Pelvic inflammatory disease refers to an infection that affects the reproductive organs of women. This article provides information on how to identify and treat this condition.

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Definition

Pelvic inflammatory disease (PID) refers to an infection that affects the reproductive organs located in the upper part of the female genital tract.

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Incidence

The exact prevalence is hard to ascertain as many cases may go undetected but is thought to be in the region of 1-3% of sexually active young women.

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Causes

1. The most frequent cause of the pelvic inflammatory disease (PID) is the spread of an infection from the cervix upwards towards the upper reproductive organs. However, in some cases, the infection can also originate from other organs such as the appendix and spread downwards towards the pelvic area.
2. There are multiple causative organisms:

• Approximately 25% of pelvic inflammatory disease (PID) cases are believed to be caused by two types of bacteria called Chlamydia trachomatis and Neisseria gonorrhoeae.
• The remaining cases of pelvic inflammatory disease (PID) may be caused by anaerobic bacteria as well as other types of endogenous agents, which can be either aerobic or facultative.

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Acute PID: CDC diagnosis criteria

Minimum criteria

• Lower abdominal tenderness
• Adnexal tenderness
• Cervical motion tenderness 

Additional criteria

• Oral temperature >38.3°C (101°F)
• Abnormal cervical or vaginal discharge
• Elevated erythrocyte sedimentation rate
• Elevated C-reactive protein
• Laboratory testing can confirm the presence of a cervical infection caused by Neisseria gonorrhoeae or Chlamydia trachomatis

Definitive criteria

• Histopathologic evidence of endometritis on endometrial biopsy
• Tubo-ovarian abscess on sonography or other radiologic tests
• Laparoscopic abnormalities consistent with PID

1. Additional diagnostic tests may be required to accurately diagnose and manage pelvic inflammatory disease (PID) as incorrect diagnosis and treatment can result in unnecessary complications.
2. In certain cases, more comprehensive diagnostic criteria may be necessary to confirm the presence of PID.

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Acute PID: Staging

(I-IDSOG-USA recommends the following stages)

Stage 1

If a woman meets the major diagnostic criteria of the Centers for Disease Control and Prevention (CDC) for pelvic inflammatory disease (PID) and one or more of its minor criteria, does not show any symptoms of peritonitis (which can be confirmed by the absence of rebound tenderness), and has not had any previous recorded upper tract infections from sexually transmitted diseases (STDs), then she may be diagnosed with PID.

Stage 2

The above criteria, with peritonitis

Stage 3

If a tubo-ovarian complex or tubo-ovarian abscess is visible during either a physical examination or an ultrasonographic examination, a woman may be diagnosed with pelvic inflammatory disease (PID).

Stage 4

Women with ruptured tubo-ovarian abscesses

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Acute PID: Hospital admission

(CDC-2010 Criteria)

Patient meeting the following criteria 

1. Generalised peritonitis
2. Patient is pregnant
3. Patient does not respond clinically to oral antimicrobial therapy
4. Patient is unable to follow or tolerate an outpatient oral regimen
5. Patient has severe illness, nausea and vomiting, or high fever
6. Patient has a tubo-ovarian abscess
7. WBC>15000 mm³
8. Temperature>101F

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Management: Surgery in acute PID

Indications

1. Rupture abscess
2. Failed response to medical treatment
3. Uncertain diagnosis

Type of surgeries

1. Colpotomy
2. Percutaneous drainage/ aspiration
3. Exploratory laparotomy

Extend of surgeries

1. Conservation- if fertility desired
2. U/L or B/L salpingo-oophorectomy with/ without hysterectomy
3. Drainage of abscess at laparotomy

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Management: Parenteral

CDC- 2010 Regimen A

The treatment for the pelvic inflammatory disease (PID) can consist of intravenous administration of either cefotetan (2 g every 12 hours) or cefoxitin (2 g every 6 hours) along with oral or intravenous administration of doxycycline (100 mg every 12 hours).

CDC- 2010 Regimen B

Clindamycin 900 mg IV every 8 hours PLUS Gentamicin loading dose IV or IM (2 mg/ kg of body weight), followed by a maintenance dose (1.5 mg/kg) every 8 hours; Single daily dosing (3-5 mg/kg) can be substituted

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Management: Oral

CDC- 2010 Oral Regimen A

Pelvic inflammatory disease (PID) can be treated with a single dose of ceftriaxone (250 mg) administered intramuscularly, along with oral administration of doxycycline (100 mg twice daily) for a duration of 14 days. Treatment may also include metronidazole (500 mg twice daily) for 14 days, but this is optional.

