatory disease involves identifying the infective organism.
Endocervical swabs should be taken to test for gonorrhea and chlamydia, and a high vaginal swab for trichomonas vaginalis and bacterial vaginosis. In
the UK, testing is via nucleic acid amplification (NAAT). Negative swabs do not exclude the diagnosis.
Full STI screen – (HIV, syphilis, gonorrhoea and Chlamydia as a minimum) should be o ered to all women with PID.
Laparoscopy – used to observe gross inflammatory changes, and to obtain a peritoneal biopsy. This is indicated only in severe cases where there is
diagnostic uncertainty.
© By TeachMeSeries Ltd (2020)
Fig 3 – Neisseria gonorrhoea can also be identified on microscopy, with a diplococci shape.
Management
The mainstay in the management of pelvic inflammatory disease is antibiotic therapy.
Treatment is a 14-day course of broad spectrum antibiotics with good anaerobic coverage. This should be commenced immediately, before the results
of swabs are available. Options include:
Analgesics such as paracetamol should be considered. The patient should be advised to rest, and avoid sexual intercourse until the antibiotic course is
complete and partner(s) are treated. All sexual partners from the last 6 months should be tested and treated to prevent recurrence and spread
of infection.
Complications
Delaying treatment or having repeated episodes of pelvic inflammatory disease (recurrent PID) can increase risks of serious and long term
complications:
Tubo-ovarian abscess
Fitz-Hugh Curtis syndrome – perihepatitis that typically causes right upper quadrant pain
© By TeachMeSeries Ltd (2020)
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Points to Consider
Patients should be o ered advice regarding the practice of safer sex and consistent use of condoms.