pelvic inflammatory disease (PID) is a polymicrobial infection of the upper female genital tract: the cervix, uterus, fallopian tubes, and ovaries; abscess may occur. PID may be sexually transmitted. Common symptoms and signs include lower abdominal pain, cervical discharge, and irregular vaginal bleeding. Long-term complications include infertility, chronic pelvic pain, and ectopic pregnancy. Diagnosis includes PCR of cervical specimens forNeisseria gonorrhoeaeand chlamydiae, microscopic examination of cervical discharge (usually), and ultrasonography or laparoscopy (occasionally). Treatment is with antibiotics.
Etiology
PID results from microorganisms ascending from the vagina and cervix into the endometrium and fallopian tubes. Neisseria gonorrhoeaeand Chlamydia trachomatisare common causes of PID; they are transmitted sexually. Mycoplasma genitalium, which is also sexually transmitted, can also cause or contribute to PID. Incidence of sexually transmitted PID is decreasing; < 50% of patients with acute PID test positive for gonorrhea or chlamydial infection.
PID usually also involves other aerobic and anaerobic bacteria, including pathogens that are associated withbacterial vaginosis. Vaginal microorganisms such as Haemophilus influenzae,Streptococcus agalactiae, and enteric gram-negative bacilli can be involved in PID, as can Ureaplasmasp. Vaginal inflammation and bacterial vaginosis help in the upward spread of vaginal microorganisms.
Risk factors
PID commonly occurs in women < 35. It is rare before menarche, after menopause, and during pregnancy.
Risk factors include
Previous PID
Presence of bacterial vaginosis or any sexually transmitted disease
Other risk factors, particularly for gonorrheal or chlamydial PID, include
Younger age
Nonwhite race
Low socioeconomic status
Multiple or new sex partners
Douching
Symptoms and Signs
Lower abdominal pain, fever, cervical discharge, and abnormal uterine bleeding are common, particularly during or after menses.
Cervicitis
In cervicitis, the cervix appears red and bleeds easily. Mucopurulent discharge is common; usually, it is yellow-green and can be seen exuding from the endocervical canal.
Acute salpingitis
Lower abdominal pain is usually present and bilateral but may be unilateral, even when both tubes are involved. Pain can also occur in the upper abdomen. Nausea and vomiting are common when pain is severe. Irregular bleeding (caused by endometritis) and fever each occur in up to one third of patients.
In the early stages, signs may be mild or absent. Later, cervical motion tenderness, guarding, and rebound tenderness are common.
Occasionally, dyspareunia or dysuria occurs.
Many women with inflammation that is severe enough to cause scarring have minimal or no symptoms.
PID due to N. gonorrhoeaeis usually more acute and causes more severe symptoms than that due to C. trachomatis, which can be indolent. PID due toM. genitalium, like that due to C. trachomatis, is also mild and should be considered in women who do not respond to first-line therapy for PID.
Complications
The Fitz-Hugh-Curtis syndrome(perihepatitis that causes upper right quadrant pain) may result from acute gonococcal or chlamydial salpingitis. Infection may become chronic, characterized by intermittent exacerbations and remissions.
A tubo-ovarian abscess(collection of pus in the adnexa) develops in about 15% of women with salpingitis. It can accompany acute or chronic infection and is more likely if treatment is late or incomplete. Pain, fever, and peritoneal signs are usually present and may be severe. An adnexal mass may be palpable, although extreme tenderness may limit the examination. The abscess may rupture, causing progressively severe symptoms and possibly septic shock.
Hydrosalpinx is fimbrial obstruction and tubal distention with nonpurulent fluid; it is usually asymptomatic but can cause pelvic pressure, chronic pelvic pain, dyspareunia, and/or infertility.
Salpingitis may cause tubal scarring and adhesions, which commonly result in chronic pelvic pain, infertility, and increased risk of ectopic pregnancy.
Diagnosis
High index of suspicion
PCR
Pregnancy test
Pelvic inflammatory disease is suspected when women of reproductive age, particularly those with risk factors, have lower abdominal pain or cervical or unexplained vaginal discharge. PID is considered when irregular vaginal bleeding, dyspareunia, or dysuria is unexplained. PID is more likely if lower abdominal, unilateral or bilateral adnexal, and cervical motion tenderness are present. A palpable adnexal mass suggests tubo-ovarian abscess. Because even minimally symptomatic infection may have severe sequelae, index of suspicion should be high.
If PID is suspected, PCR of cervical specimens forN. gonorrhoeae andC. trachomatis (which is about 99% sensitive and specific) and a pregnancy test are done. If PCR is unavailable, cultures are done. However, upper tract infection is possible even if cervical specimens are negative. At the point of care, cervical discharge is usually examined to confirm purulence; a Gram stain or saline wet mount is used, but these tests are neither sensitive nor specific.
If a patient cannot be adequately examined because of tenderness, ultrasonography is done as soon as possible.
WBC count may be elevated but is not helpful diagnostically.
If the pregnancy test is positive,ectopic pregnancy, which can produce similar findings, should be considered.
Fitz-Hugh-Curtis syndrome may mimicacute cholecystitis but can usually be differentiated by evidence of salpingitis during pelvic examination or, if necessary, with ultrasonography.