CDC- 2010 Oral Regimen B

Pelvic inflammatory disease (PID) can be treated with a single intramuscular dose of cefoxitin (2 g) along with oral administration of probenecid (1 g) given simultaneously in a single dose. The treatment also includes oral administration of doxycycline (100 mg twice daily) for 14 days. Treatment may also include metronidazole (500 mg twice daily) for 14 days, but this is optional.

CDC- 2010 Oral Regimen C

An alternative treatment option for pelvic inflammatory disease (PID) involves the administration of a third-generation cephalosporin antibiotic (such as ceftizoxime or cefotaxime) intravenously, along with oral administration of doxycycline (100 mg twice daily) for a duration of 14 days. Treatment may also include metronidazole (500 mg twice daily) for 14 days, but this is optional.

• It is uncertain which cephalosporin antibiotic is the best choice for treating pelvic inflammatory disease (PID). Although cefoxitin provides better coverage against anaerobic bacteria, ceftriaxone is more effective in treating infections caused by Neisseria gonorrhoeae.
• The cephalosporin antibiotics recommended for treating pelvic inflammatory disease (PID) may not provide adequate coverage against anaerobic bacteria, which could result in incomplete treatment. Therefore, metronidazole may need to be added to the treatment regimen to ensure effective coverage against these types of bacteria.
• In addition to its potential role in improving coverage against anaerobic bacteria, the addition of metronidazole to the treatment regimen for pelvic inflammatory disease (PID) can also be beneficial in treating bacterial vaginosis (BV), which is often linked with PID.

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Complication of PID

• Tubo-ovarian abscess
• Fitz-Hugh-Curtis syndrome
• Recurrent PID
• Ectopic pregnancy
• Infertility

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PID: Prevention

Primary prevention

1. Sexual counselling

• Practice safe sex
• Limit the number of sexual partners
• Avoid contact with high-risk partners
• Delay in sexual activity until 16 years of age

Secondary prevention

1. Screening for infections in the high-risk population.
2. Swift identification and efficient treatment of sexually transmitted infections (STIs) and urinary tract infections (UTIs).

Tertiary prevention

Early intervention & complete treatment

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Case study 1

Case

A 55-year-old postmenopausal multiparous woman presented relating a 2-day history of lower abdominal pain refractory to oral analgesia, and fever up to 99F & white vaginal discharge p/v. The most relevant medical history was a vaginal hysterectomy due to pelvic organ prolapse 9 months before this prevention.

Diagnosis

Laboratory tests revealed white blood cell count within the normal range (leukocytes 18.380/mL with 80% neutrophils), although acute phase reactants were increased (reactive C protein 100.46* 33mm)

During the pelvic examination, tenderness was observed in the vaginal cuff area and there was a discharge that contained pus, but there were no indications of wound separation. The results of the transvaginal sonography were consistent with the presence of a tubo-ovarian abscess (TOA) on both sides.

Left tubo-ovarian abscess measuring 30*40 mm
Right tubo-ovarian abscess measuring 40*70 mm

Treatment

Intravenous antibiotic treatment was initiated for PID, with cefixime, doxycycline and metronidazole. There was a clear reduction in pain and the subsequent laboratory results showed a decrease in inflammatory markers. Despite receiving antibiotic treatment, the patient's body temperature remained between 37-38º C. As a result, laparoscopic surgery was conducted. During the surgical procedure, a bilateral TOA was confirmed. The right tube measured approximately 4*7 cm and was firmly attached to the vaginal cuff and fistulated to the right margin, while the left tube measured 3*4 cm and was attached only to the pelvic peritoneum. The laparoscopic removal of both fallopian tubes was successful and there were no complications during the recovery period.

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Case study 2

Case

25 years female came with a history of white discharge p/v since 3 months, c/o dull abdominal pain since 3 months. c/o abnormal foul smell uterine bleeding since 1 month. M/H-3-8 days/ 15-20 days/ foul smell painful. O/H G1 P1 A1 1 MALE FTND LIVE 2 years back & one medical abortion 1 year back. O/E tenderness in lower abdomen per speculum examination profuse purulent discharge from uterus & cervical erosion. USG uterus enlarged with retained products in the uterus with moderate free fluids in POD.

Diagnosis

The blood test revealed increased WBC, ESR & CRP. Urine RM 40-50 pus cells. Vaginal discharge C/S heavy growth of streptococcus bacteria sensitive to ceftriaxone, metronidazole & amikacin.

Treatment

She was admitted & IV antibiotics were given after 24 hours she was posted for D & E & discharged on oral antibiotics for 15 days.

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Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr. Sejal T Modi, MD, DGO practising in Mothers maternity and nursing home, Ahmedabad.