Pelvic inflammatory disease

Refers to inflammation of the uterus, fallopian tubes, and/or ovaries as it progresses to scar formation with adhesions of surrounding tissues and organs.

PID refers to an infection-inflammation of the upper female tract including the endometrium, fallopian tubes, ovaries, or pelvic peritoneum.

Inflammation spreads from the vagina or cervix to the upper genital tract with endometritis is an intermediate stage.

Hallmark of the diagnosis is pelvic tenderness combined with inflammation of the lower genital tract.

Immune response to PID associated with increased risk of tubal factor infertility.

Infection induces selective loss of ciliated epithelial cells along fallopian tube impairs ovum transport, resulting in tubal factor infertility or ectopic pregnancy.

Inflammation can cause peritoneal adhesions along the fallopian tubes and may prevent pregnancy or cause pelvic pain.

Symptoms may be  subtle.

A previous PID, vaginal discharge, or urinary symptoms indicates PID vs appendicitis.

On physical examination, tenderness outside the RLQ, cervical motion tenderness, vaginal discharge, and positive urinalysis support the diagnosis of PID.



Many patients have silent spread of infection to the upper gentle tract resulting in subclinical PID.

Most cases related to bacterial infection, but may be associated with viral, fungal, or parasitic organisms..

Classified by affected organs, the stage of the infection, and the organism(s) causing it.

More than 84% of infections are due to sexually-transmitted cervical pathogens or bacterial vaginosis-associates microbes.

Approximately 15% of PID infections are due to respiratory or enteric organisms that colonize the lower genital tracts.

About 15% of untreated chlamydial infections progress clinically to PID.

Risk of PID after gonococcal infection may be higher.

Sexual intercourse and retrograde menstruation may be important in the movement of organisms from the lower to upper genital tract.

Sexual transmitted infections are often the cause.

Other routes of infection are possible and include lymphatic, postpartum, miscarriage, abortion, intrauterine device related, and hematogenous spread.

Major risk factors include young age, multiple sexual partners, and the use of an intrauterine device.

Two thirds of patients not aware they had PID.

More than 750,000 women are affected each year in the US.

In the last two decades the rates and severity of PID have declined in North America and Western Europe as a result of controlling Chlamydia trachomatis and Neisseria gonorrhoeae infection.

Anaerobic and facultative bacteria that are found in the vaginal flora either alone or with N. gonorrhoeae and C. trachmonitis infection in the fallopian tubes of women with acute PID.

These organisms occur in great concentration with bacterial vaginosis and are associated with an overgrowth of a complex anaerobic biofilm associated microbiome with local production of enzymes degrading cervical mucus and antimicrobial peptides.

As a result this degradation impairs the cervical barrier to ascending infection and facilitates the spread of micro organisms to the upper genital tract.

Infection causes fibrinous to suppurative change along the epithelial epithelial surface of the fallopian tube and in the peritoneal surface of the fallopian tubes and ovaries leading to scarring,adhesions, and possibly obstruction of the fallopian tubes.

Rate is highest with teenagers and first time mothers.

Causes over 100,000 cases of infertility in the US each year.

N. gonorrhoea is isolated in 40–60% of women with acute salpingitis.

C. trachomatis is estimated to be the cause in about 60% of cases of salpingitis, which may lead to PID.

Normal vaginal flora can be involved, and individual cases can be due to either a single organism or multiple agents.

10–40% of untreated women with N. gonorrhoea develop PID and 20–40% of women infected with C. trachomitis developed PID.

Symptoms range from asymptomatic to severe.

Fever, cervical motion tenderness, lower abdominal pain, vaginal discharge, dtspareunia, or irregular menstrual bleeding may be present.

Abrupt onset of severe lower abdominal pain during or shortly after menses classic presentation, although onset and severity of symptoms may be more subtle.

Aymptomatic disease may cause serious harm.

Subclinical pelvic inflammatory disease is caused by those same processes that cause acute pelvic inflammatory disease and maybe twice as common.

Chronic PID is defined as chronic infection of greater than 30 days duration due to Mycobacterium tuberculosis or actinomyces rather than chronic recurrent pain which is common after treatment of acute PID.

Laparoscopic exam can identify tubal disease, which has a 90% positive predictive value in patients with presumed PID.

Diagnostic criteria include:evidence for endometritis, thickened filled fallopian tubes, or laparoscopic findings.

Empirical antibiotic therapy is initiated when the diagnosis is suspected because of possible serious consequences that may arise from delayed management.

Differential diagnosis includes: appendicitis, ectopic pregnancy, septic abortion, hemorrhagic, twisted or ruptured ovarian cysts or tumors, uterine myoma, and acute enteritis.

Risk increases with a history of pelvic inflammatory disease, recent sexual contact, recent onset of menses, presence of an IUD, and if a partner has a sexually transmitted disease.

Highly unlikely diagnosis in the absence of recent intercourse, or if a IUD has not being used.

Common among sexually active young and adolescent women.

Pregnancy test should be obtained to rule out ectopic pregnancy.

Culdocentesis can differentiate hemoperitoneum from a ruptured ectopic pregnancy or hemorrhagic cyst, from salpingitis, ruptured pelvic abscess, or ruptured appendix.

Pelvic and vaginal ultrasounds are helpful in the differential diagnosis of ectopic pregnancy.

Laparoscopy can utilized to diagnose pelvic inflammatory disease if the diagnosis is uncertain or if the patient has not responded to antibiotic therapy after 48 hours.

No single test has adequate sensitivity and specificity to diagnose PID.

Cervical motion tenderness as a minimum clinical criterion increases the sensitivity of the CDC diagnostic criteria from 83% to 95%.

PID can cause scarring leading including chronic pelvic pain, infertility, ectopic pregnancy and other complications of pregnancy.

The infection can spread to in the peritoneum causing inflammation and the formation of scar tissue on the external surface of the liver, Fitz-Hugh-Curtis syndrome.

Tuboplastic surgery was the main approach to correct tubal obstruction or adhesion formation, however success rates tended to be very limited and In vitro fertilization (IVF) has become the main treatment for patients who want to become pregnant.

Hospitalization is reserved for the patient with tubo-ovarian abscesses, is severely ill, immunodeficient, pregnant, or incompetent.

Patients should be treated for sexually transmitted diseases, and treating their partners for STIs is a very important part of treatment and prevention.

Anyone with PID and partners of patients with PID since six months prior to diagnosis should be treated to prevent reinfection.

Neither site nor route of antibiotic administration affects the short or long-term major outcome of women with mild or moderate disease.

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