eMedicine Specialties > Obstetrics and Gynecology > Infections

Pelvic Inflammatory Disease

Author: James B Hill, MD, Chief, Division of Obstetrics, Staff Physician, Department of Obstetrics and Gynecology, Womack Army Medical Center
Coauthor(s): Ernest Lockrow, DO, Chief of Gynecology Service, Department of Obstetrics and Gynecology, Walter Reed Army Medical Center; Assistant Professor, Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences
Contributor Information and Disclosures

Updated: Aug 27, 2009

Introduction

Background

Pelvic inflammatory disease (PID) is an inflammatory disorder of the uterus, fallopian tubes, and adjacent pelvic structures. Risk factors for PID include young age at first intercourse, multiple sexual partners, intrauterine device (IUD) insertion, and tobacco smoking. A delay in diagnosis or treatment can result in long-term sequelae such as tubal infertility.

Pathophysiology

In PID, the upper female genital tract is infected by direct spread of microorganisms ascending from the vagina and cervix. The cervix produces mucus that usually protects against upward spread, but bacteria may penetrate the cervical mucus and cause widespread extension of infection.

Frequency

United States

PID affects 11% of women of reproductive age. Approximately 1 million women experience an episode of PID per year, and 20% of these women require hospitalization for treatment. The disease produces 2.5 million office visits and 125,000-150,000 hospitalizations yearly.

International

Public health efforts implemented in Scandinavia to decrease the prevalence of sexually transmitted diseases (STDs) have been quite effective.1

Mortality/Morbidity

A delay in diagnosis or treatment can result in long-term reproductive sequelae, such as tubal infertility. Each repeat episode of PID doubles the risk for tubal factor infertility. Women with a history of PID have a 7- to 10-fold increased risk for ectopic pregnancy (tubal pregnancy) compared with women with no history of PID. Chronic pelvic pain can also follow PID and occurs in 25-75% of women.

Sex

PID is an infection of the female genital tract.

Age

PID may occur more frequently in adolescents (ie, 15-19 y), but it can occur in any patients who are sexually active. Age distributions vary with geographic location and etiology. Young age at first intercourse increases risk for PID.

Short et al found that age younger than 25 years and smoking were independently associated with Mycoplasma genitalium infection, which is associated with pelvic inflammatory disease.2

Clinical

History

Patients can present with a variety of symptoms, ranging from lower abdominal pain to dysuria. A direct correlation exists between the incidence of STDs and pelvic inflammatory disease (PID) in any given population.

  • Pain is present in more than 90% of documented cases and is by far the most common presenting symptom.
    • Usually, pain is described as dull, aching, and constant; it begins a few days after the onset of the last menstrual period and tends to be accentuated by motion, exercise, or coitus.
    • Pain from PID usually lasts less than 7 days; if pain lasts longer than 3 weeks, the likelihood that PID is the correct diagnosis declines substantially.
  • Abnormal vaginal discharge is present in approximately 75% of cases.
  • Unanticipated vaginal bleeding coexists in about 40% of cases.
  • Temperature higher than 38°C (30%), nausea, and vomiting manifest late in the clinical course of the disease.

Physical

The sensitivity of the pelvic examination is only 60%. The Centers for Disease Control and Prevention (CDC) recommends the following minimal clinical criteria for the diagnosis of PID in sexually active young women: uterine/adnexal tenderness or cervical motion tenderness.

Additional criteria may be used to enhance the specificity of the minimum criteria:

  • Temperature higher than 101°F (38.3°C)
  • Abnormal cervical or vaginal mucopurulent discharge
  • Presence of white blood cells (WBCs) on saline microscopy of vaginal secretions
  • Elevated erythrocyte sedimentation rate
  • Elevated C-reactive protein level
  • Laboratory documentation of cervical infection with Neisseria gonorrhoeae or Chlamydia trachomatis

Causes

The classic high-risk patient is a menstruating woman younger than 25 years who has multiple sex partners, does not use contraception, and lives in an area with a high prevalence of STD. PID is also more prevalent among unmarried women and individuals who are young at first intercourse. The IUD confers a relative risk of 2.0-3.0 for the first 4 months following insertion, but then it decreases to baseline thereafter. Women who are not sexually active have a very low incidence of upper genital tract infection, as do women who have undergone tubal sterilization.

