pid
DESCRIPTION
ndnUDUTRANSCRIPT
PELVIC INFLAMMATORY DISEASE
Pelvic inflammatory disease (PID) is an infectious and inflammatory disorder of the upper female genital tract, including the uterus, fallopian tubes, and adjacent pelvic structures. Infection and inflammation may spread to the abdomen, including perihepatic structures (Fitz!ugh"#urtis syndrome). $he classic highris% patient is a menstruating &oman younger than ' years &ho has multiple se partners, does not use contraception, and lives in an area &ith a high prevalence of seually transmitted disease (*$D).
PID is initiated by infection that ascends from the vagina and cervi into the upper genital tract. Chlamydia trachomatis is the predominant seually transmitted organism associated &ith PID. +ther organisms implicated in the pathogenesis of PID include Neisseria gonorrhoeae, Gardnerella vaginalis, Haemophilus influenzae, and anaerobes such as Peptococcus and Bacteroides species. aparoscopic studies have sho&n that in -/0 of cases, PID is polymicrobial
$he diagnosis of acute PID is primarily based on historical and clinical findings. #linical manifestations of PID vary &idely, ho&ever1 2any patients ehibit fe& or no symptoms, &hereas others have acute, serious illness. $he most common presenting complaint is lo&er abdominal pain. 2any &omen report an abnormal vaginal discharge.
$he differential diagnosis includes appendicitis, cervicitis, urinary tract infection, endometriosis, and adneal tumors. 3ctopic pregnancy can be mista%en for PID4 indeed, PID is the most common incorrect diagnosis in cases of ectopic pregnancy. #onse5uently, a pregnancy test is mandatory in the &or%up of &omen of childbearing age &ho have lo&er abdominal pain.
PID may produce tuboovarian abscess ($+6) and may progress to peritonitis and Fitz!ugh"#urtis syndrome (perihepatitis4 see the image belo&). *ubclinical PID or a delay in diagnosis or treatment of PID can result in longterm se5uelae, such as chronic pelvic pain and tubal infertility.
78iolinstring7 adhesions of chronic Fitz!ugh#urtis syndrome.
aparoscopy is the current criterion standard for the diagnosis of PID. 9o single laboratory test is highly specific or sensitive for the disease, but studies that can be used to support the diagnosis include the erythrocyte sedimentation rate (3*:), the #reactive protein (#:P) level, and chlamydial and gonococcal D96 probes and cultures. Imaging studies (eg, ultrasonography, computed tomography ;#$<, and magnetic resonance imaging ;2:I<) may be helpful in unclear cases.
2ost patients &ith PID are treated in an outpatient setting. In selected cases, ho&ever, physicians should consider hospitalization.
Pathophysiology
2ost cases of PID are presumed to occur in ' stages. $he first stage is ac5uisition of a vaginal or cervical infection. $his infection is often seually transmitted and may be asymptomatic. $he second stage is direct ascent of microorganisms from the vagina or cervi to the upper genital tract, &ith infection and inflammation of these structures.
$he mechanism (or mechanisms) by &hich microorganisms ascend from the lo&er genital tract is unclear. *tudies suggest that multiple factors may be involved. 6lthough cervical mucus provides a functional barrier against up&ard spread, the efficacy of this barrier may be decreased by vaginal inflammation and by hormonal changes that occur during ovulation and menstruation.
In addition, antibiotic treatment of seually transmitted infections can disrupt the balance of endogenous flora in the lo&er genital tract, causing normally nonpathogenic organisms to overgro& and ascend. +pening of the cervi during menstruation, along &ith retrograde menstrual flo&, may also facilitate ascent of microorganisms.
Intercourse may contribute to the ascent of infection through rhythmic uterine contractions occurring during orgasm. =acteria may also be carried along &ith sperm into the uterus and fallopian tubes.
In the upper tract, a number of microbial and host factors appear to influence the degree of inflammation that occurs and, thus, the amount of subse5uent scarring that develops. Infection of the fallopian tubes initially affects the mucosa, but inflammation may rapidly become transmural. $his inflammation, &hich appears to be mediated by complement, may increase in intensity &ith subse5uent infections.
