Pelvic inflammatory disease (PID)
Pelvic inflammatory disease (PID) is an infection of the female reproductive organs - uterus, fallopian tubes, cervix and ovaries. PID usually occurs when sexually transmitted bacteria spread from your vagina to your uterus and upper genital tract. PID may also develop when bacteria travel up a contraceptive device or when they're introduced during gynecologic procedures, such as insertion of an intrauterine device (IUD) or an abortion.
Pelvic inflammatory disease tends to cause symptoms cyclically, toward the end of the menstrual period or for a few days afterward. For many women, the first symptoms are a low fever, mild to moderate abdominal pain (often aching), irregular vaginal bleeding, and a vaginal discharge with a bad odor. As the infection spreads, pain in the lower abdomen becomes increasingly severe and may be accompanied by nausea or vomiting. Later, the fever becomes higher, and the discharge often becomes puslike and yellow-green. However, a chlamydial infection may not produce a discharge or any other noticeable symptoms.
Sometimes infected fallopian tubes become blocked. Blocked tubes may swell because fluid is trapped. If the infection is not treated, pain in the lower abdomen may persist and irregular bleeding may occur. The infection can spread to surrounding structures, including the membrane that lines the abdominal cavity and covers the abdominal organs (causing peritonitis). Peritonitis can cause sudden, severe pain in the entire abdomen.
If infection of the fallopian tubes is due to gonorrhea or a chlamydial infection, it may spread to the tissues around the liver. Such an infection may cause pain in the upper right side of the abdomen that resembles a gallbladder disorder or stones. This complication is called the Fitz-Hugh-Curtis syndrome. A collection of pus (abscess) forms in the fallopian tubes or ovaries of about 15% of women who have infected fallopian tubes. An abscess sometimes ruptures, and pus spills into the pelvic cavity (causing peritonitis). A rupture causes severe pain in the lower abdomen, quickly followed by nausea, vomiting, and very low blood pressure (shock). The infection may spread to the bloodstream (a condition called sepsis) and can be fatal.
Pelvic inflammatory disease often produces a puslike fluid, which can result in scarring and the formation of abnormal bands of scar tissue (adhesions) in the reproductive organs or between organs in the abdomen. Infertility may result. The longer and more severe the inflammation and the more often it recurs, the higher the risk of infertility and other complications. The risk increases each time a woman develops the infection. Women who have had pelvic inflammatory disease are 6 to 10 times more likely to have a tubal pregnancy, in which the fetus grows in a fallopian tube rather than in the uterus. This type of pregnancy threatens the life of the woman, and the fetus cannot survive.
PID occurs when disease-causing organisms migrate upward from the urethra and cervix into the upper genital tract. Many different organisms can cause PID, but most cases are associated with gonorrhea and genital chlamydial infections, two very common STDs. Scientists have found that bacteria normally present in small numbers in the vagina and cervix also may play a role. Investigators are learning more about how these organisms cause PID. The gonococcus, Neisseria gonorrhea, probably travels to the fallopian tubes, where it causes sloughing (casting out) of some cells and invades others. Researchers think it multiplies within and beneath these cells. The infection then may spread to other organs, resulting in more inflammation and scarring.
Chlamydia trachomatis and other bacteria may behave in a similar manner. Researchers do not know how other bacteria that normally inhabit the vagina (e.g., organisms such as Gardnerella vaginalis and Bacteroides) gain entrance into the upper genital tract. The cervical mucus plug and secretions may help prevent the spread of microorganisms to the upper genital tract, but it may be less effective during ovulation and menses. In addition, the gonococcus may gain access more easily during menses, if menstrual blood flows backward from the uterus into the fallopian tubes, carrying the organisms with it. This may explain why symptoms of PID caused by gonorrhea often begin immediately after menstruation as opposed to any other time during the menstrual cycle. It is noteworthy that the co-incidence of menses and chlamydial infection is not a prominent feature of chlamydial PID.
There are several ways women can get PID. The most common way is to have sex with a person who has gonorrhea or chlamydia. These diseases are carried in the semen and other body fluids of infected people. During sexual contact, the germs spread to the woman's cervix. The germs can also infect the glands at the opening of the vagina, the urethra (passageway for urine) or the anus. When the cervix is infected with gonorrhea or chlamydia, normal vaginal bacteria can spread through the cervix and into the uterus, fallopian tubes, ovaries and abdomen.
Sometimes women get PID without being exposed to gonorrhea or chlamydia. Doctors aren't sure why this happens, but sometimes normal bacteria in the vagina spread into the uterus, fallopian tubes and abdomen, causing PID. PID can also occur after certain surgical procedures on the female organs. PID can occur after the insertion of an intrauterine device (IUD), but this isn't common. PID may occur after an abortion or after procedures that take a sample from the inside of the womb, such as a dilatation and curettage (D & C). Sometimes PID can occur after the cervix is treated because of an abnormal Pap smear.
PID is difficult to diagnose because the symptoms are often subtle and mild. Many episodes of PID go undetected because the woman or her health care provider fails to recognize the implications of mild or nonspecific symptoms. Because there are no precise tests for PID, a diagnosis is usually based on clinical findings. If symptoms such as lower abdominal pain are present, a health care provider should perform a physical examination to determine the nature and location of the pain and check for fever, abnormal vaginal or cervical discharge, and for evidence of gonorrheal or chlamydial infection. If the findings suggest PID, treatment is necessary.
The health care provider may also order tests to identify the infection-causing organism (e.g., chlamydial or gonorrheal infection) or to distinguish between PID and other problems with similar symptoms. A pelvic ultrasound is a helpful procedure for diagnosing PID. An ultrasound can view the pelvic area to see whether the fallopian tubes are enlarged or whether an abscess is present. In some cases, a laparoscopy may be necessary to confirm the diagnosis. A laparoscopy is a minor surgical procedure in which a thin, flexible tube with a lighted end (laparoscope) is inserted through a small incision in the lower abdomen. This procedure enables the doctor to view the internal pelvic organs and to take specimens for laboratory studies, if needed.
Antibiotics are the standard treatment for PID. Your doctor may prescribe a combination of antibiotics before receiving the results of your laboratory tests. The antibiotics may be adjusted once your results are known. Your doctor may also prescribe a painkiller and recommend bed rest. To prevent reinfection of PID, advise your sexual partner to be examined and treated. Avoid sexual intercourse until treatment is completed and tests indicate that the infection has cleared in all partners. Outpatient treatment is adequate for treating most women with PID. However, if you're seriously ill, pregnant or HIV-positive or have not responded to oral medications, you may need hospitalization. At the hospital, you may receive intravenous (IV) antibiotics, followed by oral antibiotics. Surgery is rarely necessary. However, if an abscess ruptures or threatens to rupture, your doctor may drain it. In addition, surgery may be performed on women who don't respond to treatment or who have a questionable diagnosis, such as when one or more of the signs or symptoms of PID are absent. In these cases, antibiotic treatment is often tried before surgery, because of the risks of surgery.
Prevention of pelvic inflammatory disease is essential to the health and fertility of a woman. The best way to prevent the infection is abstaining from sex. However, if a woman has sexual intercourse with only one partner, the risk of pelvic inflammatory disease is very low, as long as neither person has a sexually transmitted disease. Refraining from douching is also helpful. Barrier methods of birth control (such as condoms) and spermicides (such as vaginal foams) used with a barrier method can help prevent pelvic inflammatory disease.