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Running head: PELVIC INFLAMMATORY DISEASE
Pelvic Inflammatory Disease
Irene Zasa-Willett, FNP-s
SUNYIT
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Pelvic inflammatory disease (PID) commonly known as PID is an infection of the female
reproductive organs. The CDC reports that approximately 750,000 women are affected by this
disease each year in the United States and possibly more due to misdiagnosis (CDC, 2013).
Women who are sexually active and between the ages of 15-29 are at a much higher risk most
likely due to the number of sexual partners than any other reason and poor use of condoms
(Schuiling & Likis, 2013). Any female who is sexually active can get this disease, but certain
behaviors can increase the risk substantially such as multiple sex partners in a short period of
time and substance abuse (PubMedHealth, 2011). Among other risk factors for PID is an
existing sexually transmitted disease, a sex partner who has multiple sex partners, a past history
of PID, IUD insertion within 2 months, other recent gynecological procedure, or frequent
douching (Shuiling & Likis, 2013). Gradison (2012) reports that the cost of treatment is
approximately 1.5 billion dollars a year to treat PID. This cost includes treatment for
complications of this disease. PID is a preventable disease and often misdiagnosed. According
to Domino (2013), 30% of PID has been misdiagnosed in the past, leading to increased risks for
infertility, chronic pelvic pain, and pelvic organ scarring (Shephard, 2010).
There have been multiple organisms documented to cause PID such as N. Gonorrhea, C.
Trachomatis, anaerobes, G. Vaginalis, H. Influenza, Streptococcus Agalactaie, enteric gram
negative rods, cytomegalovirus, M. Hominis, urealyticum and M. Genitalium. The most
common being gonorrhea and chlamydia (Gradison, 2012). These microorganisms are thought
to spread in three different ways: intra-abdominally—the bacteria travels from the cervix to the
endometrium, through the salpinx and into the peritoneal cavity causing endometritis, salpingitis,
and tubal-ovarian abscesses. This complication is the most serious (Gradison, 2012). Another
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way this infection is spread is through the lymphatic system from an infection of the
parametrium from an IUD or gyn procedure. This can also cause peritonitis. The most rare
transmission is hematogenous route such as TB. However this is very rare (Gradison, 2012). In
a report released by PubMedHealth (2011) and also cited in an article by Taylor-Robinson
(2012), it was noted that the main cause of PID is gonorrhea and chlamydia. According to the
New York State Department of Health (NYSDOH) in 2011 the Oneida county rates for
gonorrhea and chlamydia (the most common organisms for PID) were 60.2 and 453.2
respectively (per 100,000). These organisms or any of the above cited organisms upset the
vaginal flora. Once an organism is introduced into the vagina it can take anywhere from a few
days to months before the infection travels up to the pelvic organs (PubMedHealth, 2011).
Symptomatology is varied among women. Some women experience very mild symptoms
and other women can experience intolerable pain and discomfort. For this reason the diagnosis
of PID for many years was difficult to ascertain. The symptoms of PID can be all or some of the
following: abnormal vaginal foul-smelling discharge, lower abdominal or back pain or aching,
pain in the upper right abdomen, abnormal menstrual bleeding, spotting, painful periods, painful
intercourse, burning when urinating, nausea, vomiting, fever, chills, rebound tenderness and
guarding (CDC, 2011).
United States Preventive Services Task Force (USPST, 2012) recommends screening for
chlamydia and gonorrhea if sexually active and under 25, pregnant or any woman who is at an
increased risk due to multiple sex partners or a partner who has multiple sex partners.
The diagnosis of PID can often be difficult. Delayed diagnosis can lead to life-altering
complications that may affect fertility and quality of life due to chronic pelvic floor pain. The
reasons for delayed diagnosis is from the imprecise nature of the disease but also include mild
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symptomology, varied levels of pain threshold among women, lack of recognition of mild
symptoms that are PID, health care providers stereotypical picture of women who may have PID
or any sexually transmitted disease, failure of the health care provider to see young teens as
sexual beings, failure to obtain accurate history from women overlooking recent IUD insertion
(CDC, 2010). The medical community has recognized the life-altering consequences due to
failure of early diagnosis of PID. For this reason CDC recommendations have been set to help
health care providers recognize and treat symptoms of PID (Sexually Transmitted Disease (STD)
Treatment Guidelines, 2010).