  • C trachomatis3 : C trachomatis, an intracellular bacterial pathogen, is the predominant STD organism causing PID. Clinically, infection with this obligate intracellular parasite may manifest as mucopurulent cervicitis.
  • Cytomegalovirus (CMV): CMV has been found in the upper genital tracts of women with PID, suggesting a potential role of CMV in PID.
  • Endogenous microflora: In iatrogenically induced infections, the endogenous microflora of the vagina predominate.
  • Gardnerella vaginalis
  • Haemophilus influenzae
  • Enteric gram-negative organisms (Escherichia coli)
  • Peptococcus species
  • Streptococcus agalactiae
  • Bacteroides fragilis: This can cause tubal and epithelial destruction.
  • Pregnancy: PID is rare in pregnancy.
  • N gonorrhoeae: In the United States, the role of N gonorrhoeae as the primary cause of PID has decreased.
  • Mycoplasma genitalium: M genitalium has been isolated in the endometrium and fallopian tubes of women who have PID.4

More on Pelvic Inflammatory Disease

Overview: Pelvic Inflammatory Disease
Differential Diagnoses & Workup: Pelvic Inflammatory Disease
Treatment & Medication: Pelvic Inflammatory Disease
Follow-up: Pelvic Inflammatory Disease
References
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References

  1. Sorbye IK, Jerve F, Staff AC. Reduction in hospitalized women with pelvic inflammatory disease in Oslo over the past decade. Acta Obstet Gynecol Scand. Mar 2005;84(3):290-6. [Medline].

  2. Short VL, Totten PA, Ness RB, Astete SG, Kelsey SF, Murray P, et al. The demographic, sexual health and behavioral correlates of Mycoplasma genitalium infection among women with clinically suspected pelvic inflammatory disease. Sex Transm Infect. Aug 24 2009;[Medline].

  3. Bakken IJ, Ghaderi S. Incidence of pelvic inflammatory disease in a large cohort of women tested for Chlamydia trachomatis: a historical follow-up study. BMC Infect Dis. Aug 14 2009;9(1):130. [Medline].

  4. Ross JD. Is Mycoplasma genitalium a cause of pelvic inflammatory disease?. Infect Dis Clin North Am. Jun 2005;19(2):407-13. [Medline].

  5. Tukeva TA, Aronen HJ, Karjalainen PT, et al. MR imaging in pelvic inflammatory disease: comparison with laparoscopy and US. Radiology. Jan 1999;210(1):209-16. [Medline].

  6. [Guideline] CDC, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. Aug 4 2006;55(RR-11):1-94. [Medline]. [Full Text].

  7. [Guideline] CDC. Update to CDC's sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR Morb Mortal Wkly Rep. Apr 13 2007;56(14):332-6. [Medline].

  8. Aledort JE, Hook EW, Weinstein MC, Goldie SJ. The cost effectiveness of gonorrhea screening in urban emergency departments. Sex Transm Dis. Jul 2005;32(7):425-36. [Medline].

  9. Cohen CR, Sinei S, Reilly M, et al. Effect of human immunodeficiency virus type 1 infection upon acute salpingitis: a laparoscopic study. J Infect Dis. Nov 1998;178(5):1352-8. [Medline].

  10. Coonrod D, Collier AC, Ashley R, et al. Association between cytomegalovirus seroconversion and upper genital tract infection among women attending a sexually transmitted disease clinic: a prospective study. J Infect Dis. May 1998;177(5):1188-93. [Medline].

