Pelvic Inflammatory Disease

What is it?

Pelvic inflammatory disease (PID) is an inflammation and infection of a woman’s upper reproductive organs. It occurs when bacteria move from the vagina, upward through a layer of mucus that protects the opening of the cervix, and into the uterus, fallopian tubes, and ovaries. PID can cause an acute illness, chronic pain, or it may be present as an almost silent long-term infection. Left untreated, it can cause scarring and irreversible damage to one or more of the reproductive organs. Scarring in the fallopian tubes can cause infertility and significantly increase the risk of an  ectopic pregnancy.

Pelvic inflammatory disease is primarily associated with Chlamydia trachomatis and Neisseria gonorrhoeae, two common  microorganisms that cause the sexually transmitted diseases (STDs) chlamydia and gonorrhoea. PID may also be caused by bacteria typically found in the vagina or gastrointestinal tract - such as Gardnerella vaginalis or Escherichia coli, and by a variety of other pathogens.

Although PID can affect any woman at any age, with or without sexual transmission, most cases occur in sexually active women of childbearing age. Those at increased risk include women who began having sex at a young age, those with multiple sexual partners, a new partner, those with the recent instrumentation of the uterus and those who have had a previous STD or PID. A woman with an intrauterine device (IUD) may be at an increased risk for a few months after its insertion. Douching may increase the risk of PID because the practice can change the vaginal normal flora and can potentially flush bacteria into the uterus. Since the uterus is sealed off during gestation, an occurrence of PID during pregnancy is rare.

Signs and Symptoms

A woman with PID may have no symptoms, mild discomfort, chronic and/or progressive pain, or she may be severely and acutely ill. Many of the signs and symptoms of PID are nonspecific and may be seen with a variety of other conditions that affect the pelvic area. Symptoms may include:

  • vaginal or cervical discharge with an unpleasant smell
  • pain in the lower abdomen – this is the most common symptom
  • abdominal tenderness
  • intermittent fever
  • painful sexual intercourse and bleeding with sex
  • painful urination
  • irregular menstrual bleeding
  • nausea

Complications of PID include infertility, long-term pelvic pain, lesions on an ovary or fallopian tube, and an ectopic pregnancy. Even a small amount of scarring in the fallopian tubes can impair fertility. It can prevent an egg from becoming fertilized or prevent a fertilized egg from reaching the uterus. If a fertilized egg begins to develop in a fallopian tube, it can rupture the tube, causing a life-threatening emergency with internal bleeding and severe pain.

Tests

The aim of testing is to diagnose pelvic inflammatory disease, to discover the microorganism(s) causing it, if possible, and to distinguish PID from other conditions with similar symptoms. There is not one single laboratory test that can definitely diagnose PID. Most cases are diagnosed based on clinical findings. Some are diagnosed when a person is screened for STDs as part of a physical examination. PID may go unrecognized and undiagnosed as frequently as two-thirds of the time because the symptoms are nonspecific. There are several tests that may be performed to help diagnose the condition.

Laboratory Tests
Some tests that may be requested to determine the cause of PID or rule out other causes of pelvic pain include:

  • Chlamydia trachomatis test – to detect chlamydia infection as cause of PID
  • Neisseria gonorrhoeae test – to detect gonorrhoea infection as cause of PID
  • Cervical culture – requested to help identify causative microorganisms, especially Neisseria gonorrhoeae. This test also helps to determine the antibiotics, which are effective against the microorganism.
  • Test for urinary tract infection (UTI)
  • Test for other STD – syphilis and HIV, which may coexist. In some centres or in selected cases doctors may request
  • Wet prep – a sample of vaginal/cervical discharge is placed on a slide and examined under a microscope. It is primarily performed to count the number of white blood cells (WBCs) in the discharge; often elevated with PID.
  • Test for other microorganisms like Mycoplasma genitelium.

Tests that are not specific for PID but may be used to detect and evaluate the inflammation and immune response associated with it include:

  • FBC (Full Blood Count) – performed to evaluate white and red blood cell counts
  • ESR (Erythrocyte Sedimentation Rate) – nonspecific indicator of inflammation
  • CRP (C-Reactive Protein) – nonspecific indicator of inflammation

A pregnancy test may be performed to determine whether a woman is pregnant and to help identify ectopic pregnancy.

Non-Laboratory Tests

  • Physical examination – an evaluation of the cervix, discharge, and degree of pain or tenderness present. Cervical motion pain and uterine pain are characteristic of PID. A diagnosis may be made based upon clinical findings.
  • Pelvic or transvaginal ultrasound – may be performed to examine reproductive organs
  • Laparoscopy – minimally invasive surgery sometimes used to confirm the diagnosis, collect biopsy samples, and evaluate organ status
  • CT (computed tomography) scan or MRI (magnetic resonance imaging) scan
  • Power Doppler ultrasound – scan that allows evaluation of blood flow and inflammation
Treatment

The medical community has set a low diagnostic threshold for this condition. This means that if the doctor suspects that a woman has PID, then she should be treated regardless of whether the diagnosis can be confirmed. This is done because it takes very little PID scarring to cause infertility.

Treatment typically includes one or more broad-spectrum antibiotics that will target Chlamydia trachomatis, Neisseria gonorrhoeae, and a range of other bacteria. If the causative microorganisms are known, then the treatment is tailored to address them. A woman’s sexual partner should also be treated so that the woman is not re-infected after treatment. It is also recommended to avoid unprotected sexual intercourse until the woman with PID and partner(s) have completed treatment and follow up.

In most cases, treatment can be given on an outpatient basis, but if the woman is acutely ill, pregnant, or not responding to treatment, then she may require hospitalization. In rare cases, for example if you have an abscess, surgery may be required.