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The term pelvic inflammatory disease (PID) usually refers to an ascending infection of the endometrium and/or fallopian tubes. Intrauterine infection can be primary (spontaneously occurring and usually sexually transmitted), or secondary to invasive intrauterine surgical procedures (e.g., dilatation and curettage, termination of pregnancy, insertion of an intrauterine device, hysterosalpingography), or to parturition.(1) Worldwide, PID is a leading cause of infertility, and in the United States, it is considered responsible for the recent upswing in ectopic pregnancy.(2)
Pelvic inflammatory disease is almost exclusively a disease of sexually active women and may be of the chronic or acute type. Chronic PID caused by Mycobacterium tuberculosis has become uncommon in industrialized countries, however, PID caused by Chlamydia trachomatis is thought to be common. In general, first episodes of acute PID are likely to be caused by N. gonorrhea and or C. trachomatis. These sexually transmitted pathogens are less often implicated in subsequent infections, or in episodes occurring in women with intrauterine devices, and/or invasive diagnostic or therapeutic procedures. Infections due to use of IUD or diagnostic procedures tend to be caused by ascending infection from endogenous vaginal flora.
The term, pelvic inflammatory disease has been used to describe an entire cascade of infections including simple cervicitis, to endometritis, to salpingitis, to pelvic peritonitis, and finally to generalized peritonitis, perihepatitis, or pelvic abscess. The distinctions may be important, however, since confirmed cases of salpingitis, or inflammation of the fallopian tubes, is most frequently associated with long-term sequellae. These sequellae include infertility due to bilateral tubal occlusion, peritubal adhesions, ectopic pregnancy due to tubal damage, chronic pelvic pain, and sometimes recurrent PID. Tubal occlusion and fibrosis secondary to fallopian tube inflammation (salpingitis) results in infertility in up to 13 percent of women following a single episode of PID, and in up to 75 percent of women after three or more episodes of PID.(3) The risk of ectopic pregnancy is increased approximately eight fold after one or more episodes of PID.(4)
Approximately 85 percent of all cases of acute PID occur by sexual transmission in females of reproductive age, with another 15 percent following procedures requiring instrumentation, including IUD insertion, abortion, or dilation and curettage.(4, 5) Acute PID develops in 1 percent of sexually active young women annually and causes more morbidity in women (15 to 25 years of age) than all other serious infections combined.(4, 6)
There have been several factors implicated in the upward spread of infection in PID. Some of these include: attachment to sperm that migrate upwards into the tubes; use of an IUD; vaginal douching; menstruation; and the presence of thin cervical mucous.
Early diagnosis and treatment are necessary to prevent or minimize tubal scarring. Unfortunately, there is neither diagnostic test nor clinical finding short of laparoscopy to definitively identify salpingitis. Obviously, routine laparoscopy is impractical. Most patients with PID have lower abdominal pain of less than three weeks duration, pelvic tenderness upon bimanual pelvic exam, and evidence of lower genital tract infection, such as greater numbers of white blood cells usually outnumbering all other cells in the vaginal fluid. Among patients with these findings, a rectal temperature above 38°C, palpable adnexal mass, and elevation of ESR over 15mm/h are factors that have additionally been identified with increased likelihood of salpingitis.
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