Pelvic inflammatory disease (PID)

If you are younger than 25 years, don’t use condoms, and have lower abdominal pain, you might be suffering from a pelvic inflammatory disease. Pelvic inflammatory disease (PID) is an infectious disease affecting your upper reproductive organs. The infectious agents first inoculate the vagina and cervix and then ascend to your upper genital tract, which includes a pair of ovaries, fallopian tubes, uterus, and may also involve the surrounding pelvis. Many women may only have subtle symptoms while others may have lower abdominal pain, vaginal discharge, pain during sex, burning pee, etc. it is a sexually transmitted disease, which is treated with antibiotics and is prevented by having safe sex using condoms and with a single partner. If left untreated, it can cause fibrosis of the fallopian tubes resulting in ectopic pregnancy or infertility.

PID is caused by organisms that are transmitted during sex. The most common organisms are chlamydia trachomatis and N. Gonorrhea accounting for less than 50% of all the cases. While 30-40% of the cases are polymicrobial, caused by a combination of organisms. Other organisms may include Gardnerella vaginalis, Haemophilus influenza, Mycoplasma genitalium, Ureaplasma urealyticum, Herpes simplex virus 2 (HSV-2), Trichomonas vaginalis, and anaerobes such as Bacteroides and Peptococcus species. 

The reasons that increase your chances of getting the infection are:

• Young and sexually active
• Having unprotected sex
• Sex with multiple partners
• Having co-existing sexually transmitted infection (STI).
• Sex with a person who is not screened for STD
• Exercising frequent douching

According to the CDC report, PID affects more than 1 million women every year in the USA and results in around 2.5 million clinic visits and 125,000-150,000 hospitalizations annually.

Sexually transmitted infections are ranked as the 5^th most common infections for which people seek medical care. As estimated by WHO, around 448 million new cases of STIs occur yearly in people between the ages of 15-49 years.

Many women may not show notable signs and symptoms. Some might present with the following;

• Lower abdominal pain, which can be mild, moderate, or severe
• Fever
• Nausea, vomiting
• Vaginal discharge
• Pain during intercourse (dyspareunia)
• Burning pee (dysuria)
• Bleeding between periods (intermenstrual bleeding)

If you suspect having PID due to the presence of the above-mentioned signs and symptoms, you must visit your healthcare provider. The diagnosis is usually made based on the history and examination. However, some investigations may need to be carried out to confirm the diagnosis. You may be advised of the following investigations:

• History: Your health care provider will begin with a detailed medical history asking about your sexual activity and presence of multiple partners, use of condoms, and history of previous or current STIs.
• Physical examination: Your doctor may perform a physical examination with special emphasis on pelvic examination to look for the presence and characteristics of a discharge, presence of cervical motion tenderness, etc.
• Vaginal and cervical swabs: You may be advised laboratory tests which include testing for bacteria in the discharge by simple staining method and by growing bacteria in the lab (culture)
• Blood tests; CBC to rule out infection and levels of hemoglobin. A blood culture may also show an organism in severe PID causing a systemic reaction. If you have risk factors, you may be tested for other STDs, especially gonorrhea, chlamydia, and HIV.
• Urinalysis Urine may be collected to test for urinary tract infection.
• Pelvic ultrasound may sometimes show abscess or fluid accumulation.

When the diagnosis is not clear, you may be advised to undergo the following:

• Laparoscopy: A tiny camera is inserted in the abdominal cavity via a small incision to look for the signs of inflammation and take a sample of fluid or abscess to check for the causative organism.
• Endometrial biopsy: A sample of the uterine lining is taken and sent to the laboratory for further analysis.

Following diseases may present as a pelvic inflammatory disease:

• Adnexal Tumors
• Appendicitis
• Ectopic Pregnancy
• Endometriosis
• Interstitial Cystitis
• Ovarian Cysts
• Ovarian Torsion
• Urinary tract infection
• Vaginitis
• Cervicitis 

PID is an infectious disease that can be cured using medicines against the causative agent. Most commonly, it is caused by bacteria and will need a course of antibiotics. The most common antibiotics prescribed are :

• A combination of cefotetan or cefoxitin and doxycycline,
• A combination of clindamycin and gentamicin.
• Another regime to be given via injections is a combination of an ampicillin/sulbactam plus doxycycline.
• It is recommended to test and treat the sexual partners as well. After being cured, you can again get infected by an untreated partner.

Severe cases may need hospitalization and the use of intravenous medications. Sometimes if the diagnosis is not clear or the medicines are ineffective, you may need to undergo laparoscopic surgery. Surgery is also indicated in cases of abscess formation and rupture. 

PID is curable and results in complete healing if treated on time before causing permanent damage. If left untreated can result in chronic pelvis pain, infertility, and ectopic pregnancy. Untreated PID can affect fertility by scarring of the fallopian tubes. 1 in 8 women finds it difficult to get pregnant after being affected by PID. PID can affect fertility. In an ectopic pregnancy, the fertilized egg is not attached to the uterus instead moves outside the womb. It is implanted somewhere else in the pelvis, usually in one of the fallopian tubes. The fallopian tubes connect the ovaries to the uterus. It grows and can burst the fallopian tubes resulting in serious health issues.

You can prevent yourself from getting affected by PID by adapting the following lifestyle changes;

• Adapting safe sex (using condoms)
• Having limited sexual partners
• Regular screening for gonorrhea
• Not having sex with someone suffering from STD
• Avoid sex until completing your full course of antibiotics
• Avoiding douching or using cleaning agents for vagina