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MODERN PREVENTION OF PELVIC INFLAMMATORY DISEASES
Shirinova Zuhra Tayirovna
Termiz University of Economics and Service
Abstract:
This article reviews the history of pelvic inflammatory disease and
provides information on how to prevent its spread. Epidemiological features of the
disease, spreading factors and diagnostic methods were analyzed in the study. The main
focus is on effective disease prevention measures, including vaccination, sanitation and
public education. This article describes strategies to prevent pelvic inflammatory
disease.
Key words:
pelvis, epidemiology, prevention, diagnosis, inflammation, labia.
Pelvic
inflammatory
disease
,
also
known
as
pelvic
inflammatory
disorder
(
PID
), is an infection of the upper part of the female reproductive system,
mainly the uterus, fallopian tubes, and ovaries, and inside of the pelvis. Often, there
may be no symptoms. Signs and symptoms, when present, may include lower
abdominal pain, vaginal discharge, fever, burning with urination, pain with
sex, bleeding after sex, or irregular menstruation. Untreated PID can result in long-
term complications including infertility, ectopic pregnancy, chronic pelvic pain,
and cancer.
The disease is caused by bacteria that spread from the vagina and cervix. It has been
present in 75 to 90 percent of cases. However, in the UK it is reported by the NHS that
infections by
only a quarter of PID cases. Often, multiple different bacteria are involved.
Without treatment, about 10 percent of those with a chlamydial infection and 40
percent of those with a gonorrhea infection will develop PID. Risk factors are generally
similar to those of sexually transmitted infections and include a high number of sexual
partners and drug use. Vaginal douching may also increase the risk. The diagnosis is
typically based on the presenting signs and symptoms. It is recommended that the
disease be considered in all women of childbearing age who have lower abdominal
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pain. A definitive diagnosis of PID is made by finding pus involving the fallopian tubes
during surgery. Ultrasound may also be useful in diagnosis.
Efforts to prevent the disease include not having sex or having few sexual partners
and using condoms. Screening women at risk for chlamydial infection followed by
treatment decreases the risk of PID. If the diagnosis is suspected, treatment is typically
advised. Treating a woman's sexual partners should also occur. In those with mild or
moderate symptoms, a single injection of the antibiotic ceftriaxone along with two
weeks of doxycycline and possibly metronidazole by mouth is recommended. For
those who do not improve after three days or who have severe disease, intravenous
antibiotics should be used.
Globally, about 106 million cases of chlamydia and 106 million cases of gonorrhea
occurred in 2008. The number of cases of PID, however, is not clear. It is estimated to
affect about 1.5 percent of young women yearly. In the United States, PID is estimated
to affect about one million people each year. A type of intrauterine device (IUD)
known as the Dalkon shield led to increased rates of PID in the 1970s. Current IUDs
are not associated with this problem after the first month.
Signs and symptoms
Illustration of pelvic inflammatory disease
Symptoms
in
PID
range
from
none
to
severe.
If
there
are
symptoms, fever, cervical motion tenderness, lower abdominal pain, new or different
discharge, painful intercourse, uterine tenderness, adnexal tenderness, or irregular
menstruation may be noted.
Other
complications
include endometritis, salpingitis, tubo-ovarian
pelvic peritonitis, periappendicitis, and perihepatitis.
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Complications
Fitz-Hugh–Curtis syndrome with perihepatic adhesions following a chlamydia
infection
PID can cause scarring inside the reproductive system, which can later cause serious
complications, including chronic pelvic pain, infertility, ectopic pregnancy (the leading
cause of pregnancy-related deaths in adult females), and other complications of
pregnancy. Occasionally, the infection can spread to the peritoneum causing
inflammation and the formation of scar tissue on the external surface of the liver (Fitz-
Hugh–Curtis syndrome).
Cause
Chlamydia trachomatis
and
Neisseria gonorrhoeae
are common causes of PID.
However, PID can also be caused by other untreated infections, like bacterial vaginosis.
