What Is Pelvic Inflammatory Disease?
Pelvic inflammatory disease (PID) is an infection of a woman's reproductive organs. Infection spreads upward from the cervix to the uterus, Fallopian tubes, ovaries, and surrounding structures. Some of these conditions are also referred to as:
- cervicitis (inflammation of the cervix);
- salpingitis (inflammation of the Fallopian tubes);
- endometritis (inflammation present in the lining tissues of the uterus); and
- peritonitis (inflammation of the peritoneum, the membrane that lines the abdominal cavity and covers most of the abdominal organs).
All of these conditions may be considered as specific diseases but many investigators group them together as variations of PID, especially if they are caused by either Chlamydia trachomatis or Neisseria gonorrhoeae.
Bacteria can infect the Fallopian tubes and cause inflammation (salpingitis). When this happens, normal tissue can become scarred and block the normal passage of an egg, causing infertility. But if Fallopian tubes are partially blocked, an egg may implant outside the uterus and cause a dangerous condition called an ectopic pregnancy. An ectopic pregnancy can cause internal bleeding and even death. Scar tissue may also develop elsewhere in the abdomen and cause pelvic pain that can last for months or years.
- The two most commonly involved bacteria that cause PID are Chlamydia trachomatis and Neisseria gonorrhoeae, which cause the sexually transmitted diseases, chlamydia and gonorrhea.
- PID can cause a wide variety of symptoms. Some women can be very ill and have severe pain and fever. Others can have no obvious symptoms or even appear ill. Thus, PID is not always easy to diagnose. But it is important for women to seek medical attention if they have any risk factors for PID or symptoms of PID.
- Sexually active adolescent females and women younger than 25 years are at greatest risk, although PID can occur at any age.
What Causes Pelvic Inflammatory Disease?
Pelvic inflammatory disease is most frequently caused by bacteria that are transmitted through sexual contact and other bodily secretions. Bacteria that cause gonorrhea and chlamydia cause more than half of cases. Many studies suggest that a number of patients with PID and other sexually transmitted diseases are often infected with two or more infectious agents, and commonly these are Chlamydia trachomatis and Neisseria gonorrhoeae. Other organisms can also cause PID but are much less common.
What Are the Symptoms of Pelvic Inflammatory Disease?
If a woman has PID, she may have any of these symptoms:
Symptoms not related to the female reproductive organs include fever, nausea, and vomiting.
PID symptoms may be worse at the end of a menstrual period and during the first several days following a period.
When Should I Call a Doctor About Pelvic Inflammatory Disease?
If a female is experiencing the following symptoms, she should see a health care provider:
Given the long-term complications PID can cause, such as infertility and ectopic pregnancy, it is recommended that females seek immediate medical attention if they have any of these symptoms:
- Lower abdominal pain or tenderness
- Fever greater than 101 F (38.3 C)
- Abnormal or foul-smelling vaginal discharge
Adult women with PID are either closely monitored or admitted to the hospital. More aggressive treatment may take place in the hospital for adolescent females, who are at a much higher risk of not following treatment plans and of having complications.
The person may be admitted to the hospital if any of the following occur:
- The definitive diagnosis of the woman's abdominal/pelvic pain is unclear.
- Ectopic pregnancy or appendicitis cannot be ruled out.
- She is pregnant.
- An abscess (a localized infection) is suspected. A tubo-ovarian abscess (TOA) is a type of disease seen frequently in PID. A tubo-ovarian abscess is a collection of bacteria, pus, and fluid (abscess) that occurs in the Fallopian tube and involves the ovary. It is most often seen in teens. A tubo-ovarian abscess is also more likely to occur in teens or adult women who use intrauterine devices (IUDs) as birth control. A teen girl with a tubo-ovarian abscess often looks sick, has a fever and pain that makes it difficult to walk. The abscess will be treated with antibiotics in the hospital by most physicians. Surgery may be needed to remove or drain the abscess.
- The person is acutely ill or cannot manage their illness at home.
What Are the Exams and Tests for Pelvic Inflammatory Disease?
A health care practitioner usually will diagnose PID by taking the individual's medical history, doing a physical exam, and ordering appropriate tests.
Physical exam findings in PID often include the following:
- a temperature greater than 101 F (38.3 C);
- abnormal vaginal discharge;
- lower abdominal tenderness when exterior pressure is applied;
- tenderness when the cervix is moved (during a bimanual or speculum exam); or
- tenderness in female organs (ovaries).
Laboratory tests may include the following:
A pelvic ultrasound, although not routinely done, can be an important tool in diagnosing complications such as tubo-ovarian abscesses, ovarian torsion, ovarian cysts, and ectopic pregnancy. Although unlikely to occur in pregnancy, PID is the most commonly missed diagnosis in ectopic pregnancies and can occur during the first 12 weeks of pregnancy.
A woman's health specialist (a gynecologist) can use a laparoscope (a small tube with a camera attached) and make small surgical incisions in and around the navel to view the reproductive organs and evaluate whether inflammation is present. The doctor can also identify an ectopic pregnancy using this technique. Definitive care can then be provided from starting IV antibiotics to removing an ectopic pregnancy.
A health care practitioner will start antibiotic therapy for PID as soon as the diagnosis is made. Gonorrhea and chlamydia are suspected and treated in every person. Pain medication and IV fluids will be given if the patient needs them.
What Are the Medications for Pelvic Inflammatory Disease?
