Pelvic Inflammatory Disease

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Basics

Description

  • Pelvic inflammatory disease (PID) is an infectious and inflammatory disorder of the upper female genital tract, including the uterus, fallopian tubes, ovaries, and adjacent pelvic structures. PID is often polymicrobial and acquired from sexually transmitted organisms (1).
  • Salpingitis is the most clinically critical diagnostic component due to its consequences for future fertility.
  • Mild to moderate PID is infection and inflammation in the absence of a tubo-ovarian abscess (TOA). Severe disease is defined as severe systemic symptoms OR the presence of a TOA (2).
  • Diagnosis may be challenging due to a lack of standardized definitions and guidelines as well as variation in signs and symptoms. Many patients with PID have subtle or nonspecific symptoms (3).

Epidemiology

Predominant age: 15 to 25 years; this number has remained constant since early 1900s.

Incidence

PID is the most common gynecologic reason for admission in the United States accounting for 18 per 10,000 recorded hospital discharges (2). The estimated prevalence of self-reported lifetime PID was 4.4% in sexually active cisgender women ages 18 to 44 years (4).

  • Lifetime prevalence has decreased steadily since 1995 across all races (4).
  • Among those with no history of prior STI, lifetime PID prevalence was higher in black versus white women (6% vs. 2.7%). Among women with a prior STI, lifetime prevalence of PID was similar by race (10% vs. 10.3%) (4).

Etiology and Pathophysiology

Multiple organisms may be etiologic agents in PID. Most cases begin with cervicitis and progress to polymicrobial pelvic organ infection. Fewer than 50% of women diagnosed with acute PID have a positive test.

  • Mixed infections are common. Chlamydia trachomatis, Neisseria gonorrhoeae, genital tract mycoplasmas (particularly Mycoplasma genitalium), aerobic and anaerobic (Bacteroides fragilis), and vaginal flora (e.g., Prevotella, peptostreptococci, Gardnerella vaginalis, Escherichia coli, Haemophilus influenzae) are common flora (1),(5),(6).
  • Many nongonococcal, nonchlamydial microorganisms recovered from upper genital tract in acute PID are associated with bacterial vaginosis.
  • Possible mechanisms for ascent from the lower genital tract include the following: (i) travel from cervix to endometrium to salpinx to peritoneal cavity; (ii) lymphatic spread via infection of the parametrium (from an IUD); and (iii) hematogenous route, although this is rare.
  • Of cases, 75% occur within 7 days of menses, when cervical mucus favors ascent of organisms.

Risk Factors

  • Sexually active and age <25 years
  • First sexual activity at young age (<15 years)
  • New/multiple sexual partners
  • Inconsistent condom use
  • Gynecologic procedures that break the cervical barrier such as endometrial biopsy, curettage, hysterosalpingography, hysteroscopy, in vitro fertilization (IVF), and insertion of IUD in the last 6 weeks
  • Other factors associated with PID:
    • Certain contraceptive methods, such as oral contraceptive pills, and spermicidal creams that can disrupt vaginal pH and microbiome and increase risk for STIs
    • Previous history of PID; 20–25% will have a recurrence.
    • Cervical ectopy
    • History of C. trachomatis; 10–40% will develop PID.
    • History of gonococcal cervicitis; 10–20% will develop PID.

General Prevention

  • Educational programs about safe sex practices such as barrier contraceptives, especially condoms
  • The U.S. Preventive Services Task Force recommends annual screening for chlamydia in all sexually active women <25 years and in those >25 years of age at increased risk (new sex partner/multiple sex partners). Moderate-quality evidence suggests that chlamydia screening reduces cases of PID (3)[A].
  • Routine STI screening in pregnancy
  • Early medical care with occurrence of genital lesions or abnormal discharge

Commonly Associated Conditions

  • If PID is suspected in a patient with an IUD and a pelvic abscess is present, an Actinomyces infection may be present and require penicillin treatment.
  • Rupture of an adnexal abscess is rare but life-threatening. Early surgical exploration is mandatory (5).
  • Chlamydial or gonococcal perihepatitis, called Fitz-Hugh–Curtis (FHC) syndrome, may occur with PID. FHC syndrome is characterized by severe pleuritic right upper quadrant pain and complicates 10% of PID cases.
  • Plasma cell endometritis has also been seen in the majority of females with PID; the density of plasma cell infiltration has been related to severity of symptoms (5).