Data suggest that PID is often polymicrobial. Isolated anaerobes and facultative
microorganisms have been obtained from the upper genital tract.
N. gonorrhoeae
has
been isolated from fallopian tubes, facultative and anaerobic organisms were recovered
from endometrial tissues.
The anatomical structure of the internal organs and tissues of the female
reproductive tract provides a pathway for pathogens to ascend from the vagina to the
pelvic cavity through the infundibulum. The disturbance of the naturally occurring
vaginal microbiota associated with bacterial vaginosis increases the risk of PID.
N. gonorrhoea
and
C. trachomati
s are the most common organisms. The least
common were infections caused exclusively by anaerobes and facultative organisms.
Anaerobes and facultative bacteria were also isolated from 50 percent of the patients
from whom
Chlamydia
and
Neisseria
were recovered; thus, anaerobes and facultative
bacteria were present in the upper genital tract of nearly two-thirds of the PID
patients. PCR and serological tests have associated extremely fastidious organism with
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endometritis, PID, and tubal factor infertility. Microorganisms associated with PID are
listed below.
Cases of PID have developed in people who have stated they have never had sex.
Bacteria
•
•
•
•
•
•
•
•
Peptostreptococcus asaccharolyticus
•
•
•
•
•
•
Coagulase-negative staphylococcus
•
•
•
•
•
•
•
•
•
•
•
•
•
•
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Diagnosis
Mucopurulent cervical discharge seen on a cotton bud
Micrograph of salpingitis – a component of pelvic inflammatory disease. H&E
Upon a pelvic examination, cervical motion, uterine, or adnexal tenderness will be
experienced.
Mucopurulent cervicitis and or urethritis may be observed. In severe
cases more testing may be required such as laparoscopy, intra-abdominal bacteria
sampling and culturing, or tissue biopsy.
Laparoscopy can visualize "violin-string" adhesions, characteristic of Fitz-Hugh–
Curtis perihepatitis and other abscesses that may be present.
Other imaging methods, such as ultrasonography, computed tomography (CT), and
magnetic imaging (MRI), can aid in diagnosis. Blood tests can also help identify the
presence of infection: the erythrocyte sedimentation rate (ESR), the C-reactive protein
(CRP) level, and chlamydial and gonococcal DNA probes.
Nucleic acid amplification tests (NAATs), direct fluorescein tests (DFA), and
enzyme-linked immunosorbent assays (ELISA) are highly sensitive tests that can
identify specific pathogens present. Serology testing for antibodies is not as useful
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since the presence of the microorganisms in healthy people can confound interpreting
the antidiv titer levels, although antidiv levels can indicate whether an infection is
recent or long-term.
Definitive criteria include histopathologic evidence of endometritis, thickened
filled fallopian tubes, or laparoscopic findings. Gram stain/smear becomes definitive
in the identification of rare, atypical and possibly more serious organisms. Two thirds
of patients with laparoscopic evidence of previous PID were not aware they had PID,
but even asymptomatic PID can cause serious harm.
Laparoscopic identification is helpful in diagnosing tubal disease; a 65 percent to
90 percent positive predictive value exists in patients with presumed PID.
Upon gynecologic ultrasound, a potential finding is
tubo-ovarian complex
, which
is edematous and dilated pelvic structures as evidenced by vague margins, but
without abscess formation.
Differential diagnosis
A number of other causes may produce similar symptoms including appendicitis,
ectopic pregnancy, hemorrhagic or ruptured ovarian cysts, ovarian torsion, and
endometriosis and gastroenteritis, peritonitis, and bacterial vaginosis among others.
Pelvic inflammatory disease is more likely to reoccur when there is a prior history
of the infection, recent sexual contact, recent onset of menses, or an IUD (intrauterine
device) in place or if the partner has a sexually transmitted infection.