  11. Hillis SD, Owens LM, Marchbanks PA, et al. Recurrent chlamydial infections increase the risks of hospitalization for ectopic pregnancy and pelvic inflammatory disease. Am J Obstet Gynecol. Jan 1997;176(1 Pt 1):103-7. [Medline].

  12. Howell MR, Kassler WJ, Haddix A. Partner notification to prevent pelvic inflammatory disease in women. Cost-effectiveness of two strategies. Sex Transm Dis. May 1997;24(5):287-92. [Medline].

  13. Howell MR, Quinn TC, Brathwaite W, et al. Screening women for chlamydia trachomatis in family planning clinics: the cost-effectiveness of DNA amplification assays. Sex Transm Dis. Feb 1998;25(2):108-17. [Medline].

  14. Irwin KL, Moorman AC, O'Sullivan MJ, Sperling R, Koestler ME, Soto I, et al. Influence of human immunodeficiency virus infection on pelvic inflammatory disease. Obstet Gynecol. Apr 2000;95(4):525-34. [Medline].

  15. Jamieson DJ, Duerr A, Macasaet MA, et al. Risk factors for a complicated clinical course among women hospitalized with pelvic inflammatory disease. Infect Dis Obstet Gynecol. 2000;8(2):88-93. [Medline].

  16. Peipert JF, Ness RB, Soper DE. Association of lower genital tract inflammation with objective evidence of endometritis. Infect Dis Obstet Gynecol. 2000;8(2):83-7. [Medline].

  17. Peipert JF, Sweet RL, Walker CK, Bass D. Evaluation of ofloxacin in the treatment of laparoscopically documented acute pelvic inflammatory disease (salpingitis). Infect Dis Obstet Gynecol. 1999;7(3):138-44. [Medline].

  18. Rock JA, Thompson JD. Telinde's Operative Gynecology. 1997. 8th ed. Philadelphia, Pa: Lippincott Williams & Wilkins Publishers; 657-684.

  19. Scholes D, Stergachis A, Heidrich FE, et al. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. N Engl J Med. May 23 1996;334(21):1362-6. [Medline].

  20. Wiesenfeld HC, Sweet RL, Ness RB, et al. Comparison of acute and subclinical pelvic inflammatory disease. Sex Transm Dis. Jul 2005;32(7):400-5. [Medline].

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Further Reading

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Keywords

pelvic inflammatory disease, PID, uterus, fallopian tubes, intrauterine device, IUD, tubal infertility, genital tract, vagina, cervix, sexually transmitted diseases, STD, ectopic pregnancy, tubal pregnancy, pelvic pain, dysuria, vaginal discharge, vaginal bleeding, Chlamydia trachomatis, C trachomatis, Gardnerella vaginalis, G vaginalis, Haemophilus influenzae, H influenzae, Escherichia coli, E coli, Peptococcus species, Streptococcus agalactiae, S agalactiae, Bacteroides fragilis, B fragilis, Neisseria gonorrhoeae, N gonorrhoeae, Mycoplasma genitalium, M genitalium, cytomegalovirus, CMV, endogenous microflora

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Contributor Information and Disclosures

Author

James B Hill, MD, Chief, Division of Obstetrics, Staff Physician, Department of Obstetrics and Gynecology, Womack Army Medical Center
James B Hill, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Ernest Lockrow, DO, Chief of Gynecology Service, Department of Obstetrics and Gynecology, Walter Reed Army Medical Center; Assistant Professor, Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences
Ernest Lockrow, DO is a member of the following medical societies: American College of Obstetricians and Gynecologists
Disclosure: Nothing to disclose.

Medical Editor

Ronald Levine, MD, Director, Section of Gynecologic Endoscopy, Professor, Department of Obstetrics and Gynecology, University of Louisville School of Medicine
Ronald Levine, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Obstetricians and Gynecologists, American Medical Association, and Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD, Professor, Coordinator of Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

 
 
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