Inflammation may etend to uninfected parametrial structures, including the bo&el. Infection may etend via spillage of purulent materials from the fallopian tubes or via lymphatic spread beyond the pelvis to produce acute peritonitis and acute perihepatitis (Fitz!ugh"#urtis syndrome).
Pregnancy-related factors
PID rarely occurs in pregnancy4 ho&ever, chorioamnionitis can occur in the first >' &ee%s of gestation, before the mucous plug solidifies and seals off the uterus from ascending bacteria. Fetal loss may result. #oncurrent pregnancy influences the choice of antibiotic therapy for PID and demands that an alternative diagnosis of ectopic pregnancy be ecluded. ?terine infection is usually limited to the endometrium but may be more invasive in a gravid or postpartum uterus.
enet!c factors
@enetically mediated variation in immune response plays an important role in susceptibility to PID. 8ariants in the genes that regulate tollli%e receptors ($:s), an important component in the innate immune system, have been associated &ith an increased progression of C trachomatis infection to PID.
Den !artog et al found a possible contributing role of singlenucleoside polymorphisms (*9Ps) in / genes encoding pattern recognition receptors in local tubal cells and circulating immune cells (eg, macrophages). $he presence of ' or more *9Ps appeared to correlate &ith increased laparoscopically identifiable tubal pathology.
PID has - principal complications, as follo&s1
• 3ctopic pregnancy
#hronic pelvic pain occurs in approimately '0 of patients &ith a history of PID. $his pain is thought to be related to cyclic menstrual changes, but it also may be the result of adhesions or hydrosalpin.
Impaired fertility is a major concern in &omen &ith a history of PID. Infection and inflammation can lead to scarring and adhesions &ithin tubal lumens. +f &omen &ith tubal factor infertility, 0 have no history of PID but have scarring of the fallopian tubes and ehibit antibodies to C trachomatis. $he rate of infertility increases &ith the number of episodes of infection.
$he ris% of ectopic pregnancy is increased >0 in &omen &ith a history of PID. 3ctopic pregnancy is a direct result of damage to the fallopian tube.
PID may produce $+6 and etend to produce pelvic peritonitis and Fitz!ugh"#urtis syndrome (perihepatitis). $+6 is reported in as many as one third of &omen hospitalized for PID.
6pproimately >',>, hospitalizations occur yearly in the ?nited *tates because of PID. ;-A< Bomen in resourcepoor countries, especially those in sub*aharan 6frica and *outheast 6sia, eperience an increased rate of complications and se5uelae4 reasons for these higher rates include lac% of access to care and inability to afford optimal care.
*tudies of $ai&anese databases that included more than C, &omen diagnosed &ith PID found that PID &as an independent ris% factor for myocardial infarction in patients older than year.and that ris% of stro%e &as increased in the - years follo&ing PID. 6nother largescale study from $ai&an found that the ris% of ovarian cancer is also increased, particularly in &omen &ho have had at least episodes of PID
#omplications of pelvic inflammatory disease
Pelvic inflammatory disease (PID) can sometimes lead to serious and longterm problems, particularly if the condition is not treated promptly &ith antibiotics.
!o&ever, most &omen &ith PID &ho complete their course of antibiotics have no longterm problems.
:ecurrent pelvic inflammatory disease
*ome &omen &ill eperience repeated episodes of PID. $his is %no&n as recurrent pelvic inflammatory disease.
$he condition can return if the initial infection is not entirely cleared, often because the course of antibiotics &as not completed, or because a seual partner has not been tested and treated.
If an episode of PID damages the &omb or fallopian tubes, it can become easier for bacteria to infect these areas in the future, ma%ing you more susceptible to developing the condition again.
:epeated episodes of PID are associated &ith an increased ris% of infertility (see belo&).
• 6bscesses
PID can sometimes cause collections of infected fluid called abscessesto develop, most commonly in the fallopian tubes and ovaries.
