This covers PID a female infection, typically for nurses, clinical officers and nurse assistants. It will help prepare nurses in inter grated reproductive health and gynaecology.

1. PELVIC INFLAMMATORY
DISEASE
MR SANDWE T.K

2. Introduction
Pelvic Inflammatory Disease (PID) is a morbid and costly sexually
transmitted bacterial upper-reproductive-tract infection affecting
non-pregnant and occasionally pregnant women.
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3. Introduction cont’d
Studies demonstrate the importance of pathogenic lower-
reproductive-tract microorganisms ascending from the endocervix to
mediate endometritis, salpingitis, and sometimes peritonitis
(Hacker et al, 2004).
MR SANDWE T.K 3

4. Introduction cont’d
PID is a common and serious complication of some sexually
transmitted diseases (STDs), especially Chlamydia and gonorrhoea
(CDC, 2002). Sexually active adolescents are at greatly increased risk
of contracting PID, which causes a significant number of
hospitalizations for women (Manahan et al, 2007).
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5. Introduction cont’d
In this write up, definitions, prevalence’s, causes, predisposing
factors, pathophysiology, signs and symptoms, investigations,
management, complications and prevention of PID will be discussed.
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6. Specific objectives
At the end of the presentation, students should be able to;
• Define the term Pelvic Inflammatory Disease
• State the prevalence of PID
• Mention the causes of PID
• State the predisposing factors to PID
• Describe the pathophysiology of PID
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7. Specific objectives cont’d
• List signs and symptoms for PID
• Describe the management for PID
• State the complications of PID
• Mention prevention measures
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8. Definitions of PID
1. Pelvic inflammatory Disease is An inflamantory condition involving
the pelvic organs i.e. cervix (cervicitis), uterus (endometritis),
salpinx (salpingitis) and ovaries (oophoritis), MoH, (2008).
2. Pelvic inflammatory disease (PID) is any acute, sub-acute, recurrent,
or chronic infection of the oviducts and ovaries, with adjacent
tissue involvement (Springhouse, 2003).
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9. Figure 1: Diagram of the uterus and the uterine
tubes
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10. Prevalence of PID
• More than 10% of reproductive-age women report a history of PID in
the US. About 15% to 30% of women with inadequately treated
gonoccocal or chlamydial cervicitis develop PID(Hacker et al, 2004).
• Reliable national data on the prevalence of reproductive infections do
not exist in most developing countries (Althaus, 1991).
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11. Prevalence of PID cont’d
• Each year in the United States, it is estimated that more than 1 million
women experience an episode of acute PID. More than 100,000
women become infertile each year as a result of PID, and a large
proportion of the ectopic pregnancies occurring every year are due to
the consequences of PID (CDC, 2002).
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12. Prevalence of PID cont’d
• Sexually active women in their childbearing years are most at risk,
and those under age 25 are more likely to develop PID than those
older than 25. This is partly because the cervix of teenage girls and
young women is not fully matured, increasing their susceptibility to
the STDs that are linked to PID (CDC, 2002).
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13. CAUSES OF PID
PID can result from infection with aerobic or anaerobic organisms.
The most important single agent causes of PID include Chlamydia
trachomatis and Neisseria gonorrhoea (Hacker et al, 2004).
Endogenous aerobic bacteria include;
• E. Coli
• Klebsiella
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14. Causes of PID cont’d
• Streptococcus species
Endogenous anaerobes bacteria include;
• Bacteroides
• Peptostreptococcus and peptococcus
• Mycoplasma hominis
• Actinomycetes
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15. PREDISPOSING FACTORS TO PID
• Age- sexually active women below 25 years
• History of Chlamydia or gonorrhoea infection
• Sexual intercourse with more partners
• Douching
• Induced abortion
• Dilatation and curettage or endometrial biopsy
• Intra-uterine devise (IUD) insertion or use
• Hysterosalpingography
• Laparoscopy
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16. PATHOPHYSIOLOGY OF PID
According to Manahan et al, 2007, the pathogenic organisms are
usually introduced from outside the body and pass up the cervical
canal into the uterus. The common causative organisms include
gonococci, chlamydiae, Haemophilus and streptococci. The causative
organisms invade the pelvis by way of the fallopian tubes or through
the uterine veins or lymphatics.
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17. Pathophysiology of PID cont’d
• Many of the pathogens lodge in the fallopian tubes and create an
acute or chronic inflammatory reaction.
• Purulent material collects in the tubes; adhesions and strictures
form; and sterility, one of the most serious consequences of PID may
occur.
• Partial obstruction of the tubes may predispose a woman to ectopic
pregnancy because the fertilized ovum cannot reach the uterus
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18. Pathophysiology of PID cont’d