The diagnostic criterion that has been recommended by the CDC is also cited in the
multiple articles reviewed including an article in The American Family Physician (2008). These
articles do not overlook the importance of a precise history of the women’s symptoms, sexual
history and pelvic examination necessary in order to identify the criteria that must be met. The
diagnostic criteria is as follows: cervical motion tenderness, uterine tenderness and/or adnexal
tenderness, signs of lower genital tract inflammation such as cervical exudates or friability,
and/or increased leukocytes in vaginal secretions, and/or fever, foul-smelling discharge, elevated
sed. rate and c-reactive protein, and/or laboratory diagnosis of gonorrhea or chlamydia (STD
Treatment Guidelines, 2010). Further and more specific criteria for diagnosing PID may be
necessary for women with complaints of pain but have no other signs or risk factors. Doppler
study, sonograms and laparoscopy may show abnormalities consistent with PID. Endometrial
biopsy may need to be done as endometriosis may be the only sign of PID in some women
(Healey, Priya & Quinn, 2010).
The criteria helps health care providers better diagnose and treat this disease. The need for
these criteria is because the symptoms of PID may mimic the signs/symptoms of other disease
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entities. Some of the differential diagnoses are adnexal mass, malignancy, fibroid tumors,
appendicitis, ectopic pregnancy, endometriosis, interstitial cystitis, ovarian cysts, ovarian torsion,
and irritable bowel disease (Shephard, 2010).
In order to provide optimal treatment for women with PID it is advised that the health
practitioner be aware of the most common organism that is being found in their area of practice.
This does not change the treatment in as much to ensure sensitivity to the medication that is
prescribed (Rotblatt, Montoya, Plant, Guerry, & Kerndt, 2013).
Empiric treatment for PID should be started immediately in sexually active young women or
any women at high risk for STI if they are experiencing unexplained lower abdominal pain. In
an article that reviewed studies for unexplained pelvic pain by Abatangelo, Okereke, ParhamFoster, et al. (2010) there has been no harm done to patients treated empirically when no other
source for pelvic pain can be found.
Treatment for PID must be effective against N. gonorrhea and C. trachomatis (Gradison,
2012). The guidelines recommend medications to target anaerobic microorganisms as well since
some women have been found to have these organisms (Gradison, 2012). Mycoplasma
genitalium infection has been found to be associated with treatment failure in some women. The
guidelines are not suggestive to include treatment of this as of yet. More studies need to be done
to determine routine treatment for this organism (Gradison, 2012).
Recommended treatment guidelines from CDC include both oral and IV therapy for mild to
moderate PID. For severe PID it is suggested that the patient be hospitalized 24-48 hours for IV
therapy and then may switch to oral therapy. Noncompliance issues with the patient need to be
determined by the provider with regards to hospitalization. Hospitalization is recommended for
any woman who is pregnant, has tubo-ovarian abscess or underlying comorbidity (CDC, 2010).
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Various studies have shown that compliant woman with mild to moderate disease have had
similar clinical outcomes as those on IV therapy (AHRQ, 2002). The consideration for
outpatient treatment should be provider judgment (Evans, Jaleel, Kinsella, Aggarwal, 2008).
Women who have not shown clinical improvement within 72 hours of oral treatment should be
re-evaluated and given IV therapy as an outpatient or inpatient (Evans, Jaleel, et al., 2008).
Regimen A is suggested for mild to moderate disease. This consists of Cefotetan IV every 12
hours or Cefoxitin IV every 6 hours plus Doxycycline PO or IV every 12 hours. If there is tuboovarian involvement add metronidazole to provide more anaerobic coverage (CDC, 2010).
Regimen B can be followed instead which includes Clindomycin IV every 8 hours plus
Gentamycin every 8 hours or as a loading dose. With clinical improvement in 24 hours may
switch to Doxycycline twice a day for 14 days or Clindamycin four times a day for 14 days.
Clindamycin provides better anaerobic coverage (CDC, 2010). There are alternative regimens
by there is limited data to support the use of other parenteral medications. These alternative
drugs are Ampicillin/Sulbactam plus Doxycycline or Azithromycin or combined with a 12 day
course of metronidazole (CDC, 2010 and AHRQ, 2010). For very severe disease, combined
treatments are suggested, but varied according to the severity and length of illness.
