Pelvic Inflammatory Disease
Pelvic inflammatory disease is an infection of the upper female reproductive organs.
Pelvic inflammatory disease can affect the cervix (causing mucopurulent cervicitis), the uterus (causing endometritis), the fallopian tubes (causing salpingitis), and sometimes the ovaries (causing oophoritis). Pelvic inflammatory disease is the most common preventable cause of infertility in the United States. Infertility occurs in about one of five women with pelvic inflammatory disease. About one third of women who have had pelvic inflammatory disease develop the infection again.
Pelvic inflammatory disease usually occurs in sexually active women. It rarely affects girls before their first menstrual period (menarche) or women during pregnancy or after menopause. Risk is increased for women who are younger than 24 and who do not use a barrier contraceptive (such as a condom or diaphragm), who have many sex partners, who have a sexually transmitted disease or bacterial vaginosis, or who use an intrauterine device (IUD).
Infection is usually caused by bacteria that enter the vagina, most commonly, during sexual intercourse. Usually, pelvic inflammatory disease is caused by the bacteria that cause gonorrhea (Neisseria gonorrhoeae) or chlamydial infection (Chlamydia trachomatis), which are sexually transmitted diseases (see Section 17, Chapter 200 and Section 17, Chapter 200). Bacteria may also enter the vagina during douching. Less commonly, bacteria enter the vagina during a vaginal delivery, an abortion, or a medical procedure, such as dilation and curettage (D and C).
Pelvic inflammatory disease typically starts in the cervix and uterus. Usually, both fallopian tubes are infected, although symptoms may be worse on one side. The ovaries are not usually infected, unless the infection is severe.
Symptoms
Pelvic inflammatory disease tends to cause symptoms cyclically, toward the end of the menstrual period or for a few days afterward. For many women, the first symptoms are a low fever, mild to moderate abdominal pain (often aching), irregular vaginal bleeding, and a vaginal discharge with a bad odor. As the infection spreads, pain in the lower abdomen becomes increasingly severe and may be accompanied by nausea or vomiting. Later, the fever becomes higher, and the discharge often becomes puslike and yellow-green. However, a chlamydial infection may not produce a discharge or any other noticeable symptoms.
Sometimes infected fallopian tubes become blocked. Blocked tubes may swell because fluid is trapped. If the infection is not treated, pain in the lower abdomen may persist and irregular bleeding may occur. The infection can spread to surrounding structures, including the membrane that lines the abdominal cavity and covers the abdominal organs (causing peritonitis). Peritonitis can cause sudden, severe pain in the entire abdomen.
If infection of the fallopian tubes is due to gonorrhea or a chlamydial infection, it may spread to the tissues around the liver. Such an infection may cause pain in the upper right side of the abdomen that resembles a gallbladder disorder or stones. This complication is called the Fitz-Hugh-Curtis syndrome.
A collection of pus (abscess) forms in the fallopian tubes or ovaries of about 15% of women who have infected fallopian tubes. An abscess sometimes ruptures, and pus spills into the pelvic cavity (causing peritonitis). A rupture causes severe pain in the lower abdomen, quickly followed by nausea, vomiting, and very low blood pressure (shock). The infection may spread to the bloodstream (a condition called sepsis) and can be fatal.
Pelvic inflammatory disease often produces a puslike fluid, which can result in scarring and the formation of abnormal bands of scar tissue (adhesions) in the reproductive organs or between organs in the abdomen. Infertility may result. The longer and more severe the inflammation and the more often it recurs, the higher the risk of infertility and other complications. The risk increases each time a woman develops the infection.
Women who have had pelvic inflammatory disease are 6 to 10 times more likely to have a tubal pregnancy, in which the fetus grows in a fallopian tube rather than in the uterus. This type of pregnancy threatens the life of the woman, and the fetus cannot survive.
Prevention
Prevention of pelvic inflammatory disease is essential to the health and fertility of a woman. The best way to prevent the infection is abstaining from sex. However, if a woman has sexual intercourse with only one partner, the risk of pelvic inflammatory disease is very low, as long as neither person has a sexually transmitted disease. Refraining from douching is also helpful.
Barrier methods of birth control (such as condoms) and spermicides (such as vaginal foams) used with a barrier method can help prevent pelvic inflammatory disease.
Diagnosis and Treatment
A doctor suspects the diagnosis based mainly on the severity and location of the pain. A physical examination, including a pelvic examination, is performed. A sample is usually taken from the cervix and tested to determine whether the woman has gonorrhea or a chlamydial infection. Other symptoms and laboratory test results help confirm the diagnosis. The white blood cell count is usually high. Ultrasonography of the pelvis may be performed. If the diagnosis is still uncertain or if the woman does not respond to treatment, the doctor may insert a viewing tube (laparoscope) through a small incision near the navel to view the inside of the abdominal cavity.
As soon as possible, antibiotics are usually given. Typically, two different antibiotics that are effective against a variety of organisms are used. Most women are treated at home. However, hospitalization is usually necessary if the infection does not improve within 48 hours, if symptoms are severe, if the woman may be pregnant, or if an abscess is detected.
If abscesses persist despite treatment with antibiotics, surgery may be necessary. A ruptured abscess requires emergency surgery.
Women should refrain from sexual intercourse until antibiotic therapy is completed and a doctor confirms that the infection is completely eliminated, even if symptoms disappear. All recent sex partners should be tested for infection and treated. If pelvic inflammatory disease is diagnosed and treated promptly, a full recovery is more likely.
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