Pelvic Inflammatory Disease

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As has been indicated earlier, Pelvic Inflammatory Disease may be either acute or chronic. PID is a common cause of morbidity, and accounts for 1 in 60 consultations by women under the age of 45 (Simms et al., 2000). It has been reported that a delay of a few days in receiving appropriate treatment can increase the risk of sequelae, which include infertility, ectopic pregnancy and chronic pelvic pain (Hillis et al., 1993).

The RCOG Guidance (2003) recommends that, owing to a lack of definitive clinical diagnostic criteria, a low threshold for the empirical treatment of

PID is recommended. They also suggest that in severe cases, or where there is diagnostic doubt, the woman should be admitted to hospital for further investigation and treatment.

CAUSES

PID is usually the result of ascending infection from the endocervix, causing endometritis, salpingitis, parametritis, oophoritis, tubo-ovarian abscess and/or pelvic peritonitis. Sexually transmitted infections, such as Chlamydia trachomatis and Neisseria gonorrhoeae are identified as causative agents. Mycoplasma genitalium anaerobes and other organisms may also be implicated (Bevan et al., 1995).

CLINICAL FEATURES

• Lower abdominal pain and tenderness

• Deep dyspareunia

• Abnormal vaginal or cervical discharge

• Abnormal vaginal bleeding

• Cervical excitation and adnexal tenderness on motion

• Nausea and vomiting

SHORT-TERM COMPLICATIONS Fitz-Hugh-Curtis syndrome

This takes the form of peri-hepatitis and is generally chlamydial or gonococ-cal in origin. Laparoscopy reveals oedema of the liver capsule and adhesions to the peritoneum.

Pelvic abscess

These are detected by the palpation of an adnexal mass, confirmed by ultrasound. Antibiotics may reduce the abscess, but occasionally surgery is necessary.

LONG-TERM COMPLICATIONS Chronic pain

The exact origin of chronic pelvic pain is difficult to ascertain. It may be due to recurrence of infection or adhesions and scarring in the pelvic cavity caused by previous infection. The patient may present with pain following sexual intercourse or with pain during a certain time in the menstrual cycle as organs move in response to hormonal influence.

Recurrence

Subsequent attacks are said to be more likely after one episode of PID. Ectopic pregnancy

Owing to scarring in the Fallopian tubes, ectopic pregnancies are more likely in women who have earlier suffered from PID.

Impaired fertility

Again as a result of the scarring following each episode of PID, the likelihood of fertility impairment increases.

Diagnosis

Clinical symptoms and signs lack sensitivity and specificity (the positive predictive value of clinical diagnosis is 65-90 per cent compared with laparoscopic diagnosis) (Bevan et al., 1995). Microbiological tests for gonorrhoea and Chlamydia in the lower genital tract are recommended, as a positive result strongly supports the diagnosis of PID (Bevan et al., 1995; Morcos et al., 1993). An elevated erythrocyte sedimentation rate (ESR) or c-reactive protein rate (CRP) also supports the diagnosis (Miettinen et al., 1993). While laparoscopy may strongly support a diagnosis of PID, it is not routinely justified on the basis of cost. Endometrial biopsy and ultrasound scanning may also be helpful when there is diagnostic difficulty; but there is insufficient evidence to support their routine use at present. The absence of endocervical or vaginal pus cells has a good negative predictive value (95 per cent) for a diagnosis of PID, but their presence is non-specific (poor positive predictive value: Yudin et al., 2003).

MANAGEMENT (BASHH, 2005) Medical

Adequate pain relief is essential. BASHH guidelines (2005) recommend a low threshold for the empiric treatment of PID. Broad-spectrum antibiotics are suggested to cover gonorrhoea and Chlamydia along with the treatment of aerobic and anaerobic bacteria. BASHH also recommend women who are at high risk of gonococcal PID being treated with a cephalosporin-based regimen as opposed to a quinolone-based one. Overall treatment is influenced by robust evidence on local antimicrobial sensitivity patterns, the specific infection in this setting, costs, patient preferences and compliance, along with the severity of the infection.

Metronidazole is included to improve the coverage for anaerobic bacteria. Anaerobes are of relatively greater importance in patients with severe PID, and metronidazole may be discontinued in those patients with mild or moderate PID who are unable to tolerate it.

Intrauterine coil device

Faculty of Family Planning Guidelines (2004), recommend that there is no need to remove an intrauterine device unless symptoms fail to resolve.

Pregnancy and breastfeeding

• PID in pregnancy is associated with an increase in both maternal and fetal morbidity; therefore parenteral therapy is advised, although none of the suggested evidence-based regimens are of proven safety in this situation.

• There are insufficient data from clinical trials to recommend a specific regimen.

• The risk of giving any of the recommended antibiotic regimens in very early pregnancy (prior to a positive pregnancy test) is low, with any significant drug toxicity resulting in failed implantation (BASHH, 2005).

Surgical management

• Laparoscopy - division of adhesions and drainage of pelvic abscesses. Ultrasound-guided aspiration of pelvic fluid.

Follow-up

A 72-hour review is recommended for those with moderate or severe clinical presentation. If there is not substantial improvement at this point further investigation as an inpatient, parenteral therapy and/or surgical intervention may be necessary. A four-week review following therapy will ensure:

1. an adequate clinical response to treatment;

2. compliance with oral antibiotics;

3. screening and treatment of sexual contacts; and

4. awareness of the significance of PID and its sequelae.

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