• Inflammatory adhesions become so severe that surgical removal of
the uterus, tubes, and ovaries may be necessary.
• The infection usually remains localised in the lower abdomen and
pelvis, although abscesses may form.
• Severe abdominal pain, lower abdominal cramping, intermenstrual
bleeding, dyspareunia, fever and chills, malaise, nausea and vomiting
are manifestations in acute PID.
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19. Pathophysiology of PID cont’d
• A sensation of pelvic pressure and back pain may also be present. A
foul smelling vaginal discharge is copious and commonly purulent and
may cause pruritis and excoriation .
• Physical examination usually reveals abdominal tenderness on
palpation and, on bimanual examination, adnexal tenderness and
cervical motion tenderness (Chandelier sign).
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20. Pathophysiology of PID cont’d
• Masses may be felt, indicating enlargement of the fallopian tubes or
ovaries or the presence of an abscess. However, it is also possible to
be asymptomatic and have normal laboratory values.
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21. Signs and symptoms
• Symptoms of PID vary from none to severe. When PID is caused by
chlamydial infection, a woman may experience mild symptoms or no
symptoms at all, while serious damage is being done to her
reproductive organs.
• Because of vague symptoms, PID goes unrecognized by women and
their health care providers about two thirds of the time (CDC, 2002).
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22. Symptoms
• Abnormal vaginal discharge
• Pain in the lower abdomen (often of a mild, aching nature)
• Pain in the right upper abdomen
• Abnormal menstrual bleeding
• Fever and chills
• Painful urination
• Nausea and vomiting
• Painful sexual intercourse
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23. signs
• Lower abdominal tenderness with or without rebound tenderness
• Cervical excitation
• Adnexia tenderness to palpation and motion
• Occasional diarrhoea
• Mucopurulent cervicitis
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24. Management of PID
Investigations
Tests commonly used to diagnosis PID include:
• Nucleic acid amplified tests (NAATs), antigenic, or culture tests
should be done to detect chlamydial and gonococcal infections.
• Gram stain of secretions from the endocervix or cul-de-sac; culture
and sensitivity testing aids selection of the appropriate antibiotic.
Urethral and rectal secretions may also be cultured.
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25. Investigations cont’d
• Ultrasonography or computed tomography scanning- to identify an
adnexal or uterine mass. (X-rays seldom identify pelvic masses.)
• Culdocentesis- to obtain peritoneal fluid or pus for culture and
sensitivity testing.
• Laparoscopy - surgical procedure in which a thin, rigid tube with a
lighted end and camera (laparoscope) is inserted through a small
incision in the abdomen.
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26. Investigations cont’d
NOTE: The patient’s history is also significant because PID is
commonly associated with recent sexual intercourse, IUD insertion,
childbirth (puerperal sepsis), or abortion.
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27. Treatment
Therapeutic goals for treating PID include;
• Elimination of reproductive tract infection and
inflammation
• Improvement of symptoms and physical findings
• Prevention or minimization of long term sequelae
• Eradication of causal agents from the patient and her
sexual partners
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28. Treatment cont’d
• PID can be cured with several types of antibiotics. A health care
provider will determine and prescribe the best therapy.
• However, antibiotic treatment does not reverse any damage that has
already occurred to the reproductive organs. If a woman has pelvic
pain and other symptoms of PID, it is critical that she seek care
immediately (CDC, 2004).
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29. Treatment cont’d
• Because of the difficulty in identifying organisms infecting the internal
reproductive organs and because more than one organism may be
responsible for an episode of PID, PID is usually treated with at least
two antibiotics that are effective against a wide range of infectious
agents.
• These antibiotics can be given by mouth or by injection
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30. Centre for Disease Control and Prevention
recommended treatment for pid, 2002.
• In patient treatment
Regimen A
• Cefoxitin 2g IV every 6 hours or Cefotetan 2g IV every 12 hours, plus
• doxycycline 100mg IV 12 hourly until improved, followed by
doxycycline 100mg orally bid, to complete 14 days
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31. Centre for Disease Control and Prevention
recommended treatment for pid, 2002.
Regimen B
• Clindamycin 900mg IV every 8 hours
• plus,
• Gentamycin 2mg/kg IV once, followed by 1.5 mg/kg IV 8 hourly until
improved, followed by Doxycycline 100mg orally bid, to complete 14
days.
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32. Centre for Disease Control and Prevention recommended
treatment for pid, 2002.
Out patient treatment
Regimen A
• Ofloxacin 400mg orally bid for 14 days
• Or
• Levofloxacin 500mg every day for 14 days with or without,
• Metronidazole 500mg bid orally for 14 days
MR SANDWE T.K 32