Acute pelvic inflammatory disease is highly unlikely when recent intercourse has
not taken place or an IUD is not being used. A sensitive serum pregnancy test is
typically
obtained
to
rule
out
ectopic
pregnancy. Culdocentesis will
differentiate hemoperitoneum (ruptured ectopic pregnancy or hemorrhagic cyst) from
pelvic sepsis (salpingitis, ruptured pelvic abscess, or ruptured appendix).
Pelvic and vaginal ultrasounds are helpful in the diagnosis of PID. In the early stages
of infection, the ultrasound may appear normal. As the disease progresses, nonspecific
findings can include free pelvic fluid, endometrial thickening, uterine cavity distension
by fluid or gas. In some instances the borders of the uterus and ovaries appear indistinct.
Enlarged ovaries accompanied by increased numbers of small cysts correlates with
PID.
Laparoscopy is infrequently used to diagnose pelvic inflammatory disease since it
is not readily available. Moreover, it might not detect subtle inflammation of the
fallopian tubes, and it fails to detect endometritis. Nevertheless, laparoscopy is
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conducted if the diagnosis is not certain or if the person has not responded to antibiotic
therapy after 48 hours.
No single test has adequate sensitivity and specificity to diagnose pelvic
inflammatory disease. A large multisite U.S. study found that cervical motion
tenderness as a minimum clinical criterion increases the sensitivity of
the CDC diagnostic criteria from 83 percent to 95 percent. However, even the modified
2002 CDC criteria do not identify women with subclinical disease.
Prevention
Regular
testing
for sexually
infections is
encouraged
for
prevention. The risk of contracting pelvic inflammatory disease can be reduced by the
following:
•
Using barrier methods such as condoms; see human sexual behaviour for other
listings.
Using latex condoms to prevent STIs that may go untreated.
•
Seeking medical attention if you are experiencing symptoms of PID.
•
Using hormonal combined contraceptive pills also helps in reducing the chances of
PID by thickening the cervical mucosal plug & hence preventing the ascent of
causative organisms from the lower genital tract
•
Seeking medical attention after learning that a current or former sex partner has, or
might have had a sexually transmitted infection.
•
Getting a STI history from your current partner and strongly encouraging they be tested
and treated before intercourse.
•
Diligence in avoiding vaginal activity, particularly intercourse, after the end of a
pregnancy (delivery, miscarriage, or abortion) or certain gynecological procedures, to
ensure that the cervix closes.
•
Reducing the number of sexual partners; As in sexual monogamy.
Treatment
Treatment is often started without confirmation of infection because of the serious
complications that may result from delayed treatment. Treatment depends on
the infectious agent and generally involves the use of antibiotic therapy although there
is no clear evidence of which antibiotic regimen is more effective and safe in the
management of PID. If there is no improvement within two to three days, the patient is
typically advised to seek further medical attention. Hospitalization sometimes becomes
necessary if there are other complications. Treating sexual partners for possible STIs
can help in treatment and prevention. There should be no wait for STI results to start
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treatment. Treatment should not be avoided for longer than 2-3 days due to increasing
the risk of infertility.
For women with PID of mild to moderate severity, parenteral and oral therapies
appear to be effective. It does not matter to their short- or long-term outcome whether
antibiotics are administered to them as inpatients or outpatients. Typical regimens
include cefoxitin or cefotetan plus doxycycline, and clindamycin plus gentamicin. An
alternative
parenteral
regimen
is ampicillin/sulbactam plus
doxycycline. Erythromycin-based medications can also be used. A single study
suggests superiority of azithromycin over doxycycline. Another alternative is to use a
parenteral regimen with ceftriaxone or cefoxitin plus doxycycline. Clinical experience
guides decisions regarding transition from parenteral to oral therapy, which usually can
be initiated within 24–48 hours of clinical improvement.
•
When PID is caught early there are treatments that can be utilized, however these
treatments will not undo any damage PID may has caused.
•
If previously having a PID diagnosis and were to be exposed to another STI the risk of
having PID reoccur is higher
•
Early treatment can not prevent the following:
•
chronic abdominal pain.