Because samples of the bacteria from the upper genital tract are difficult to obtain and because many different organisms may be responsible for PID, especially if it is not the person's first occurrence, the doctor will usually prescribe at least two antibiotics at the same time that are effective against a wide range of infectious bacteria. The CDC recommends that all antibiotic treatments should be effective against N. gonorrhoeae and C. trachomatis. The CDC lists several choices of antibiotics to use (for example, cefotetan (Cefotan, Apatef), 2 g IV every 12 hour plus doxycycline (Vibramycin, Monodox), 100 mg orally or IV every 12 hours). The duration of treatments vary according to the extent of the disease; the caregivers usually determine the length of treatments for each individual.
The doctor may provide IV antibiotics at the office, by a visiting nurse, or in a clinic. Emergency department doctors may also provide oral and IV antibiotic treatment. Depending on the severity of the particular case of PID, a doctor may also choose to admit the person for hospital treatment.
- If the patient is pregnant, it is likely they are going to be admitted into the hospital. If the doctor is unsure that the person has PID, a gynecologist will be consulted. If the doctor cannot rule out appendicitis or another surgical emergency, a surgeon may be consulted. Likewise, if the person is found to have an abscess (tubo-ovarian abscess), they will be admitted to the hospital.
- If the person is not admitted to the hospital and does not improve within 72 hours of starting treatment, then the patient should be reevaluated. Such patients may be given IV antibiotics and be admitted to the hospital.
What Surgery is Available for Pelvic Inflammatory Disease?
Untreated PID can cause chronic pelvic pain and scarring in about 20% of women. These conditions are difficult to treat but are sometimes improved with surgery. Surgery may also be needed to remove or drain a tubo-ovarian abscess if present.
What Is the Follow-up for Pelvic Inflammatory Disease?
Take all medications the health care practitioner prescribes. Symptoms may resolve before the infection is cured and the person may feel much better, but they should still finish taking all the antibiotics prescribed. Patients should follow-up with the doctor or in a clinic within 3 days to monitor improvement. Whether on oral or IV therapy, most individuals usually improve within 72 hours.
- If symptoms worsen, even with treatment, prior to the 72-hour follow-up appointment, the individual should return to the doctor's office or hospital. Additional testing, treatments, and surgery may be required to effectively reduce symptoms and eliminate PID.
- Patients should not have sexual activity until the infection is cured. Any sexual partners the patients have had within 2 months of becoming infected with PID should also be treated.
How Can I Prevent Pelvic Inflammatory Disease?
The following steps may be taken to avoid pelvic inflammatory disease or to keep PID from becoming worse:
- Practice safe sex: if people choose to have sexual intercourse, they should use barrier devices such as a latex condom. Use only water-based lubricants with condoms. For oral sex, use a device called a dental dam. It's a rubbery device a person places over the opening of the vagina before having oral sex. As an alternative, a person can cut an unlubricated male condom open and place it over the opening to the vagina. However, no barrier devices are 100% effective (in either birth control or preventing PID); for some people, the choice is not to have sexual relations.
- Birth control pills and intrauterine devices do not prevent PID. Recently inserted intrauterine devices (IUDs), in fact, may increase the risk of getting PID.
- STD treatment: Sexual partners need to be treated if the person is diagnosed with a bacterial infection such as a sexually transmitted disease. The individual may become reinfected if this is not done; in addition, the sexual partner may become ill also.
- Individuals should limit the number of sexual partners and avoid high-risk partners (for example, those that do not use condoms) to reduce the chance of infections.
- If people are at risk for PID (for example, individuals that have multiple partners and earn money from sexual encounters), they should have regular tests for sexually transmitted diseases done.
- Frequent vaginal douching is a potential risk factor for PID. Douching may push bacteria into the upper genital tract. Douching also may ease discharge caused by an infection, so women may not think they have symptoms and may delay seeking medical care. Douches are not recommended; the vagina cleans itself naturally. Regular showers and baths are enough to keep the body clean.
- Wipe from front to back after a bowel movement. This keeps bacteria from entering the vagina.
- If a person has vaginal itching, do not scratch. Wash with water only, use no potentially irritating soaps and discuss the symptoms with a health care practitioner.
As in other sexually transmitted diseases, education about prevention techniques is a way to reduce the chance of getting PID.
What Is the Prognosis for Pelvic Inflammatory Disease?
If diagnosed and treated early, the patient outcome is good. The outcome may not be as good if individuals wait too long before treatment and/or continue to engage in unsafe sexual practices. Complications that can occur include:
- Tubal damage and scarring can result in infertility. PID is the most common cause of infertility in women. Following a single episode of PID, 8% of women were infertile; after two episodes, 19.5% of women were infertile; and after three or more episodes, 40% of women were infertile.
- Ectopic pregnancy rates are 12%-15% higher in women who have had an episode of pelvic inflammatory disease.
- Ovarian abscesses can occur after an episode of PID. Untreated PID also puts you at risk for a tubo-ovarian abscess (TOA). Rupture of a TOA can result in widespread peritoneal infection with shock and can be fatal.
- Females diagnosed with PID are at increased risk of getting PID again. As many as one-third of women who have had PID will have the disease at least one more time. With each case, the risk of becoming infertile is increased.
- Chronic pelvic pain is defined as pain in the reproductive organs or pelvis of at least six months duration that is severe enough to impact a woman's functioning. The pain may occur both during and/or apart from the menstrual period. As many as one-third of women with PID develop chronic pelvic pain, although the exact reasons for this are unclear. Chronic pelvic pain may be related to the scarring and inflammation associated with PID and occurs in up to 18% of women with PID.
- Enlargement of a Fallopian tube is known as hydrosalpinx. After an episode of PID, the damaged Fallopian tube can become blocked, fluid-filled and enlarged.