33. Centre for Disease Control and Prevention recommended
treatment for pid, 2002.
Regimen B
• Ceftriaxone 250 mg IM single dose
Or,
• Cefoxitin 2 g IM single dose and probenecid 1 g orally,
• Plus,
• Doxycycline 100mg bid, to complete 14 days with or
without,
• Metronidazole 500mg orally bid for 14 days
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34. Indications for hospitalization
Hospitalization to treat PID may be recommended if the woman ;
• Is severely ill (e.g., nausea, vomiting, and high fever)
• Is Pregnant
• Does not respond to or cannot take oral medication and needs
intravenous antibiotics
• Has an abscess in the fallopian tube or ovary (tubo-ovarian abscess)
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35. Indications for hospitalization cont,d
• Needs to be monitored to be sure that her symptoms are not due to
another condition that would require emergency surgery (e.g.,
appendicitis).
• If symptoms continue or if an abscess does not go away, surgery may
be needed.
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36. Nursing care
Aim
• To relieve pain
• To promote self esteem and
• Promote quick recovery.
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37. Room
• Quiet to promote rest as patient may have chronic pain.
• Clean to prevent secondary infection.
• Well ventilated to eliminate bad odour that patient may present with.
• Should have necessary equipments
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38. Position
• The patient should be put in upright or semi upright position to
promote drainage of discharge from the uterus.
• Patient should be encouraged to sit out of bed as this will also
promote drainage of discharge from the uterus.
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39. Observations
• Vital signs should be done 4hourly except BP that can be done
routinely.
• Temp done to determine if fever settling or not as patient usually
have fever.
• Pulse to detect any tachycardia as patient is likely to have tachycardia
due to infection.
• Respirations to detect any deviation from normal.
• BP is done to detect any hypotension which can come as a result of
septicemia.
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40. Cont’d
• Observe for the signs of dehydration come ion which can come as a
result of fever.
• Watch for abdominal rigidity and distension.
• Observe for the signs of developing peritonitis such as tender
abdomen.
• Observe the response of the patient to treatment.
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41. Hygiene
• Encourage patient to change pads and pants more frequently.
• The patient should wash hands before and after changing the pads
and pants to prevent cross infection.
• Pay attention to general hygiene to promote self esteem, blood
circulation etc.
• Change the soiled linen as soon as possible to promote comfort of
patient and avoid bad odour in the room.
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42. Cont’d
• Perineal care should be done to reduce the foul smell and promote
comfort and self esteem
• Inspect the vaginal discharge for amount, colour and smell.
• Involve the patient in her care as much as possible as this tend to
decrease fear and anxiety.
• Involve the husband or family members in her care as this will prevent
feelings of isolation from the family.
• Work calmly as a nurse to avoid instilling fear in a woman.
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43. Psychological care
• Explain all treatments, procedures and the condition to the patient as
this will promote cooperation and relieve apprehension patient may
be facing.
• Involve the patient in her care as much as possible as this tend to
decrease fear and anxiety.
• Involve the husband or family members in her care as this will prevent
feelings of isolation from the family.
• Work calmly as a nurse to avoid instilling fear in a woman.
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44. Pain management
• Give prescribed analgesics such as panadol to relieve pain.
• Provide quiet room to promote rest.
• Warm compresses may be applied on the back and the abdomen or
sitz baths to provide comfort.
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45. FLUID REPLACEMENT
• Give IV fluids as ordered to replace and improve blood circulation.
• Stop fluid loss by administering the prescribed antiemetic.
• Encourage patient to take a lot of fluids when vomiting has stopped.
• Prevent complications by providing IV line and site care, regulation of
flow and rate.
• Monitor intake and output and record the observations.
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46. Nutrition
• Encourage balanced diet rich in proteins, vitamins to fight the
infections and promote healing.
• Encourage patient to drink fluids to replace lost fluids through the
discharge, sweating and vomiting.
• Give small frequent feeds that are attractive to promote appetite.
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47. Elimination
• Relieve pain which makes patient hesitate to void and open bowels so
that they can pass stool and urine.
• Observe the colour of vomitus, amount and odour.
• Record readings on fluid balance chart and balance intake and output.
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48. PREVENTION OF INFECTION
• Practice infection control measure by proper hand washing with a
