Pelvic inflammatory disease overview

# Overview
Pelvic inflammatory disease is a generic term for the infection of the female uterus, fallopian tubes, and/or ovaries as it progresses to scar formation with adhesions to nearby tissues and organs.  This may lead to tissue necrosis (with or without abscess formation). Pus can be released into the peritoneum.  Two-thirds of patients with laparoscopic evidence of previous PID were not aware they had ever had PID. PID is often associated with sexually transmitted diseases, as it is a common result of such infections. PID is a vague term and can refer to viral, fungal, or parasitic infections, though it most often refers to bacterial infections. PID should be classified by affected organs, the stage of the infection, and the causative organism(s). Although an STD is often the cause, other routes are possible, including lymphatic, postpartum, post-abortal (either miscarriage or abortion) or intrauterine device (IUD)-related and hematogenous spread.

# Causes
PID occurs when bacteria move upward from a woman's vagina or cervix (opening to the uterus) into her reproductive organs. Many different organisms can cause PID, but a majority of cases are associated with gonorrhea and/or chlamydia, two very common bacterial STDs.

# Risk Factors
Pelvic inflammatory disease is more likely to occur in patients with a history of pelvic inflammatory disease, recent sexual contact, recent onset of menses, an IUD in place, or if a patient's partner has a sexually transmitted disease. Acute pelvic inflammatory disease is highly unlikely when recent intercourse has not taken place and an IUD is not being used.

# Natural History, Complications and Prognosis
While PID itself may be cured, effects of the infection can be permanent. This makes early identification by someone who can prescribe appropriate curative treatment critical for the prevention of damage to the reproductive system. Since early gonococcal infection may be asymptomatic, regular screening of high-risk individuals (e.g., though with a history of multiple partners, history of any unprotected sex, or people with symptoms) and patients who have undergone certain procedures (e.g., post pelvic operation, postpartum, miscarriage,or abortion). Prevention is also very important in maintaining viable reproductive capabilities. If the initial infection is mostly in the lower tract, a patient will likely not have reproductive difficulties after sufficient treatment. If the infection is in the fallopian tubes or ovaries, serious complications are more likely to occur.

# Diagnosis

## History and Symptoms
PID is difficult to diagnose because the symptoms are often subtle and mild. Many episodes of PID go undetected because the patient or her health care provider fails to recognize the implications of mild or non-specific symptoms. Because there are no precise tests for PID, a diagnosis is usually based on clinical findings. There may be no actual symptoms of PID for a given patient. If symptoms are present, then fever, cervical motion tenderness, lower abdominal pain, new or different discharge, painful intercourse, or irregular menstrual bleeding may be noted. It is important to note that PID can occur and cause serious harm without causing any noticeable symptoms. Other signs and symptoms include unusual vaginal discharge that may have a foul odor, painful intercourse, painful urination, and pain in the right upper abdomen (rare).

## Laboratory Findings
No single test has adequate sensitivity and specificity to diagnose pelvic inflammatory disease. Laboratory findings that look for signs of infection include C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and WBC count. A sensitive serum pregnancy test should be obtained to rule out ectopic pregnancy. Gram-stain/smear becomes important in identification of rare and possibly more serious organisms.

## Ultrasound
A pelvic ultrasound is a helpful procedure for diagnosing PID. An ultrasound can view the pelvic area to see whether the fallopian tubes are enlarged or whether an abscess is present. Pelvic and vaginal ultrasounds are helpful in the differential diagnosis of ectopic pregnancy of over six weeks.

## Other Diagnostic Studies
Culdocentesis will differentiate hemoperitoneum (ruptured ectopic pregnancy or hemorrhagic cyst) from pelvic sepsis (salpingitis, ruptured pelvic abscess, or ruptured appendix).

# Treatment

## Medical Therapy
Treatment depends on the cause and generally involves use of antibiotic therapy. If the patient has not improved within two to three days after beginning treatment with the antibiotics, they should return to the hospital for further treatment. Drugs should also be given orally and/or intravaneously to the patient while in the hospital to begin treatment immediately to increase the effectiveness of antibiotic treatment. Hospitalization may be necessary if there is a tubo-ovarian abscess, the patient is very ill, immunodeficiency exists, the patient is pregnant, there is cervical incompetence, or because this or something else life threatening can not be ruled out.  Treating partners for STDs is a very important part of treatment and prevention. Anyone with PID and partners of patients with PID since six months prior to diagnosis should be treated to prevent reinfection. Psychotherapy is highly recommended to women diagnosed with PID as the fear of redeveloping the disease after being cured may exist. It is important for a patient to communicate any issues and/or uncertainties they may have to a doctor, especially a specialist such as a gynecologist, and in doing so, to seek follow-up care.

## Surgery
If symptoms continue or if an abscess does not go away, surgery may be needed. Complications of PID, which can include chronic pelvic pain and scarring, tend to be difficult to treat, though they sometimes improve with surgery.