What is pelvic inflammatory disease?
Pelvic inflammatory disease (PID) is a condition in which there is infection of pelvic organs that is the uterus, fallopian tubes and ovaries as well as the surrounding tissues. It is an extremely common condition, and about 20% of all women attending a gynaecology outpatient clinic will have PID. The condition is easily treated if diagnosed early and managed appropriately.
What are the causes of PID?
PID is caused by an infection by certain bacteria. The infection ascends from the vagina. It can occur spontaneously, but more often after minor and major surgical procedures like medical termination of pregnancy (MTP), curettage (D&C) and other minor operations performed on the cervix or uterus. Sexually transmitted disease is causative in more than 60-75% of pelvic inflammatory disease, of which gonorrhoea accounts for 30% cases in developed countries. The commonly infecting organisms could be N. gonorrhoea, Chlamydia or Mycobacterium tuberculi.
The intrauterine contraceptive device use has increased chances of getting pelvic infection by three fold. Change in vaginal PH in immune-compromised situations, like anaemia, tissue damage or chronic disease makes the normal commensals infective. Of these the most common causative organism is the E.Coli.
The pelvic infection is a recurrent condition. A second attack can occur in 12% and a third one in 35% and a fourth attack in 75% cases. Recurrences can be prevented by more aggressive and complete treatment of both partners, followed by preventive measures like aseptic technique, use of barrier contraceptives and prevention of sexually transmitted diseases.
What are the symptoms?
Most patients of PID have a general feeling of ill health. The disease can have an acute or a chronic presentation. In the acute presentation, along with abdominal pain there maybe high grade fever, dysuria, vomiting and dehydration. Chronic cases, present with pain in lower abdomen, backache, pain during intercourse, irregular periods and vaginal discharge. The gynaecologist will usually elicit pain on internal examination.
Can the disease severity be staged?
The PID can be staged into five stages depending upon the severity. Stage 1 is acute salpingitis without peritonitis, Stage 11 is acute salpingitis with peritonitis, Stage 111 is acute salpingitis with super-imposed tubal -occlusion or tubo-ovarian abscess, Stage 1V is ruptured tubo-ovarian abscess and Stage V is tubercular salpingitis.
What are the possible diagnosis?
The differential diagnosis includes ovarian tumours, ectopic pregnancy, endometriosis, tubercular masses, fibroids, septic abortions and appendicitis or gall bladder infection. Based on clinical picture and few differentiating, features, the final diagnosis can be determined.
How is it diagnosed?
PID is diagnosed from the patients, history and clinical examination. Ultrasonography may be useful in the diagnosis of severe PID, suspected abscess, ectopic pregnancy or peritonitis. High vaginal and cervical swab cultures are done to detect the offending organism and its appropriate antibiotic.
Full blood count and cultures are sometimes done. Polymerase Chain Reaction (PCR) is now available for viruses like the HPV and HIV, bacterial organisms, Chlamydia, and tuberculosis, for rapid diagnosis. Culdocentesis or passing a needle through the vagina into the pelvic cavity to diagnose and treat pelvic abscess. Laparoscopic examination, ultrasound /CT scan and MRI are sometimes done to confirm diagnosis and determine stage.
What is the treatment?
The treatment of PID is by antibiotics and painkillers. Ciprofloxacin and metronidazole are the most commonly used medicines. Painkillers, such as ibuprofen and diclofenac, are often required.
In severe acute cases the patient may need hospitalisation and treatment with intravenous antibiotics. In less severe cases, patients may be treated, on an outpatient basis with oral antibiotics. Antibiotic treatment is usually given for 7-10 days.
Chronic cases may need treatment for longer periods like 6 to 8 weeks. Local treatment can be effective, with the use of vaginal pessaries containing antibiotics and anti-fungal agents.
Patients resistant to treatment may have collections of pus in the pelvic cavity. These patients may require laparoscopy, for diagnosis and simultaneous treatment. In very severe illness, not responding to high dose antibiotics, an open operation may be needed to remove the infected focus-uterus (hysterectomy) and /or tubes and ovaries.
Preventive measures like early treatment of all infections, avoidance of high risk behaviours for sexually transmitted disease and use of barrier contraceptives, avoidance of un-necessary pregnancy terminations and avoiding use of IUCD for nulliparous women, do reduce risks of infections.
What are the long term effects of the untreated or partially treated disease?
In current practice, due to the antibiotics, although mortality has reduced, morbidity continues to pose problems. The patients present with chronic pain, menstrual disturbances, infertility and possible risk of ectopic pregnancy. About 15% patients continue to be troubled by symptoms, 20 to 25% have recurrences and 20% develop chronic pelvic pain, and 15% develop infertility.