6bscesses may be treated &ith antibiotics, but sometimes laparoscopic surgery (%eyhole surgery) may be needed to drain the fluid a&ay. $he fluid can also sometimes be drained using a needle thats guided into place using an ultrasound scan.
ongterm pelvic pain
*ome &omen &ith PID develop longterm (chronic) pain around their pelvis and lo&er abdomen, &hich can be difficult to live &ith and can lead to further problems such as depression and difficulty sleeping (insomnia).
If you develop chronic pelvic pain, you may be given pain%illers to help control your symptoms and tests to determine the cause may be carried out. If pain%illers do not help control your pain, you may be referred to a pain management team or a specialist pelvic pain clinic.
• 3ctopic pregnancy
6n ectopic pregnancy is &hen a fertilised egg implants itself outside of the &omb, usually in one of the fallopian tubes.
If PID infects the fallopian tubes, it can scar the lining of the tubes, ma%ing it more difficult for eggs to pass through. If a fertilised egg gets stuc% and begins to gro& inside the tube, it can cause the tube to burst, &hich can sometimes lead to severe and lifethreatening internal bleeding.
$herefore, medication to stop the egg gro&ing or surgery to remove it may be recommended if you are diagnosed &ith an ectopic pregnancy.
• Infertility
6s &ell as increasing your ris% of having an ectopic pregnancy, scarring or abscesses in the fallopian tubes can ma%e it difficult for you to get pregnant if eggs cannot pass easily into the &omb.
Its estimated that about one in every > &omen &ith PID becomesinfertile as a result of the condition, &ith the highest ris% in &omen &ho had delayed treatment or repeated episodes of PID. !o&ever, a long term study in the ?* sho&ed that &omen &ho had been successfully treated for PID had the same pregnancy rates as the rest of the population.
=loc%ed or damaged fallopian tubes can sometimes be treated &ith surgery, but if this is not possible and you &ant to have children, you may &ant to consider an assisted conception techni5ue such as invitro fertilisation (I8F).
.
Pelvic inflammatory disease (PID) is an infectious and inflammatory disorder of the upper female genital tract, including the uterus, fallopian tubes, and adjacent pelvic structures. Infection and inflammation may spread to the abdomen, including perihepatic structures (Fitz!ugh"#urtis syndrome). $he classic highris% patient is a menstruating &oman younger than ' years &ho has multiple se partners, does not use contraception, and lives in an area &ith a high prevalence of seually transmitted disease (*$D).
PID is initiated by infection that ascends from the vagina and cervi into the upper genital tract. Chlamydia trachomatis is the predominant seually transmitted organism associated &ith PID. +ther organisms implicated in the pathogenesis of PID include Neisseria gonorrhoeae, Gardnerella vaginalis, Haemophilus influenzae, and anaerobes such as Peptococcus and Bacteroides species. aparoscopic studies have sho&n that in -/0 of cases, PID is polymicrobial
$he diagnosis of acute PID is primarily based on historical and clinical findings. #linical manifestations of PID vary &idely, ho&ever1 2any patients ehibit fe& or no symptoms, &hereas others have acute, serious illness. $he most common presenting complaint is lo&er abdominal pain. 2any &omen report an abnormal vaginal discharge.
$he differential diagnosis includes appendicitis, cervicitis, urinary tract infection, endometriosis, and adneal tumors. 3ctopic pregnancy can be mista%en for PID4 indeed, PID is the most common incorrect diagnosis in cases of ectopic pregnancy. #onse5uently, a pregnancy test is mandatory in the &or%up of &omen of childbearing age &ho have lo&er abdominal pain.
PID may produce tuboovarian abscess ($+6) and may progress to peritonitis and Fitz!ugh"#urtis syndrome (perihepatitis4 see the image belo&). *ubclinical PID or a delay in diagnosis or treatment of PID can result in longterm se5uelae, such as chronic pelvic pain and tubal infertility.
