The female genital system consists of the lower and upper genital tracts. Anatomically, the lower tract consists of the vulva, vagina and cervix while the upper part consists of the uterus, fallopian tubes, ovaries and the supporting tissues. Pelvic inflammatory disease (PID) is the infection of the upper genital tract, plus or minus the ovaries.
PID is often referred to as an ascending infection because the upper tract is relatively free from microorganisms compared to the lower tract which contains several harmless bacteria called “the normal flora”. There is a barrier at the level of the cervix. If this barrier is breached for any reason, the bacteria would ascend to the upper tract, causing PID.
Most PIDs are sexually transmitted, chiefly due to Neisseria gonorrhoea and Chlamydia trachomatis. Infection can also occur following instrumentation or surgical procedures whereby the cervix and uterus are accessed from below (eg. D&C, cervical/endometrial biopsy, hysteroscopy, intrauterine contraceptive device insertion, etc.)
What are the common signs and symptoms of PID?
*Lower abdominal/pelvic pain – usually starting after the menstrual period.
*Low back pain
*Nausea and vomiting
*Abnormal vaginal discharge – can be absent
*Loss of appetite
*Dysmenorrhoea (menstrual pain)
*Dyspareunia (painful sexual intercourse)
***Note that PID can be totally asymptomatic and the first sign could be an incidental finding of a complication in a chronic case.
***Other diseases that mimic PID must be ruled out. These include acute appendicitis, acute gastritis, urinary tract infections and problems of early pregnancy. Of course, pregnancy must be excluded as most patients are sexually active.
As noted above, most cases of PID go silently without symptoms. Some could resolve spontaneously and others progress chronically to complications. Once you notice any of the symptoms, it is important to see your doctor immediately. The doctor would take a detailed history, examine you and request that you do some tests. Some of the tests you should do include:
*high vaginal swab – for microscopy, culture and other advanced (DNA-based) tests
*full blood count – to check for elevated white cell count
*pelvic ultrasound – to detect possible tubo-ovarian abscess (collection of pus around the ovaries)
*renal and liver function tests – in complicated cases
*laparoscopy – the gold standard for diagnosis, but not always necessary
*other tests to rule out differential diagnosis eg. Urine analysis and culture
What are the long-term complications of untreated or poorly treated PID?
*Infertility – due to adhesions in the tubes and ovaries (20% following one episode of PID, increasing with recurrent episodes)
*Chronic pelvic pain
*Increased risk of ectopic pregnancy (implantation of embryo outside the uterus, mainly due to adhesions)
*Transmission to sexual partner
*Septicaemia, septic shock and possibly, death.
Antibiotics should be started as soon as diagnosis is established. Usually, a combination regimen is used to cover a wide range of bacteria. Specific antibiotics must be used for specific bacteria isolated from the lab tests. Intravenous forms are preferred in severe cases, but can be switched to oral after 24-48hours. It is important to trace all recent sexual partners and let them get treated. Other STDs (such as HIV, Hepatitis B, etc) should also be tested for and managed as appropriate.
How can PID be prevented?
*General screening of “at risk” individuals, such as sexually active young women, those with multiple sexual partners, pregnant women, HIV positive persons, etc.
*Promotion of abstinence from indiscriminate sexual activities
*Use of condom
*Mutual faithfulness between sexual partners
*Prompt treatment of acute disease to prevent chronic disease and it’s complications.