Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) is infection of a woman's reproductive organs. Infection spreads upward from the cervix to the uterus, fallopian tubes, ovaries, and surrounding structures.

Bacteria can infect the fallopian tubes and cause inflammation. When this happens, normal tissue can become scarred and block the normal passage of an egg. You may become infertile (unable to become pregnant). But if your tubes are partially blocked, an egg may implant outside the uterus and cause a dangerous condition called an ectopic pregnancy. An ectopic pregnancy can cause internal bleeding and even death. Scar tissue may also develop elsewhere in your abdomen and cause pelvic pain that can last for months or years.

• The 2 most commonly involved bacteria that cause PID are those of the sexually transmitted diseases gonorrhea and chlamydia.

• PID can cause a wide variety of symptoms. Some women can be very ill and have severe pain and fever. Others can have no obvious symptoms or even appear ill. Thus, PID is not always easy to diagnose. But it is important for you to seek medical attention if you have any risk factors for PID or symptoms of PID.

• PID affects more than 1 million women in the United States per year. Nearly 250,000 women are hospitalized annually because of PID.

• Sexually active women younger than 25 years are at greatest risk, although PID can occur at any age.

Pelvic inflammatory disease is caused by germs that are transmitted through sexual contact and other bodily secretions. Bacteria that cause gonorrhea and chlamydia cause more than half of cases. Other organisms found in the vagina can also cause PID but are much less common.

• If you have PID, you may have any of these symptoms:
  
  
  • Abdominal pain (especially lower abdominal pain) or tenderness
    
    
  • Back pain
    
    
  • Abnormal uterine bleeding
    
    
  • Unusual or heavy vaginal discharge
    
    
  • Painful urination
    
    
  • Painful sexual intercourse

• Symptoms not related to the female reproductive organs include fever, nausea, and vomiting.

• Your symptoms may be worse at the end of your menstrual period and during the first several days following a period.

If you are experiencing the following symptoms, you should see your health care provider:

• Abdominal pain that does not go away
  
  
• Irregular vaginal bleeding
  
  
• Foul-smelling vaginal discharge
  
  
• Unusual vaginal discharge
  
  
• Fever, nausea, vomiting

Given the long-term complications PID can cause, such as infertility and ectopic pregnancy, it is recommended that you seek immediate medical attention if you have any of these symptoms:

• Lower abdominal pain or tenderness
  
  
• Fever greater than 101°F (38.3°C)
  
  
• Abnormal or foul-smelling vaginal discharge

Adult women with PID are either closely monitored or admitted to the hospital. More aggressive treatment may take place in the hospital for adolescents, who are at a much higher risk of not following treatment plans and of having complications.

You may be admitted to the hospital if any of the following are true:

• The diagnosis is unclear.
  
  
• Ectopic pregnancy or appendicitis cannot be ruled out.
  
  
• You are pregnant.
  
  
• An abscess (an infection) is suspected.
  
  
• You are acutely ill or cannot manage your illness at home.

Your health care provider will diagnose PID by taking your medical history, doing a physical exam, and ordering appropriate tests.

• Physical exam findings include the following:
  
  
  • A temperature greater than 101°F (38.3°C)
    
    
  • Abnormal vaginal discharge
    
    
  • Lower abdominal tenderness when felt
    
    
  • Tenderness when your cervix is moved
    
    
  • Tenderness in your female organs
• 
  
• Laboratory tests may include the following:
  
  
  • A urine pregnancy test if you are of childbearing age
    
    
  • Urinalysis to check for bladder and kidney infection
    
    
  • A complete blood count (although fewer than half of women with acute PID have a high white blood cell count indicating an infection)
    
    
  • Cervical cultures for gonorrhea and chlamydia
    
    
  • Testing for other sexually transmitted diseases, including syphilis and HIV
    
    
  • Additional tests if you have more severe symptoms
• 
  
• Imaging: A pelvic ultrasound, although not routinely done, can be an important tool in diagnosing complications such as tubo-ovarian abscesses, ovarian torsion, ovarian cysts, and ectopic pregnancy. Although unlikely to occur in pregnancy, PID is the most commonly missed diagnosis in ectopic pregnancies and can occur during the first 12 weeks of pregnancy.
  
  
• Exploratory surgery: A woman’s health specialist (a gynecologist) can use a laparoscope (a small tube with a camera attached) to make small incisions in and around your navel to view surrounding reproductive organs for inflammation. The doctor can also identify an ectopic pregnancy. Definitive care can then be provided from starting IV antibiotics to removing an ectopic pregnancy.

|Medical Treatment|

Your health care provider will start antibiotic therapy for PID as soon as the diagnosis is made. Gonorrhea and chlamydia are suspected and treated in every person. Pain medication and IV fluids will be given if you need them.

|Medications|

Because samples of the bacteria from the upper genital tract are difficult to obtain and because many different organisms may be responsible for your PID, especially if it is not your first occurrence, the doctor will prescribe at least 2 antibiotics at the same time that are effective against a wide range of infectious germs.

Your doctor may provide IV antibiotics through the office, visiting nurse, or clinic. Emergency department doctors can also provide oral and IV treatment. Depending on the severity of the particular case of PID, a doctor may also choose to admit you for hospital treatment.