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Basics

Description

  • Pelvic inflammatory disease (PID) is an infectious and inflammatory disorder of the upper female genital tract, including the uterus, fallopian tubes, ovaries, and adjacent pelvic structures. PID is often polymicrobial and acquired from sexually transmitted organisms (1).
  • Salpingitis is the most clinically critical diagnostic component due to its consequences for future fertility.
  • Mild to moderate PID is infection and inflammation in the absence of a tubo-ovarian abscess (TOA). Severe disease is defined as severe systemic symptoms OR the presence of a TOA (2).
  • Diagnosis may be challenging due to a lack of standardized definitions and guidelines as well as variation in signs and symptoms. Many patients with PID have subtle or nonspecific symptoms (3).

Epidemiology

Predominant age: 15 to 25 years; this number has remained constant since early 1900s.

Incidence

PID is the most common gynecologic reason for admission in the United States accounting for 18 per 10,000 recorded hospital discharges (2). The estimated prevalence of self-reported lifetime PID was 4.4% in sexually active cisgender women ages 18 to 44 years (4).

  • Lifetime prevalence has decreased steadily since 1995 across all races (4).
  • Among those with no history of prior STI, lifetime PID prevalence was higher in black versus white women (6% vs. 2.7%). Among women with a prior STI, lifetime prevalence of PID was similar by race (10% vs. 10.3%) (4).

Etiology and Pathophysiology

Multiple organisms may be etiologic agents in PID. Most cases begin with cervicitis and progress to polymicrobial pelvic organ infection. Fewer than 50% of women diagnosed with acute PID have a positive test.

  • Mixed infections are common. Chlamydia trachomatis, Neisseria gonorrhoeae, genital tract mycoplasmas (particularly Mycoplasma genitalium), aerobic and anaerobic (Bacteroides fragilis), and vaginal flora (e.g., Prevotella, peptostreptococci, Gardnerella vaginalis, Escherichia coli, Haemophilus influenzae) are common flora (1),(5),(6).
  • Many nongonococcal, nonchlamydial microorganisms recovered from upper genital tract in acute PID are associated with bacterial vaginosis.
  • Possible mechanisms for ascent from the lower genital tract include the following: (i) travel from cervix to endometrium to salpinx to peritoneal cavity; (ii) lymphatic spread via infection of the parametrium (from an IUD); and (iii) hematogenous route, although this is rare.
  • Of cases, 75% occur within 7 days of menses, when cervical mucus favors ascent of organisms.

Risk Factors

  • Sexually active and age <25 years
  • First sexual activity at young age (<15 years)
  • New/multiple sexual partners
  • Inconsistent condom use
  • Gynecologic procedures that break the cervical barrier such as endometrial biopsy, curettage, hysterosalpingography, hysteroscopy, in vitro fertilization (IVF), and insertion of IUD in the last 6 weeks
  • Other factors associated with PID:
    • Certain contraceptive methods, such as oral contraceptive pills, and spermicidal creams that can disrupt vaginal pH and microbiome and increase risk for STIs
    • Previous history of PID; 20–25% will have a recurrence.
    • Cervical ectopy
    • History of C. trachomatis; 10–40% will develop PID.
    • History of gonococcal cervicitis; 10–20% will develop PID.

General Prevention

  • Educational programs about safe sex practices such as barrier contraceptives, especially condoms
  • The U.S. Preventive Services Task Force recommends annual screening for chlamydia in all sexually active women <25 years and in those >25 years of age at increased risk (new sex partner/multiple sex partners). Moderate-quality evidence suggests that chlamydia screening reduces cases of PID (3)[A].
  • Routine STI screening in pregnancy
  • Early medical care with occurrence of genital lesions or abnormal discharge

Commonly Associated Conditions

  • If PID is suspected in a patient with an IUD and a pelvic abscess is present, an Actinomyces infection may be present and require penicillin treatment.
  • Rupture of an adnexal abscess is rare but life-threatening. Early surgical exploration is mandatory (5).
  • Chlamydial or gonococcal perihepatitis, called Fitz-Hugh–Curtis (FHC) syndrome, may occur with PID. FHC syndrome is characterized by severe pleuritic right upper quadrant pain and complicates 10% of PID cases.
  • Plasma cell endometritis has also been seen in the majority of females with PID; the density of plasma cell infiltration has been related to severity of symptoms (5).

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