Infections

PELVIC INFLAMMATORY DISEASE

Pelvic Inflammatory Disease (PID) refers to a spectrum of diseases that arise from sexually transmitted and other infections ascending upwards from the cervix. This can include infections of the endometrium and parametrium (womb), Fallopian tubes (salpingitis), ovaries and even the pelvic lining itself (pelvic peritonitis).

The infections that cause it include Gonorrhoea, Chlamydia, Trichomoniasis and "anaerobic" bacteria as well as those causing Non Specific Urethritis (NSU) in men.

The symptoms a woman can have with PID vary greatly and can include pelvic pain, dyspareunia (pain during intercourse), vaginal discharge, abnormal vaginal bleeding, fevers and lethargy. There are many other conditions that cause a similar and overlapping spectrum of symptoms and the most important ones are appendicitis, ectopic pregnancy, endometriosis and complications of ovarian cysts.

Of the above, ectopic pregnancy is perhaps the most dangerous as it can be fatal if a foetus that is developing outside the womb ruptures and bleeds. For this reason, women with severe pelvic pain usually have a pregnancy test performed when seeing a doctor in order to exclude ectopic pregnancies.

It can be quite difficult to diagnose PID and the only definitive way of doing this is by performing a laparoscopy which is a keyhole surgery investigation to examine the pelvis. For obvious reasons this is not possible or practical for the large number of women who see doctors with pelvic pain. Ultrasound scans of the pelvis are informative but not always 100% accurate, as they can miss cases of PID where the level of inflammation is mild. In addition to this the severity of symptoms can be totally unrelated to the degree of inflammation present in the pelvis.

In practice, most doctors diagnose PID after taking a careful history from the patient and performing a physical examination. The most important aspect of the examination is the "bimanual" or "internal" examination. If it is very painful when the doctor touches the cervix (cervical excitation) this is often interpreted as a sign of infection above the cervix. This is used by many physicians as the deciding factor as to whether to treat a woman for infection or not.

The management of a woman with PID starts with the taking of a number of tests for sexually transmitted infections (STIs). If these are positive that lends support to a diagnosis of PID. However, it must be remembered that even if these tests are negative, this does not mean that PID is not present. This is because the swabs can only reach as far inside as the cervix and cannot detect infection higher up i.e. in the womb or Fallopian tubes.

The woman will need to start a course of antibiotic tablets that usually continue for two weeks. There are several approved combinations of antibiotics and the choice of a regimen depends on local guidelines, allergies and whether or not the woman is pregnant. In severe cases of PID the patient may be hospitalised and need to receive intravenous antibiotics (injections). Antibiotic regimens are typically "broad spectrum" that is to say they cover a wide range of potential infections including the anaerobic bacteria. These include the drugs Doxycycline, Ofloxacin and Metronidazole.

It is essential that the sexual partner(s) of a woman with PID are checked and treated for STIs. Both partners must abstain from sex whilst treatment continues and until a woman has either improved clinically or infection has been ruled out. If a sexual partner is untreated or the couple continue having sex then there is a high risk of the infection persisting.

If a woman with PID has an intra-uterine contraceptive device (coil) fitted then some doctors will remove this when the diagnosis of PID is made. It is believed that it would be hard to eradicate infection with the presence of a coil, however opinions and practices about this vary.

Once treatment has been started it is important for a woman to be seen again within three to four days and also at the end of the treatment period. At the first review visit, if the diagnosis is correct and the antibiotics are being taken then the woman can expect to feel a lot better. If she is not feeling better, then alternative diagnoses need to be considered and explored. At the final follow-up visit a doctor will check if the patient and her partner have successfully completed their antibiotics as well as reviewing the final results of the initial STI tests.

Some of the complications of PID are chronic pelvic pain, menstrual irregularities, a risk of ectopic pregnancy and even infertility. For this reason most doctors have a low threshold for treating suspected PID when a woman presents to them with pelvic pain. Compliance with treatment and follow-up is essential to evaluate whether or not the PID has been adequately treated and to arrange other tests should the initial diagnosis prove to be wrong. It is also worth bearing in mind that if an initial diagnosis of PID is subsequently proven wrong, a woman will sustain very little harm from a short course of antibiotics provided that allergies etc are taken into account.

A question that patients often have is "how will PID affect fertility?" It is thought that approximately 10% of women will have "tubal occlusion" (blocked tubes) after one episode of PID. The proportion rises with the number of episodes of PID and the longer an infection is left untreated, the more harm it could potentially be causing. However, it must be remembered that fertility is a complicated subject and there are numerous causes for it that are unrelated to STIs. Hence, although prompt treatment of STIs is always recommended this will not guarantee fertility in future years.