Pelvic inflammatory disease (PID) is an infection of the female
reproductive organs.
It is a leading cause of infertility in women.
Women with sexually transmitted diseases (STDs) are at greater risk of
developing PID.
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In most cases of PID, bacteria enter the vagina during
sexual intercourse and move up into the cervix, uterus, fallopian
tubes and to the ovaries.
Symptoms include pain in the lower abdomen, vaginal discharge,
abnormal bleeding and fever.
What is pelvic inflammatory disease (PID)?
Pelvic inflammatory disease
(PID) is an infection of the upper genital tract and can affect the uterus, fallopian tubes and ovaries. The disease
usually occurs when sexually
transmitted bacteria move up from the vagina through the cervix into the upper genital tract.
Aside from AIDS, PID is the most common - and most serious - complication
arising from sexually transmitted diseases (STDs) among women.
What causes PID?
The most common causes of PID are sexually transmitted micro-organisms
which can lead to diseases such as gonorrhoea and chlamydia. The
micro-organisms that cause these STDs are passed on through the sexual
organs from the male to the female partner by being transmitted to the vagina
and cervix during intercourse. From there, they can travel into the
female internal reproductive organs. Bacteria participating in the
developing infection can also be those ones which are normally found in the large
intestine (colon). This may happen when intestinal bacteria get access to
the vagina, especially when vaginal intercourse occurs right after anal
sex.
Less common, PID can be
caused by other organisms such as TB, and rarely by those causing bilharzia
(schistosomiasis) and leprosy.
Who gets PID and who is at risk?
PID is more common in women under the
age of 35 who are sexually active.
The following factors increase the risk of PID:
High-risk sexual practices, such as having
unprotected intercourse, multiple sex partners or having sex with a person who
has (or has had) other sexual partners.
Women with STDs of the lower genital tract
(vagina, cervix) - especially gonorrhoea and chlamydia.
A prior episode of PID increases the risk of another episode.
Sexually active teenagers are more likely to develop
PID than older
women.
The more sexual partners a woman has, the greater her risk of developing
PID.
Research has also shown that women who perform
vaginal douching once or twice a month may be
more likely to develop PID. This is because these women often try to treat their already existing
discharge and vaginal infection by douching which may also promote
bacteria to travel into
the upper genital tract.
Symptoms and signs of PID
Acute PID often starts shortly after a period, with lower
abdominal pain that becomes progressively worse. A woman with PID may experience vomiting, high fever and a
copious, foul-smelling vaginal discharge. However, a low-grade fever, mild to
moderate abdominal pain, irregular bleeding and vaginal discharge can also
be symptoms of the disease. When examined by a doctor, the abdomen is
tender and even rigid, and if the cervix is moved during the
gynaecological examination, this will increase the pain.
After an acute attack, chronic PID may follow with
chronic pelvic pain, irregular periods and possibly infertility, all signs
of adhesion formation and scarring within and around the fallopian tubes and
ovaries as well as other pelvic organs.
Flaring up of the disease may occur commonly with bowel organisms.
How is PID diagnosed?
Generally, a diagnosis of PID will be based on the presence of lower
abdominal tenderness, a raised temperature and the clinical findings on
gynaecological examination - vaginal and cervical discharge and
tenderness of the uterus, tubes and ovaries during palpation. While performing
the speculum examination, the doctor will take swabs to test for chlamydia,
gonorrhoea and other micro-organisms. While doing the palpation, the
doctor may feel a swelling and resistance either on one or both sides of the
uterus, indicating severe inflammation of the fallopian tubes and ovaries
(adnexal mass). These findings may be confirmed, if necessary, by an abdominal
or transvaginal ultrasound examination.
If the symptoms are only on one side, together with an unclear history,
the differential diagnosis of an acute appendicitis or an ectopic pregnancy has
to be taken into account and a laparoscopy may be performed. This is a
surgical procedure under general anaesthesia during which an endoscope (a thin
fibre-optic tube with light supply) is inserted through a small incision just
below the navel. This procedure allows the gynaecologist to visually examine the
uterus, fallopian tubes and ovaries as well as the appendix and other pelvic
structures. During laparoscopy, the gynaecologist will take the decision whether
the condition is due to PID which will be treated conservatively with
antibiotics, or whether to proceed with surgery by removing an inflamed appendix
or an ectopic pregnancy.
