Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) is a catch-all name for different types of bacterial infection in the pelvis. It can mean infection of the cervix (cervicitis), womb (endometritis), fallopian tubes (salpingitis), or ovaries (oophoritis). PID can affect several of these places at the same time, and can spread outside the womb, into the space surrounded by the sac which contains the bowels (the peritoneum). Infection of the sac itself is called peritonitis. About 1 in 50 sexually active women in the UK develop PID each year. It most commonly develops in women aged between 15 and 24.

PID is referred to as acute or chronic, depending on whether it is a sudden, severe infection (acute), or long-term, less intense but persistent problem (chronic).

Who’s at risk:

PID is commoner in women who:

PID seems to be less common than average in women who take the combined oral contraceptive pill.

Symptoms

There is a lot of variation between individuals when it comes to the type and severity of symptoms that can be experienced.

Acute PID can cause only a mild lower abdominal pain, maybe with vaginal discharge and pain during sex, through to very bad pain in the lower back and all through the abdomen and pelvis, along with feeling very ill with a high fever and maybe vomiting.

Chronic PID often causes deep pain during intercourse and a persistent continuous low abdominal pain, and back pain, over which the periods are unusually painful and heavy. This waxes and wanes over time, sometimes seeming to get better, only to get worse again. The unremitting cycle is emotionally exhausting and depression is a common problem with chronic PID.

Complications

Untreated PID can cause permanent blockages of the Fallopian tubes, resulting in reduced or zero fertility. The egg released each month by the ovary simply cannot travel to the womb.

The constant attempts of the body to fight against and heal Chronic PID results in fibrous scars in the pelvis forming. These stick organs such as the bowel, womb or fallopian tubes together (adhesions). Adhesions cause long-term pain, often variable in form and hard to treat. Chronic (persistent) pain develops in about 1 in 5 cases.

Blocked Fallopian tubes and adhesions affect the route of the egg released each month in the ovary. The egg can get stuck in a Fallopian tube, or not even get in and drift into the pelvic cavity. If an egg is fertilised outside the womb, the result is an ectopic pregnancy. Ectopic pregnancy within a Fallopian tube is very dangerous, as it can burst the Fallopian tube, causing massive sudden haemorrhage. A ruptured ectopic pregnancy typically presents with severe, sudden, normally one-sided pelvic pain, and vaginal bleeding, at around 6 weeks since the first day of the last period. It is a surgical emergency and requires an operation very swiftly. If you have had PID and become pregnant, you have about a 1 in 10 chance that the pregnancy will be ectopic.

About 1 in 5 women who have PID have a further episode. This is usually within two years.

Investigations

In acute PID, a a full blood count (FBC) is useful to give an indication of how severe the infection is: a high white cell count (WCC) represents a strong defence reaction by the body to a severe infection.

A sample of vaginal discharge can be analysed to find out what bacteria are causing the infection, and which antibiotics they will respond to. A swab from just inside the opening of the cervix (the os) can help pick up chlamydial DNA –a very useful test.

Ultrasound scans of the pelvis help to rule alternative causes of pelvic pain. If it shows up fluid in the pelvis, outside the womb, it tends to back up a diagnosis of PID.

Directly looking at the pelvic organs can be done with laparoscopy (“keyhole surgery”), which also allows fluid to be taken for sampling.

Treatment

Antibiotics are the treatment for PID, usually taken as tablets, but a severe infection requires intravenous antibiotics. Two different types are taken for 10 days to combat the infection.

Good pain relief is important, and a good explanation of the problem helps to reduce anxiety, which otherise magnifies the pain and distress of severe pelvic pain. Laparoscopy can be useful in chronic PID to physically break down any adhesions in the pelvis, This may reduce some of the pain.

Prevention

Safe sex practices such as barrier methods of contraception, and having regular check-ups at GUM clinics if there are multiple sexual partners wiil reduce the contribution that STIs make to PID.