germicidal soap.
• Precautions to be taken when handling and disposing soiled pads and
used gloves.
• Disinfect linen and bed pans.
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49. Rest/activity
• Encourage the patient to rest a lot during the acute phase to promote
healing.
• Passive exercises are done to promote blood circulation in the acute
phase but, as condition improves, active exercises are encouraged.
• Handle the client minimally during the active phase by doing the
procedures at the same time to promote rest.
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50. INFORMATION EDUCATION & COMMUNICATION
• Modes of transmission of disease.
• Good sexual practice to prevent STIs.
• Possible complications, e.g Ectopic pregnancy
• Perineal care.
• Compliance to treatment.
• Dangers of intentional abortions.
• Avoid sexual intercourse until completes Treatment.
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51. PREVENTION
• Practicing safer sex to prevent STIs like gonorrhoea and Chlamydia
• Avoid criminal abortions.
• Early diagnosis and treatment for STIs.
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52. Nursing management
Nursing interventions are largely aimed at supportive measures such
as;
• After establishing that the patient doesn’t have drug allergies,
administer antibiotics and analgesics as necessary.
• Encourage bed rest in a semi-fowlers position to assist with pelvic
drainage.
• Heat applied to the abdomen may be comforting but tub or sitz baths
should be avoided during active infection.
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53. Nursing management cont’d
• Check for fever. If it persists, carefully monitor fluid intake and output,
watching the patient for signs of dehydration.
• Encourage adequate oral fluids about 2000ml of fluids daily is
recommended
• Watch for abdominal rigidity and distention, possible signs of
developing peritonitis.
• Provide frequent perineal care if vaginal drainage occurs every 3 to 4
hours and maintain scrupulous hygiene after urination and
defecation.
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54. Nursing management cont’d
• To prevent a recurrence, explain the nature and seriousness of PID,
and encourage the patient to comply with the treatment regimen.
• Stress the need for the patient’s sexual partner to be examined and,
if necessary, treated for infection.
• Because PID may cause painful intercourse, advise the patient to
consult with her physician about sexual activity.
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55. Complications
• Ectopic pregnancy- a partially blocked or slightly damaged fallopian
tube may cause a fertilized egg to remain in the fallopian tube and
begins to grow.
• Chronic pelvic pain- Scarring in the fallopian tubes and other pelvic
structures can also cause chronic pelvic pain
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56. Complications cont’d
• Infertility- If the fallopian tubes are totally blocked by scar tissue,
sperm cannot fertilize an egg, and the woman becomes infertile.
Infertility also can occur if the fallopian tubes are partially blocked or
even slightly damaged. About one in ten women with PID becomes
infertile.
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57. Complications cont’d
• Tubo-ovarian abscess- If the first or subsequent
episodes of inflammation are not adequately treated
then the condition can become chronic and abscesses
can form in the pelvis.
• Peritonitis- extension of the PID infection into the
peritoneal cavity
• Mortality – Sexually transmitted infections are among
the most important causes of mortality world wide
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58. Prevention
Primary prevention (Monahan et al,2007)
• The surest way to avoid transmission of STDs is to abstain from sexual
intercourse, or to be in a long-term mutually monogamous
relationship with a partner who has been tested and is known to be
uninfected.
• Latex male and female condoms, when used consistently and
correctly, can reduce the risk of transmission of chlamydia and
gonorrhea.
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59. Primary Prevention cont’d
• An appropriate sexual risk assessment by a health care provider
should always be conducted and may indicate more frequent
screening for some women.
• Primary prevention mainly consists of information, education and
communication to young sexually active women
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60. Secondary prevention
• Women can protect themselves from PID by taking action to prevent
STDs or by getting early treatment if they do get an STD.
• CDC recommends yearly chlamydia testing of all sexually active
women age 25 or younger, older women with risk factors for
chlamydial infections (those who have a new sex partner or multiple
sex partners), and all pregnant women.
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61. Secondary prevention cont’d
• Any genital symptoms such as an unusual sore, discharge with odor,
burning during urination, or bleeding between menstrual cycles could
mean an STD infection. If a woman has any of these symptoms, she
should stop having sex and consult a health care provider
immediately (Hacker et al,2004).
• Compliance to treatment is very important
MR SANDWE T.K 61