78iolinstring7 adhesions of chronic Fitz!ugh#urtis syndrome.
aparoscopy is the current criterion standard for the diagnosis of PID. 9o single laboratory test is highly specific or sensitive for the disease, but studies that can be used to support the diagnosis include the erythrocyte sedimentation rate (3*:), the #reactive protein (#:P) level, and chlamydial and gonococcal D96 probes and cultures. Imaging studies (eg, ultrasonography, computed tomography ;#$<, and magnetic resonance imaging ;2:I<) may be helpful in unclear cases.
2ost patients &ith PID are treated in an outpatient setting. In selected cases, ho&ever, physicians should consider hospitalization.
Pathophysiology
2ost cases of PID are presumed to occur in ' stages. $he first stage is ac5uisition of a vaginal or cervical infection. $his infection is often seually transmitted and may be asymptomatic. $he second stage is direct ascent of microorganisms from the vagina or cervi to the upper genital tract, &ith infection and inflammation of these structures.
$he mechanism (or mechanisms) by &hich microorganisms ascend from the lo&er genital tract is unclear. *tudies suggest that multiple factors may be involved. 6lthough cervical mucus provides a functional barrier against up&ard spread, the efficacy of this barrier may be decreased by vaginal inflammation and by hormonal changes that occur during ovulation and menstruation.
In addition, antibiotic treatment of seually transmitted infections can disrupt the balance of endogenous flora in the lo&er genital tract, causing normally nonpathogenic organisms to overgro& and ascend. +pening of the cervi during menstruation, along &ith retrograde menstrual flo&, may also facilitate ascent of microorganisms.
Intercourse may contribute to the ascent of infection through rhythmic uterine contractions occurring during orgasm. =acteria may also be carried along &ith sperm into the uterus and fallopian tubes.
In the upper tract, a number of microbial and host factors appear to influence the degree of inflammation that occurs and, thus, the amount of subse5uent scarring that develops. Infection of the fallopian tubes initially affects the mucosa, but inflammation may rapidly become transmural. $his inflammation, &hich appears to be mediated by complement, may increase in intensity &ith subse5uent infections.
Inflammation may etend to uninfected parametrial structures, including the bo&el. Infection may etend via spillage of purulent materials from the fallopian tubes or via lymphatic spread beyond the pelvis to produce acute peritonitis and acute perihepatitis (Fitz!ugh"#urtis syndrome).
Pregnancy-related factors
PID rarely occurs in pregnancy4 ho&ever, chorioamnionitis can occur in the first >' &ee%s of gestation, before the mucous plug solidifies and seals off the uterus from ascending bacteria. Fetal loss may result. #oncurrent pregnancy influences the choice of antibiotic therapy for PID and demands that an alternative diagnosis of ectopic pregnancy be ecluded. ?terine infection is usually limited to the endometrium but may be more invasive in a gravid or postpartum uterus.
enet!c factors
@enetically mediated variation in immune response plays an important role in susceptibility to PID. 8ariants in the genes that regulate tollli%e receptors ($:s), an important component in the innate immune system, have been associated &ith an increased progression of C trachomatis infection to PID.
Den !artog et al found a possible contributing role of singlenucleoside polymorphisms (*9Ps) in / genes encoding pattern recognition receptors in local tubal cells and circulating immune cells (eg, macrophages). $he presence of ' or more *9Ps appeared to correlate &ith increased laparoscopically identifiable tubal pathology.
PID has - principal complications, as follo&s1
• 3ctopic pregnancy
#hronic pelvic pain occurs in approimately '0 of patients &ith a history of PID. $his pain is thought to be related to cyclic menstrual changes, but it also may be the result of adhesions or hydrosalpin.
Impaired fertility is a major concern in &omen &ith a history of PID. Infection and inflammation can lead to scarring and adhesions &ithin tubal lumens. +f &omen &ith tubal factor infertility, 0 have no history of PID but have scarring of the fallopian tubes and ehibit antibodies to C trachomatis. $he rate of infertility increases &ith the number of episodes of infection.
