How serious is Pelvic Inflammatory Disease and how does it affect the fertility in women?
What is Pelvic Inflammatory Disease (PID)?
Pelvic inflammatory disease, or PID, is an infection of the organs of a women’s reproductive system. They include the uterus, ovaries, fallopian tubes, and cervix. Usually this is an acute infection, but in some cases, the inflammation may persist for a long time and then it is known as chronic PID and is associated with long term sequelae.
What are the causes for Pelvic Inflammatory Disease?
It’s usually caused by a sexually transmitted infection (STI), like chlamydia or gonorrhea.
Gardnerella vaginalis, anaerobes and other organisms commonly found in the vagina may also be implicated. Occasionally, PID can develop after a miscarriage or termination of pregnancy, after having a baby or after a procedure such as insertion of an intrauterine device (IUD) or coil
Clinical signs and symptoms of PID can be as follows:
- lower abdominal pain which is typically bilateral PID
- deep dyspareunia
- abnormal vaginal bleeding, including post coital, inter-menstrual and menorrhagia
- abnormal vaginal or cervical discharge which is often purulent
- lower abdominal tenderness which is usually bilateral
- adnexal tenderness on bimanual vaginal examination • cervical motion tenderness on bimanual vaginal examination
- fever (>38°C)
Some of these also can be signs of other serious medical conditions, like appendicitis or an ectopic pregnancy (a pregnancy that happens in a fallopian tube outside the womb.
Diagnosis
A diagnosis of PID, and empirical antibiotic treatment, should be considered and usually offered in any young (under 25) sexually active woman who has recent onset, bilateral lower abdominal pain associated with local tenderness on bimanual vaginal examination, and in whom pregnancy has been excluded.
Swabs may be taken from the vagina and cervix to test for infection. It usually takes a few days for the results to come back.
- a positive swab result confirms that there is an infection
- a negative swab result, however, does not mean that definitely there is no infection.
Further tests:
- Blood tests to exclude other infection, such as CBC, CRP, etc
- Ultrasound of the pelvis, usually TVS
- Laparoscopy can be used to diagnose PID or even drain a pelvic abscess
Differential diagnosis
- Ectopic pregnancy
- Acute appendicitis
- Urinary tract infection
- Ovarian cyst related complications
- Endometriosis
- Functional pain
What is the Treatment options for PID
Pelvic inflammatory disease (PID) is an infection of the female reproductive system. It’s usually caused by a sexually transmitted infection. It is likely that delaying treatment increases the risk of long term sequelae such as ectopic pregnancy, infertility and pelvic pain.
Broad spectrum antibiotic therapy is required for PID to cover N. gonorrhoeae, C. trachomatis and a variety of aerobic and anaerobic bacteria commonly isolated from the upper genital tract in women.
A prolonged course of combination / broad spectrum antibiotics may be needed to cover most of the causative organisms and sometimes even hospitalisation may be needed.
What is the General Advice given for PID?
- Rest is advised for those with severe disease.
- Appropriate analgesia should be provided
- Intravenous therapy is recommended for patients with more severe clinical disease e.g. pyrexia > 38 degree C, clinical signs of tubo-ovarian abscess, signs of pelvic peritonitis etc.
- Patients should be advised to avoid unprotected intercourse until they, and their partner(s), have completed treatment and follow-up
When is hospitalisation advised for PID?
In more serious cases, treatment may include a stay in the hospital. There may be several reasons for this:
- Despite taking antibiotics , if symptoms aren’t improving, more tests may be needed to figure out why.
- IV antibiotics may be needed.
- Development of tubo-ovarian abscess- This happens when part of an ovary or fallopian tube fills with infected fluid that needs to be drained. IV antibiotics are usually given first to see if they’ll clear up the infection.
General Discussion points for PID:
What if there is an IUCD?
If symptoms of PID are not improving within a few days of starting treatment and there is an IUCD, the doctor may recommend that to have it removed. If there has been unprotected intercourse in the last 7 days before it is removed, there is a risk of pregnancy, and emergency hormonal contraception (the morning-after pill) may be offered.
Should the partner be treated?
If there is development of PID as a result of an STI, any sexual partner with in the last 6 months should be tested for infection, even if they are well.
When can you have sex again?
Avoid having any sexual contact for 1 week after completion of the course of treatment, to avoid reinfection.
Are there any long-term effects?
Treatment with antibiotics is usually successful for acute PID. Long-term problems can arise if it is untreated, if treatment is delayed, or if there is a severe infection.
The long-term effects can be (With particular reference to the fallopian tubes):
- scarring of the fallopian tube, which can cause: an increased risk of ectopic pregnancy (due to damage to the mucosa and cilia)
- difficulties in becoming pregnant
- an abscess in a fallopian tube and/or ovary
- Development of Hydrosalpinx
- Pelvic adhesions, involving the tubes and ovaries.
- Persistent pelvic pain
Repeated episodes of PID increase the risk of future fertility problems. Risks of further infection can be reduced by using condoms and by making sure that both partner(s) have been treated.
Key points to note regarding PID:
- Pelvic inflammatory disease (PID) is an inflammation of the pelvic organs.
- Diagnosis is usually based on symptoms, examination and test results.
- Acute PID is usually treated successfully with antibiotics. Rarely, surgical treatment may be required.
- It is advisable to avoid having any sexual contact until you and your partner have completed the course of treatment and follow-up.
- Tubal factor Implication : From the Fertility point of view, the damage to the Fallopian tubes is the main concern. Usually there is primary or secondary infertility, or there may be a history of ectopic pregnancy. Evaluation of the tubes for patency (using methods like, HSG, HyCoSy, and/or Laparoscopy) is of prime importance for counselling the patient and advising further regarding mode of treatment.
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