Pelvic inflammatory disease (PID) is an infection of the female reproductive organs caused by bacteria that spreads from the vagina or cervix. Common symptoms include abdominal pain and unusual discharge. Left untreated, PID can cause long-term complications like infertility, ectopic pregnancy, and chronic pelvic pain. PID is diagnosed based on symptoms and examination findings and treated with antibiotics. Prevention focuses on safer sex practices and STI screening/treatment to reduce risk of initial infection.

1. Pelvic Inflammatory Disease
(PID)
SSS
LP
12/10/2014

2. PID
• Who?
– Who can have PID
– Who may be at elevated risk
• What?
– What is PID
– What causes PID
– What does PID cause (symptoms, long-term effects)
• How?
– How to prevent PID
– How to diagnose PID
– How to treat PID
• Additional recommendations, facts, and statistics about PID

3. Who?
• Anyone with an upper reproductive tract that
contains any combination of the following:
– Cervix
– Uterus
– Fallopian/uterine tubes
– Ovaries
• In the US, PID affects 750,000 to 1 million people
per year
• Rates of PID are highest with teenagers and first-
time mothers

4. May be at elevated risk if…
• Had PID in the past
• Have an “immature” cervix (<25 years)
• Have a STI, especially if…
– …that STI is GC or CT
– …STI was present at IUD insertion
• Practices douching
• Has multiple partners and/or partner(s) with
multiple partners

5. What is PID?
• An infection of the cervix, uterus, fallopian
tubes, and/or ovaries
• A serious complication of some STIs and other
untreated infections

6. What causes PID?
• Polymicrobial (caused by a wide variety of sexually
transmitted organisms): viral, bacterial, fungal, parasitic
• Gonorrhea and chlamydia cause up to 50%
• Endogenous microorganisms found at high levels in cases of
bacterial vaginosis
– Gram positive and negative anaerobic organisms
– Gram positive and negative aerobic/facultative rods and cocci
• Mycoplasm genitalium
– Associated with milder symptoms, this small parasitic bacterium
lives on the ciliated epithelial cells of the urinary and genital
tracts in humans. Can also cause urethritis and cervicitis.
• Postpartum or postabortal (miscarriage or abortion)
infections

7. Symptoms you may notice
• Often asymptomatic (2/3)
• Pain
– Lower abdominal, pelvic, cervical and/or uterine
– During sex
– During urination
• Fever
• Discharge unusual for you
– May have a foul odor
– Increased amount
• Irregular menstrual bleeding

8. Symptoms you may not notice
• Tenderness
– Abdominal and pelvic organ tenderness
– Endometritis: inflammation of the endometrium,
sometimes causing uterine tenderness
– Salpingitis: infection and inflammation in the fallopian
tubes, sometimes causing adnexal (fallopian tubes &
ovaries) tenderness
– Cervical motion tenderness: excruciating pain on bimanual
pelvic exam that may not be felt otherwise
• Inflammation
– Two thirds of patients with laparoscopic evidence of
previous PID were not aware they had had an episode;
however, even asymptomatic PID can cause serious harm

9. Long-term Effects
• Infertility
– Bacteria can cause normal tissue in the fallopian tubes to
turn in to scar tissue
– Scarring blocks or interrupts the movement of eggs into
the uterus
– 10% of people with PID become infertile
– Increased likelihood of infertility with each PID episode
• Ectopic pregnancy
– Partially blocked or slightly damaged fallopian tube may
cause a fertilized egg to get stuck in the tube
– If egg proceeds to grow here, can cause ruptured fallopian
tube, severe pain, internal bleeding, and even death

10. More Long-term Effects
• Tubo-ovarian abscess (TOA)
– A serious short-term complication of PID
– An inflammatory mass on the fallopian tube,
ovary, or (occasionally) other adjacent pelvic
organs
– May rupture or increase risk of ectopic pregnancy
• Chronic pelvic pain (due to scarring of pelvic
structures)

11. PID Prevention/Risk Reduction
• Safer sex practices, especially barrier methods
– To reduce STI exposure and avoid initial infection
• Routine STI testing
– To identify infections as early as possible
– Testing at first prenatal visit & pre-IUD insertion
• STI treatment
– To ensure early treatment of STIs, increased accessibility of
care is essential. So is education about finishing complete
courses of treatment.
• Access to safe, legal birth and abortion services
– To reduce risk of postpartum and postabortal infection

12. How do you know if it’s PID?
• Difficult to diagnose because…
– often asymptomatic or minor/subtle symptoms
– no precise tests exist
– there is no single finding on physical examination
that is sensitive and specific for the diagnosis
• Initial diagnosis is based on…
– history of PID symptoms
– pelvic exam showing evidence of PID
– ruling out other causes of symptoms

13. R/O
• Pregnancy test to exclude ectopic pregnancy and
because PID can occur concurrently with pregnancy
• Other causes of pelvic pain
– Appendicitis
– Ovarian cysts or tumors
– Twisted ovarian cyst
– Degeneration of a myoma/fibroid
– Acute enteritis (inflammation of small intestine)
• If PID does not respond to initial treatment, other
invasive procedures such as endometrial biopsy may be
used to investigate other causes of symptoms