$he ris% of ectopic pregnancy is increased >0 in &omen &ith a history of PID. 3ctopic pregnancy is a direct result of damage to the fallopian tube.
PID may produce $+6 and etend to produce pelvic peritonitis and Fitz!ugh"#urtis syndrome (perihepatitis). $+6 is reported in as many as one third of &omen hospitalized for PID.
6pproimately >',>, hospitalizations occur yearly in the ?nited *tates because of PID. ;-A< Bomen in resourcepoor countries, especially those in sub*aharan 6frica and *outheast 6sia, eperience an increased rate of complications and se5uelae4 reasons for these higher rates include lac% of access to care and inability to afford optimal care.
*tudies of $ai&anese databases that included more than C, &omen diagnosed &ith PID found that PID &as an independent ris% factor for myocardial infarction in patients older than year.and that ris% of stro%e &as increased in the - years follo&ing PID. 6nother largescale study from $ai&an found that the ris% of ovarian cancer is also increased, particularly in &omen &ho have had at least episodes of PID
#omplications of pelvic inflammatory disease
Pelvic inflammatory disease (PID) can sometimes lead to serious and longterm problems, particularly if the condition is not treated promptly &ith antibiotics.
!o&ever, most &omen &ith PID &ho complete their course of antibiotics have no longterm problems.
:ecurrent pelvic inflammatory disease
*ome &omen &ill eperience repeated episodes of PID. $his is %no&n as recurrent pelvic inflammatory disease.
$he condition can return if the initial infection is not entirely cleared, often because the course of antibiotics &as not completed, or because a seual partner has not been tested and treated.
If an episode of PID damages the &omb or fallopian tubes, it can become easier for bacteria to infect these areas in the future, ma%ing you more susceptible to developing the condition again.
:epeated episodes of PID are associated &ith an increased ris% of infertility (see belo&).
• 6bscesses
PID can sometimes cause collections of infected fluid called abscessesto develop, most commonly in the fallopian tubes and ovaries.
6bscesses may be treated &ith antibiotics, but sometimes laparoscopic surgery (%eyhole surgery) may be needed to drain the fluid a&ay. $he fluid can also sometimes be drained using a needle thats guided into place using an ultrasound scan.
ongterm pelvic pain
*ome &omen &ith PID develop longterm (chronic) pain around their pelvis and lo&er abdomen, &hich can be difficult to live &ith and can lead to further problems such as depression and difficulty sleeping (insomnia).
If you develop chronic pelvic pain, you may be given pain%illers to help control your symptoms and tests to determine the cause may be carried out. If pain%illers do not help control your pain, you may be referred to a pain management team or a specialist pelvic pain clinic.
• 3ctopic pregnancy
6n ectopic pregnancy is &hen a fertilised egg implants itself outside of the &omb, usually in one of the fallopian tubes.
If PID infects the fallopian tubes, it can scar the lining of the tubes, ma%ing it more difficult for eggs to pass through. If a fertilised egg gets stuc% and begins to gro& inside the tube, it can cause the tube to burst, &hich can sometimes lead to severe and lifethreatening internal bleeding.
$herefore, medication to stop the egg gro&ing or surgery to remove it may be recommended if you are diagnosed &ith an ectopic pregnancy.
• Infertility
6s &ell as increasing your ris% of having an ectopic pregnancy, scarring or abscesses in the fallopian tubes can ma%e it difficult for you to get pregnant if eggs cannot pass easily into the &omb.
Its estimated that about one in every > &omen &ith PID becomesinfertile as a result of the condition, &ith the highest ris% in &omen &ho had delayed treatment or repeated episodes of PID. !o&ever, a long term study in the ?* sho&ed that &omen &ho had been successfully treated for PID had the same pregnancy rates as the rest of the population.
=loc%ed or damaged fallopian tubes can sometimes be treated &ith surgery, but if this is not possible and you &ant to have children, you may &ant to consider an assisted conception techni5ue such as invitro fertilisation (I8F).
.