Pelvic inflammatory disease (PID) is caused by upward spread of infectious microorganisms through the cervix and into the uterus, fallopian tubes, ovaries and peritoneal cavity. Although multiple organisms can be responsible—and gonorrhea and Chlamydia are common causes—the specific agent is often never identified.
PID affects approximately 1.5 million American women annually and costs an estimated $1.06 billion. Long-term complications include chronic pelvic pain, painful intercourse, infertility, and ectopic pregnancy. (Rein DB, Kassler WJ, Irwin KL, Rabiee L. Direct medical cost of pelvic inflammatory disease and its sequelae: decreasing, but still substantial. Obstet Gynecol 2000;95:397-402)
Risk Factors for Pelvic Inflammatory Disease
PID most commonly occurs in women under 35 years of age. It is rare before menarche (onset of menstruation), during pregnancy, or after menopause. Factors that increase risk include:
- Presence of a sexually transmitted infection
- Sexual intercourse at an early age
- Non-white race
- Lower socioeconomic status
- Multiple or new sexual partners
- Previous episode of PID
- Alcohol use
(Adapted from Suss AL, et al. Risk factors for pelvic inflammatory disease in inner-city adolescents. Sex Transm Dis 2000;27:289-91 and The Merck Manual, 18th Edition 2006 p 2087)
Signs and Symptoms of Pelvic Inflammatory Disease
In some women with pelvic infection, symptoms are mild or absent. Those women seeking medical care often present with:
- Lower abdominal pain (If Fitz-Hugh-Curtis syndrome has developed, could be upper right abdominal pain)
- Fever
- Back pain
- Vomiting
- Vaginal discharge, itching, or odor
- Irregular vaginal bleeding
Complications of Pelvic Inflammatory Disease
- Fitz-Hugh-Curtis syndrome: inflammation around the liver due to acute pelvic infection; patients develop nausea, vomiting, fever, and right upper abdominal pain that mimics liver or gallbladder disease
- Tubo-ovarian abscess: 15% of women with infected fallopian tubes develop an abscess in a tube or ovary; if the abscess ruptures, septic shock can result
- Infertility: Tubal scarring and adhesions interfere with passage of ova (and sperm)
- Ectopic pregnancy: Adhesions and inflammation can lead to implantation of a fertilized ovum in abnormal locations (fallopian tubes, ovary, or in peritoneal cavity)
- Chronic pelvic pain
- Dyspareunia (pain with intercourse)
- Menstrual irregularities
Diagnosis of Pelvic Inflammatory Disease
- The diagnosis of PID is mainly clinical. If a woman of reproductive age presents with typical symptoms—even if those symptoms are minimal—further investigation is warranted. A pelvic examination is usually performed, and specimens are obtained for culture and other tests.
- Urine is collected for culture and pregnancy testing. A blood count is routinely performed.
- Depending on findings from physical examination and preliminary tests, additional investigations might include ultrasound, CT, MRI, or even laparoscopy.
Treatment of Pelvic Inflammatory Disease
- Patients with mild or moderate PID can be treated as outpatients. Women with severe illness (e.g., dehydration, peritonitis, abscess, uncontrollable vomiting) or who are pregnant may require hospitalization.
- Antibiotics are administered initially to cover gonorrhea and Chlamydia. If laboratory tests indicate the presence of other organisms, the antibiotic regimen is altered.
- Abscesses often require prolonged administration of IV antibiotics, and they may need to be drained via laparoscopy or with the help of ultrasound or CT.
- Ruptured abscesses require immediate surgery.
Prevention of Pelvic Inflammatory Disease
Screening for asymptomatic STIs has been shown to reduce the incidence of PID. Routine screening of all sexually active women younger than 25 years for Chlamydia (and for gonorrhea, in women at risk) is recommended by the CDC and the US Preventive Services Task Force. Infected women and their partners should be appropriately treated. (Sexually transmitted diseases treatment guidelines 2002. Centers for Disease Control and Prevention. MMWR Recomm Rep 2002;51(RR-6):1-78)
Additionally, limiting risk factors for sexually transmitted infections (STIs) will help to reduce the incidence of PID. Sexual promiscuity, alcohol use, unprotected sex, and other behaviors must be addressed.