Oral treatment for PID can be utilized if the infection does not include tubo-ovarian abscess
or the patient is not pregnant or have a serious underlying disease (CDC, 2010). Oral medication
is followed after an IM injection of antibiotics. Ceftriaxone or Cefoxitin IM + Probenicid by
mouth is given IM for one dose along with Doxycycline with or without metronidazole for 14
days. Other parenteral 3rd generation cephalosporin such as Cefexime plus Doxycycline twice a
day with or without metronidazole twice a day for 14 days can also be used. The addition of
metronidazole should be considered because of the anaerobic organisms suspected in PID (CDC
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2010). PID is a serious disease and can lead to fulminating infection affecting all vital organs if
left untreated. There are no known safe alternative or natural treatments for PID.
Although most cases of PID can be treated successfully as an outpatient there are some
reasons where outpatient treatment is not indicated and inpatient care is necessary. Women who
present with acute abdomen, severe nausea and vomiting due to treatment, pregnancy, poor
improvement noted, tubo-ovarian abscess, poor compliance with treatment, Severe intolerable
upper abdominal pain suggestive of hepatic involvement or immunocompromise disease
(Abatangelo, et al. 2010).
Care for women with PID in the emergency room unless hospitalized provides for poor
follow up. It is recommended that women seen in the emergency room (ER) be followed by
their primary physician (Abatangelo et al. 2010). ER physicians are encouraged to provide
counseling to patients with PID to follow up with their primary care provider. Unfortunately,
some women may not have a provider. ER providers should stress the importance of obtaining a
primary provider and know the resources in the area if the patient needs help in accessing health
care services. Education and counseling on prevention of PID is crucial for patients to
understand the risks and practice prevention. Education and counseling can be in pamphlet form
that is printed in large print and using language on 5th grade reading level. It should never be
assumed a patient can read. Therefore, verbal information should also be provided. This
education should include practicing safe sex, limit the number of partners, get tested as often as
you need to, don’t routinely douche, and after toileting wipe from front to back. It is also
important for the patient to understand their partner should be tested for any STD.
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Health providers should be well informed of resources in their community available to the
patient for help and support. Referrals to reduce high risk behavior should be done after
discussing this with the patient.
Despite multiple advances in medicine and health promotion over the century preventable
disease continues to exist and adversely affect the future of young people. Strong motivational
factors sometimes exist in patients that affect the ability to change their behavior. Clinicians are
too often pressed for time, which does not allow for meaningful discussion with their patients.
Recognition of barriers to care for out patients is a necessary facet for positive outcomes. Wolff,
Kaplan, & Liss (2010) have identified some of these barriers. These barriers include
assumptions of a women’s sexuality, educational level, understanding, and poor knowledge of
community resources.
In conclusion, PID is a serious infection that can lead to serious complications. As health care
providers understanding the disease process and presentation as well as understanding incidence
rates of certain diseases in your community is necessary in order to provide optimal care and
improving outcomes for patients.
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References
Agency for Healthcare Research and Quality. (2002). Women with pelvic
inflammatory disease treated as outpatients have long-term outcomes comparable to those
treated as inpatients; U.S. Department of Health and Human Services.
http://archive.ahrq.gov/news/press/pr2002/pelvicpr.htm.
Agency for Healthcare Research and Quality. (2010). Pelvic inflammatory
disease: Sexually transmitted diseases treatment guidelines. Retrieved from Health and
Human Services website: http://www.guideline.gov/content.aspx?id=25586.
Abatangelo, L., Okereke, L., Parham-Foster, C., Parrish, C., Scaglione, L., Zotte,
D., & Taub, L. (2010). If pelvic inflammatory disease is suspected empiric treatment should
be initiated. Journal of the American Academy f Nurse Practitioners, 22(Feb.), 117-22. doi:
http://dx.doi.org/10.1111/J.1745-7599.2009.00478.x
Center for Disease Control, (2011). Sexually transmitted diseases: Factsheet.
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Center for Disease Control and Prevention. National Center for HIV/AIDS, Viral
Hepatitis, STD and TB Prevention , Division of STD Prevention. (2010). Sexually
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Domino, F. (2013). Pelvic inflammatory disease. The 5-minute Clinical Consult
(21 ed., pp. 961-2). Philadelphia, Penn.: Wolters Kluwer Health/Lippincott Williams &
Wilkins
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