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iz udžbenika
pelvic inflammatory disease (PID) is a polymicrobial infection of the upper female genital tract: the cervix, uterus, fallopian tubes, and ovaries; abscess may occur. PID may be sexually transmitted. Common symptoms and signs include lower abdominal pain, cervical discharge, and irregular vaginal bleeding. Long-term complications include infertility, chronic pelvic pain, and ectopic pregnancy. Diagnosis includes PCR of cervical specimens for Neisseria gonorrhoeae and chlamydiae, microscopic examination of cervical discharge (usually), and ultrasonography or laparoscopy (occasionally). Treatment is with antibiotics.
Etiology
PID results from microorganisms ascending from the vagina and cervix into the endometrium and fallopian tubes. Neisseria gonorrhoeae and Chlamydia trachomatis are common causes of PID; they are transmitted sexually. Mycoplasma genitalium, which is also sexually transmitted, can also cause or contribute to PID. Incidence of sexually transmitted PID is decreasing; < 50% of patients with acute PID test positive for gonorrhea or chlamydial infection.
PID usually also involves other aerobic and anaerobic bacteria, including pathogens that are associated with bacterial vaginosis. Vaginal microorganisms such as Haemophilus influenzae, Streptococcus agalactiae, and enteric gram-negative bacilli can be involved in PID, as can Ureaplasma sp. Vaginal inflammation and bacterial vaginosis help in the upward spread of vaginal microorganisms.
Risk factors
PID commonly occurs in women < 35. It is rare before menarche, after menopause, and during pregnancy.
Risk factors include
Previous PID
Presence of bacterial vaginosis or any sexually transmitted disease
Other risk factors, particularly for gonorrheal or chlamydial PID, include
Younger age
Nonwhite race
Low socioeconomic status
Multiple or new sex partners
Douching
Symptoms and Signs
Lower abdominal pain, fever, cervical discharge, and abnormal uterine bleeding are common, particularly during or after menses.
Cervicitis
In cervicitis, the cervix appears red and bleeds easily. Mucopurulent discharge is common; usually, it is yellow-green and can be seen exuding from the endocervical canal.
Acute salpingitis
Lower abdominal pain is usually present and bilateral but may be unilateral, even when both tubes are involved. Pain can also occur in the upper abdomen. Nausea and vomiting are common when pain is severe. Irregular bleeding (caused by endometritis) and fever each occur in up to one third of patients.
In the early stages, signs may be mild or absent. Later, cervical motion tenderness, guarding, and rebound tenderness are common.
Occasionally, dyspareunia or dysuria occurs.
Many women with inflammation that is severe enough to cause scarring have minimal or no symptoms.
PID due to N. gonorrhoeae is usually more acute and causes more severe symptoms than that due to C. trachomatis, which can be indolent. PID due to M. genitalium, like that due to C. trachomatis, is also mild and should be considered in women who do not respond to first-line therapy for PID.
Complications
The Fitz-Hugh-Curtis syndrome (perihepatitis that causes upper right quadrant pain) may result from acute gonococcal or chlamydial salpingitis. Infection may become chronic, characterized by intermittent exacerbations and remissions.
A tubo-ovarian abscess (collection of pus in the adnexa) develops in about 15% of women with salpingitis. It can accompany acute or chronic infection and is more likely if treatment is late or incomplete. Pain, fever, and peritoneal signs are usually present and may be severe. An adnexal mass may be palpable, although extreme tenderness may limit the examination. The abscess may rupture, causing progressively severe symptoms and possibly septic shock.
Hydrosalpinx is fimbrial obstruction and tubal distention with nonpurulent fluid; it is usually asymptomatic but can cause pelvic pressure, chronic pelvic pain, dyspareunia, and/or infertility.
Salpingitis may cause tubal scarring and adhesions, which commonly result in chronic pelvic pain, infertility, and increased risk of ectopic pregnancy.
Diagnosis
High index of suspicion
PCR
Pregnancy test
Pelvic inflammatory disease is suspected when women of reproductive age, particularly those with risk factors, have lower abdominal pain or cervical or unexplained vaginal discharge. PID is considered when irregular vaginal bleeding, dyspareunia, or dysuria is unexplained. PID is more likely if lower abdominal, unilateral or bilateral adnexal, and cervical motion tenderness are present. A palpable adnexal mass suggests tubo-ovarian abscess. Because even minimally symptomatic infection may have severe sequelae, index of suspicion should be high.
If PID is suspected, PCR of cervical specimens for N. gonorrhoeae and C. trachomatis (which is about 99% sensitive and specific) and a pregnancy test are done. If PCR is unavailable, cultures are done. However, upper tract infection is possible even if cervical specimens are negative. At the point of care, cervical discharge is usually examined to confirm purulence; a Gram stain or saline wet mount is used, but these tests are neither sensitive nor specific.
If a patient cannot be adequately examined because of tenderness, ultrasonography is done as soon as possible.
WBC count may be elevated but is not helpful diagnostically.
If the pregnancy test is positive, ectopic pregnancy, which can produce similar findings, should be considered.
Other common causes of pelvic pain include endometriosis, adnexal torsion, ovarian cyst rupture, and appendicitis. Differentiating features of these disorders are discussed elsewhere (see Pelvic Pain).
Fitz-Hugh-Curtis syndrome may mimic acute cholecystitis but can usually be differentiated by evidence of salpingitis during pelvic examination or, if necessary, with ultrasonography.
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