•
infertility and or ectopic pregnancies.
•
scar tissue within or outside the fallopian tubes.
Prognosis
Early diagnosis and immediate treatment are vital in reducing the chances of later
complications from PID. Delaying treatment for even a few days could greatly increase
the chances of further complications. Even when the PID infection is cured, effects of
the infection may be permanent, or long lasting. This makes early identification
essential.
A limitation of this is that diagnostic tests are not included in routine check-ups, and
cannot be done using signs and symptoms alone; the required diagnostic tests are more
invasive than that. Treatment resulting in cure is very important in the prevention of
damage to the reproductive system. Around 20 percent of women with PID develop
infertility. Even women who do not experience intense symptoms or are asymptomatic
can become infertile. This can be caused by the formation of scar tissue due to one or
more episodes of PID, and can lead to tubal blockage. Both of these increase the risk
of the inability to get pregnant, and 1% results in an ectopic pregnancy.
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pelvic/abdominal pain develops post PID 40% of the time.
as a post pelvic operation, the period of time immediately after childbirth
(postpartum), miscarriage or abortion increase the risk of acquiring another infection
leading to PID.
Epidemiology
Globally about 106 million cases of chlamydia and 106 million cases of gonorrhea
occurred in 2008. The number of cases of PID; however, is not clear. This is largely
due to diagnostic tests being invasive and not included in routine check-ups, despite
PID being the most common reason for individuals to admit themselves under
gynecological care. It is estimated to affect about 1.5 percent of young women yearly.
In the United States PID is estimated to affect about one million people yearly. Rates
are highest with teenagers and first time mothers. PID causes over 100,000 women to
become infertile in the US each year.
Prevalence
Records show that...
•
18/10000 recorded discharges in the US after a diagnosis of PID.
•
Prevalence of self reported cases of PID for 18–44 was approximately 4.4%.
•
Findings that PID has an associated risk with previous STI diagnosis compared to
women with no previous STI diagnosis
•
1.1% of women, 16-46 years of age, in England and Wales are diagnosed with PID.
Despite the indications of a general decrease in PID rates, there is an observed rise
in the prevalence of gonorrhea and chlamydia. With that, in order to decrease the
prevalence of PID, one should test for gonorrhea and chlamydia.
Two nationally representative probability surveys referenced are the National
Health and Nutrition Examination Survey (NHANES) and the National Survey of
Family Growth (NSFG) surveyed women aged 18 to 44 from 2013 to 2014.
The results:
•
2.5 million women have had a PID diagnosis in the past.
•
The self-reported history decreased from 4.1% in 2013 to 3.6% in 2017.
•
It is possible that increased screening at annual gynecologist appointments has led to
an earlier detection and prevention of PID.
•
In white non-Hispanic women, the prevalence decreased from 4.9% to 3.9%, and in
Hispanic women, the prevalence decreased from 5.3% to 3.7%. In black non-Hispanic
women, the prevalence increased from 3.8% to 6.3%.
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•
The highest burden of PID recently is in black women and women living in the
Southern United States where there is a higher prevalence of STIs as well.
•
Disparities between races could be due to lower socioeconomic status. Those with a
lower income are less likely to get an annual gynecologist appointment or other
preventative measures and are more likely to be uninsured.
Population at risk.
•
Those who are sexually active with female (intact)reproductive organs and are under
the age of 25
•
Rarely observed in females who have had a hysterectomy
•
Overall age range 18-44
•
Those who have an STI that has gone untreated.
•
Women with more than one sexual partner
•
Inconsistent condom use for those not in a mutually monogamous relationship
Etiology of PID:
•
Untreated STI
•
multiple sexual partners
•
Sexually active under the age of 25
•
Usage of a douche
•
Causes damage to the bacteria that lives within the vagina
•
Slight increase risk when using an IUD not a massive increase in risk.
•
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