14. PID Diagnosis may be confirmed by…
• Lab tests to confirm presence of an infection
– Bacterial STI diagnosis
– Cultures of cervical and genital tract* secretions
– Cervical examination for friability (sensitive and
bleeds easily when rubbed)
– Evidence of WBCs and trichomonads in genital
tract fluid microscopy
– Evaluation of genital tract pH
– Whiff test (potassium hydroxide + discharge)
*or “vaginal”

15. PID Diagnosis may be confirmed by…
• Culdocentesis
– A procedure in which a needle is inserted into the pelvic cavity
through the genital tract wall to obtain a sample of pus
– Pus is then used to differentiate between bleeding (due to
ruptured ectopic pregnancy or hemorrhagic cyst) and pelvic
sepsis (salpingitis, ruptured pelvic abscess, or ruptured
appendix)
• Transgenital-tract* Ultrasonography, or MRI
– To view enlarged fallopian tubes or an abscess
• Laparoscopy
– A “minor” surgical procedure in which a thin, flexible tube with
a lightened end is inserted through a small incision in the lower
abdomen, allowing the clinician to view the internal pelvic
organs and take specimens for laboratory studies
*“Transvaginal”

16. Can you cure PID?
• Yes, the causes of PID are treatable and
curable, especially when discovered early.
• However, while you can treat the
complications of PID, you cannot always
“cure” or reverse the long-term effects of
these complications, even after PID itself has
resolved.

17. So, how do you treat PID?
• Antibiotics, usually multiple
– Ceftriaxone or cefoxitin plus doxycycline, with or without
metronidazole
– Cefoxitin or cefotetan plus doxycycline
– Clindamycin plus gentamicin
– Ampicillin/sulbactam plus doxycycline
• A PID patient’s partner(s) should also be treated to
decrease risk of re-infection by the microorganisms that
cause PID, even if the partner(s) show(s) no symptoms
• As with other antibiotics courses, all medication must be
taken to prevent re-infection, even once symptoms have
subsided

18. Other treatments
• Hospitalization or surgical intervention if
needed, to remove TOAs
• Additional followup care is indicated if patient
sees no improvements within 2-3 days of
beginning treatment
• Psychotherapy is highly recommended for
patients during and after treatment, since
many PID patients may experience fear and
stress about recurrence of PID

19. Additional Recommendations
• PID patients are encouraged to abstain from sex until
treatment is complete
• Repeat STI testing is recommended 3-6 months after a
successful treatment, due to a high rate of reinfection
by GC/CT within 6 months of treatment
• All patients with acute PID should be offered HIV
testing
• In the future, people who have had at least one
episode of PID in the past are strongly encouraged to
adopt risk reduction and prevention strategies
discussed earlier, since complications of PID are
additive with each episode

20. A note about IUDs & PID
• The risk of PID associated with IUDs is primarily
confined to the first 3 weeks after insertion and is
uncommon thereafter
• Evidence is insufficient to recommend the removal of
IUDs in people with PID
• However, caution should be exercised if IUD remains in
place, with close clinical followup
• Rates of treatment failure and recurrent PID in people
continuing to use their IUD after PID is unknown, and
no data have been collected regarding treatment
outcomes by type of IUD (hormonal/levonorgestrel or
copper)

21. A note about HIV and PID
• In some studies, HIV-infected cis-women with PID were
more likely to have TOAs than their HIV-uninfected
counterparts
• Both groups of cis-women responded equally well to
standard antibiotic regimens
• Microbiologic findings for the HIV-infected group
showed higher rates of certain microorganisms, like
candida and streptococcal infections
• Unclear whether the management of immunodeficient
HIV-infected people with PID requires more aggressive
interventions (like hospitalization)

22. Pregnancy and PID
• PID while already pregnant? Requires
hospitalization and standard antibiotics
• 10% of people in the US with diagnosed PID
become infertile
• Once infertile, what are your options to conceive?
– Fertility may be restored via tuboplastic surgery to
correct tubal obstruction or pelvic adhesions (scar
tissue), but has low success rate
– In vitro fertilization (IVF) can bypass tubal infertility
issues to allow PID patients to become pregnant

23. Some Stats
• Is the number of people in the US being
diagnosed with PID increasing?
– What do you think?

24. Some Stats
• Is the number of people in the US being
diagnosed with PID increasing?
– No. It’s actually declining. Why might this be?

25. Why Fewer PID Diagnoses in US?
• Changes in STI rates
• Increases in CT screening coverage
• Availability of antimicrobial therapies that
increase adherence to treatment
– Single shot or short course antibiotics
• More sensitive diagnostic technologies

26. Still, let’s not get complacent
• Based on a nationally representative sample from 2006-
2010, 4.2% of US cis-women have reported being treated
for PID in their lifetime
• Data from a Scandinavian study indicated that cis-women
with PID were…
– 6x more likely to have ectopic pregnancy
– 8% more likely to be infertile after 1 PID episode
– 40% more likely to be infertile after 3 episodes
– 18% more likely to have chronic pelvic pain after 1 episode
• Lack of evidence/studies about transgender, gender
nonconforming, or intersex/DSD patients with PID is
concerning because cases of PID in these populations may
be going unnoticed and/or untreated

27. Sources
• http://www.mayoclinic.com/health/pelvic-
inflammatory-disease/DS00402
• http://www.cdc.gov/std/pid/stdfact-pid-
detailed.htm
• http://en.wikipedia.org/wiki/Pelvic_inflammat
ory_disease