• If you are pregnant, you are going to be admitted into the hospital. If the doctor is unsure that you have PID, a gynecologist will be consulted. If the doctor cannot rule out appendicitis or another surgical emergency, a surgeon may be called to examine you.
  
  
• If you do not improve within 72 hours of starting treatment, then you should be reevaluated to make sure you have PID. You may be given IV antibiotics and be admitted to the hospital.

|Surgery|

Untreated PID can cause chronic pelvic pain and scarring in about 20% of women. These conditions are difficult to treat but are sometimes improved with surgery.

|Follow-up|

Take all medications your health care provider prescribes. Your symptoms may go away before the infection is cured and you may feel much better, but finish taking all the antibiotics prescribed for you. Follow up with your doctor or in a clinic within 3 days to monitor improvement. Whether on oral or IV therapy, you usually improve within 72 hours.

• If you are being treated and your symptoms get worse prior to the 72-hour follow–up appointment, you should return to the doctor's office or hospital. If you do not improve, you may require additional testing and maybe surgery.
  
  
• You should not have sexual activity until the infection is cured. Any sexual partners you have had within 2 months of getting PID should also be treated.

|Prevention|

You can take these steps to avoid pelvic inflammatory disease or to keep PID from getting worse:

• Frequent vaginal douching is a potential risk factor for PID. Douching may push bacteria into the upper genital tract. Douching also may ease discharge caused by an infection, so you may not think you have a symptom and would delay seeking medical care. Do not use douches. Your vagina cleans itself naturally. Regular showers and baths are enough.
  
  
• Wipe from front to back after a bowel movement. This keeps bacteria from entering your vagina.
  
  
• If you have vaginal itching, do not scratch. Wash with water only, use no potentially irritating soaps.
  
  

As in other sexually transmitted diseases, education is the way to prevent PID.

• Practice safe sex, if you choose to have sexual intercourse. Use barrier devices such as a latex condom. Use only water-based lubricants with condoms. For oral sex, use a device called a dental dam. This is often used by dentists. It’s a rubbery device you place over the opening of your vagina before having oral sex. If you don’t have a dental dam, you can cut an unlubricated male condom open and place it over the opening to your vagina.
  
  
• Birth control pills and intrauterine devices do not prevent PID. Recently inserted intrauterine devices (IUDs), in fact, may put you at risk.
  
  
• Make sure your sexual partner is treated if you are diagnosed with a bacterial infection such as a sexually transmitted disease, or you may become reinfected. Limit your sexual partners and avoid high-risk partners.
  
  
• If you are at risk for PID, have regular tests for sexually transmitted diseases.

|Outlook|

If you are diagnosed and treated early, your outcome is good. The outcome may not be as good if you wait too long before treatment and/or engage in unsafe sexual practices. Complications can occur:

• Tubal damage and scarring can result in infertility. PID is the most common cause of infertility in women. Following a single episode of PID, 8% of women were infertile; after 2 episodes, 19.5% of women were infertile; and after 3 or more episodes, 40% of women were infertile.
  
  
• Ectopic pregnancy is 6 times more common in women who have had PID at least once. In the United States, half of all women with such pregnancies have had a prior episode of PID.
  
  
• Chronic pelvic pain is present in up to 18% of women with PID.
  
  
• Ovarian abscesses can occur after an episode of PID. Untreated PID also puts you at risk for a tubo-ovarian abscess (TOA). A TOA is a collection of bacteria, pus, and fluid that occurs in the fallopian tube. It is most often seen in teens. A TOA is also more likely to occur in teens or adult women who use intrauterine devices (IUDs) as birth control. A teen girl with a TOA often looks sick and has a fever and pain that makes it difficult to walk. The abscess will be treated in the hospital with antibiotics, and surgery may be needed to remove it.

If you have PID, you are at increased risk of getting PID again. As many as one third of women who have had PID will have the disease at least one more time. With each case, your risk of becoming infertile is increased.

|Web Links|

National Institute of Allergy and Infectious Diseases, National Institutes of Health, Fact Sheet, Pelvic Inflammatory Disease

National Women's Health Information Center, Pelvic Inflammatory Disease or call (800) 994-9662

Centers for Disease Control and Prevention (CDC), National Prevention Information Network or call (800) 458-5231; CDC National Center for HIV, STD and TB Prevention

American Social Health Association

The American College of Obstetricians and Gynecologists

Planned Parenthood Federation of America or (800) 230-7526

Author: Minal Patel, MD, Clinical Assistant Instructor, Department of Emergency Medicine, Kings County Hospital Center.

Coauthor(s): Richard Sinert, MD, Director of Research, Assistant Professor, Department of Emergency Medicine, King's County Hospital Center, State University of New York at Downstate.

Editors: Mitchell J Goldman, DO, FAAP, FAAEM, Director of Pediatric Emergency Medicine, Emergency Medicine, St Vincent Emergency Physicians, Inc; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; James Quinn, MD, Director of Research Department of Medicine, Division of Emergency Medicine University of California at San Francisco Medical Center.