62. Secondary prevention cont’d
• Treating STDs early can prevent PID. Women who are told they have
an STD and are treated for it should notify all of their recent sex
partners so they can see a health care provider and be evaluated for
STDs. Sexual activity should not resume until all sex partners have
been examined and, if necessary, treated.
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63. Follow up care
Women treated as out-patients are reminded of the importance of
completing the antibiotic regimen and seeking appropriate follow up
care since PID can have serious consequences for fertility. Partner
notification, treatment and counselling should be done continuous
(Manahan et al, 2007).
MR SANDWE T.K 63

64. Tertially prevention
• Rehabilitation through counselling sessions for those women who
develop complications. The family should be involved in the care of
the women and any decisions to be made.
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65. Conclusion
Pelvic inflammatory disease (PID) is a general term that refers to
infection of the uterus (womb), fallopian tubes and other
reproductive organs. It is a common and serious complication of
some sexually transmitted diseases (STDs), especially Chlamydia and
gonorrhoea.
MR SANDWE T.K 65

66. Conclusion cont’d
• PID can damage the fallopian tubes and tissues in and near the uterus
and ovaries. PID can lead to serious consequences including infertility,
ectopic pregnancy (a pregnancy in the fallopian tube or elsewhere
outside of the womb), abscess formation, and chronic pelvic pain.
MR SANDWE T.K 66

67. References
• Althaus, F.A. (1991). Reproductive Tract Infections
and Women’s Health, Guttmacher institute, Vol. 17
No4.
• Centre for Disease Control and Prevention,
(2002). Sexually transmitted diseases treatment
guidelines, May 10 2002; 51(RR-6):1-78. Available at
http//www.medscape.com/medline/abstract/121845
49, accessed on 29th November, 2009 at 10hrs.
MR SANDWE T.K 67

68. References cont’d
• Hacker, N.F., Moore, J.G., and Gambone, J.C. (2004). Essentials of
Obstetrics and Gynaecology,4th edition, Elsevier Inc. New Delhi.
110024.
• Ministry of Health. (2008). Standard Treatment Guidelines, Essential
Medicines List, Essential Laboratory Supplies for Zambia, 2nd edition.
Lusaka.
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69. References cont’d
• Monahan, F.D., Sands, J.K., Neighbors, M., Marek, J.F., and Green, C.J.
(2007). Phipps’ Medical- Surgical Nursing: Health and Illness
Perspective, 8th edition. Elsevier Ltd, St. Louis, Missouri 63146.
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70. References cont’d
• Springhouse, (2003). Handbook of diseases, Lippincott Williams &
Wilkins, Available at: http//www.wrongdiagnosis.com/p/pelvic-
inflammatory-disease/allbooks.htm.
Accessed on the 30th November, 2009.
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