How can PID be prevented?
Most cases of PID could be prevented if sexually active couples are mutually monogamous. If "she" has sexual intercourse only with "him", and "he"
has sexual intercourse only with "her", there would be no third (possibly
contaminated) person who would bring sexually transmissible micro-organisms into
their intimate relationship.
Second choice of prevention is what is often
referred to as "safe sex" which means trying to prevent contamination with
micro-organisms (which are possibly present in the other partner) by using
barrier contraception (condoms, spermicides with cervical caps or diaphragms).
However, the "safety" is variable and depends on several factors (consistency of
use, slipping-off condoms, breakage etc). The safety factor of condom use,
for example, has to be seen in the right perspective: if sperms manage to enter
the genital tract when a condom breaks and cause a pregnancy, so can STD
micro-organisms enter the genital tract and cause PID.
PID may develop due to particular circumstances and not every
contamination with a STD will automatically lead to PID. Certain hygienic
factors play a role and the following should be kept in mind:
Vaginal contamination with intestinal bacteria
should be avoided. Contamination may occur after anal intercourse or, after a bowel motion if the
perineal area is wiped wrongly from back to front thereby
promoting bacteria from the colon to enter the vagina .
If tampons are used during menstruation, they
should be changed regularly at appropriate intervals.
Women should avoid regular vaginal
douching. This may disturb the normal eco-system of the vaginal bacterial
flora. If women become dependent on douching as part of their hygiene and aim
to reduce vaginal discharge, they should rather see a gynaecologist for a
thorough examination.
Sexual intercourse should be avoided for at least
two weeks after a miscarriage, a D&C or a termination of pregnancy
(abortion). The cervix is dilated during these procedures and the cervical
barrier is breached so that bacteria can enter the upper genital tract easier.
After having an IUD inserted, a condom should be
used for two weeks.
Women at risk for PID should have an annual Pap
smear and consult their doctor in the event of any vaginal
discharge.
How is PID treated?
Acute PID requires immediate treatment with
antibiotics, started as soon as specimens have been obtained to determine to
which antibiotics the causative organism is sensitive. Treatment can be started
before the results of these tests are back and the antibiotics changed later if
necessary.
A serious case is treated in hospital with intravenous antibiotics. Milder
cases can be treated with oral antibiotics on an outpatient basis.
Immediate treatment is essential since the risk of infertility increases with
increasing inflammation.
Many women with PID have sexual partners who have
no symptoms, even though these partners may be infected with organisms that can
cause PID. Because of the risk of reinfection, sexual partners should be
examined, even if they do not exhibit
symptoms, and treated whenever necessary.
What is the outcome of PID?
A woman who has had PID
more than once is likely to suffer scarring of the fallopian tubes, which may
partially or completely block the normal passage between the uterus and the
ovaries. This can lead to an ectopic pregnancy and also increases the risk of
infertility. If an ectopic pregnancy occurs, the fertilised egg implants in the
fallopian tube rather than in the uterus. These pregnancies
are not viable and can lead to serious complications if not diagnosed early.
Abscesses may develop in the tubes, ovaries and
elsewhere in the pelvis during the acute or subacute
stage of PID. If these do not respond to antibiotic treatment they often have
to be removed surgically.
PID can also cause chronic pelvic pain
and this condition may sometimes be improved with surgery. With
each episode of reinfection and recurrence of PID, the risk of
infertility is increased.
When to see a doctor
A doctor should be consulted if a woman suffers
from abdominal pain or tenderness, a vaginal discharge with an
offensive smell, menstrual cramps or a high fever. A doctor should also be called
if an IUD was recently inserted and it is causing
discomfort, or if a woman had unprotected sex with
a partner who she thinks might have an
STD.
(Reviewed by Prof Bert Schaetzing, Faculty of Health Sciences, University of Stellenbosch)
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