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Pelvic Inflammatory Disease (PID)

by David E. Soper, MD

Pelvic inflammatory disease is an infection of the upper female reproductive organs.

  • The infection is usually transmitted during sexual intercourse with an infected partner.

  • Typically, women have pain in the lower abdomen, a vaginal discharge, and irregular vaginal bleeding.

  • The diagnosis is based on symptoms, analysis of secretions from the cervix and vagina, and sometimes ultrasonography.

  • Having sexual intercourse with only one partner and using barrier contraceptives (such as condoms) with spermicides reduces the risk of infection.

  • Antibiotics can eliminate the infection.

Pelvic inflammatory disease may be an infection of the lining of the uterus (endometritis), the fallopian tubes (salpingitis), or both. If the infection is severe, it can spread to the ovaries (oophoritis) or produce a collection of pus in the fallopian tubes (tubo-ovarian abscess).

Pelvic inflammatory disease is the most common preventable cause of infertility in the United States. Infertility occurs in about one of five women with pelvic inflammatory disease.

About one third of women who have had pelvic inflammatory disease develop the infection again.

Pelvic inflammatory disease usually occurs in sexually active women. It rarely affects girls before their first menstrual period (menarche) or women during pregnancy or after menopause. Risk is increased for the following women:

  • Those who are sexually active and younger than 35

  • Those who do not use a barrier contraceptive (such as a condom or diaphragm)

  • Those who have many sex partners

  • Those who have a sexually transmitted disease or bacterial vaginosis

  • Those who have had pelvic inflammatory disease before

  • Those of lower socioeconomic status (who usually have less access to health care)

Causes

Pelvic inflammatory disease is usually caused by bacteria from the vagina. Most commonly, the bacteria are transmitted during sexual intercourse with a partner who has a sexually transmitted disease. These sexually transmitted bacteria are those that cause gonorrhea ( Neisseria gonorrhoeae—see Gonorrhea) or chlamydial infection ( Chlamydia trachomatis—see Chlamydial and Other Infections). Gonorrhea and chlamydial infection typically spread from the vagina to the cervix, where they cause infection (cervicitis). These infections may remain in the cervix or spread upward, causing pelvic inflammatory disease.

Pelvic inflammatory disease also commonly occurs in women who have bacterial vaginosis (see Bacterial Vaginosis). The bacteria that cause bacterial vaginosis normally reside in the vagina. They cause symptoms and spread to other organs only if they increase in number (overgrow). Whether bacterial vaginosis is sexually transmitted is unknown.

Less commonly, women are infected during a vaginal delivery (see Postpartum Infections), an abortion, or a medical procedure, such as dilation and curettage (D and C) or gynecologic surgery—when bacteria are introduced into the vagina or when bacteria that normally reside in the vagina are moved into the uterus. Whether douching increases the risk of infection is unclear.

Did You Know...

  • The most common preventable cause of infertility is pelvic inflammatory disease.

Symptoms

Symptoms commonly occur toward the end of the menstrual period or during the few days after it. For many women, the first symptom is mild to moderate pain (often aching) in the lower abdomen, which may be worse on one side. Other symptoms include irregular vaginal bleeding and a vaginal discharge, sometimes with a bad odor. As the infection spreads, pain in the lower abdomen becomes increasingly severe and may be accompanied by a low-grade fever (usually below 102° F [38.9° C]) and nausea or vomiting. Later, the fever may become higher, and the discharge often becomes puslike and yellow-green. Women may have pain during sexual intercourse or urination. The infection may be severe but cause mild or no symptoms. Symptoms due to gonorrhea tend to be more severe than those of a chlamydial infection, which may not cause a discharge or any other noticeable symptoms.

Sometimes infected fallopian tubes become blocked. Blocked tubes may swell because fluid is trapped. Women may feel pressure or have chronic pain in the lower abdomen.

The infection can spread to surrounding structures, including the membrane that lines the abdominal cavity and covers the abdominal organs (causing peritonitis). Peritonitis can cause sudden or gradual severe pain in the entire abdomen.

If infection of the fallopian tubes is due to gonorrhea or a chlamydial infection, it may spread to the tissues around the liver. Such an infection may cause pain in the upper right side of the abdomen. The pain resembles that of a gallbladder disorder or stones. This complication is called the Fitz-Hugh-Curtis syndrome.

An abscess forms in the fallopian tubes or ovaries of about 15% of women who have infected fallopian tubes, particularly if they have had the infection a long time. An abscess sometimes ruptures, and pus spills into the pelvic cavity (causing peritonitis). A rupture causes severe pain in the lower abdomen, quickly followed by nausea, vomiting, and very low blood pressure (shock). The infection may spread to the bloodstream (a condition called sepsis) and can be fatal.

Pelvic inflammatory disease often produces a puslike fluid, which can result in the formation of abnormal bands of scar tissue (adhesions) in the reproductive organs or between organs in the abdomen. Infertility and chronic pelvic pain may result. The longer and more severe the inflammation and the more often it recurs, the higher the risk of infertility and other complications. The risk increases each time a woman develops the infection.

Women who have had pelvic inflammatory disease are 6 to 10 times more likely to have a tubal pregnancy, in which the fetus grows in a fallopian tube rather than in the uterus. This type of pregnancy threatens the life of the woman, and the fetus cannot survive.

Diagnosis

Doctors suspect the disease if women have pain in the lower abdomen or if they have an unexplained discharge from the vagina, particularly if they are of childbearing age. A physical examination, including a pelvic examination, is done. Pain felt in the pelvic area during the pelvic examination supports the diagnosis.

A sample of fluid (swab) is usually taken from the cervix and tested to determine whether the woman has gonorrhea or a chlamydial infection. A pregnancy test is done to see whether the woman may have a tubal pregnancy, which could be the cause of the symptoms. Other symptoms and laboratory test results help confirm the diagnosis.

Ultrasonography of the pelvis is done if pain prevents an adequate physical examination or if more information is needed. It can detect abscesses in the fallopian tubes or ovaries and a tubal pregnancy. If the diagnosis is still uncertain or if the woman does not respond to treatment, the doctor may insert a viewing tube (laparoscope) through a small incision near the navel to view the inside of the abdomen and to obtain a sample of fluids for testing.

Prevention

Prevention of pelvic inflammatory disease is essential to the health and fertility of a woman. The only foolproof way to prevent the infection is abstaining from sex. However, if a woman has sexual intercourse with only one partner, the risk of pelvic inflammatory disease is very low, as long as neither person is infected with the bacteria that cause sexually transmitted diseases.

Barrier methods of birth control (such as condoms) and spermicides (such as vaginal foams) used with a barrier method can help prevent pelvic inflammatory disease.

Treatment

As soon as possible, antibiotics for gonorrhea and chlamydial infection are usually given by mouth or by injection into a muscle. If needed, the antibiotics are changed after test results are available.

Most women are treated at home. However, hospitalization is usually necessary in the following situations:

  • The infection does not lessen within 48 hours.

  • The woman has severe symptoms or a high fever.

  • The woman may be pregnant.

  • An abscess is suspected.

  • The woman is vomiting and thus cannot take antibiotics by mouth at home.

  • Doctors cannot confirm the diagnosis of pelvic inflammatory disease and cannot rule out disorders that require surgery (such as appendicitis) as possible causes.

In the hospital, antibiotics are given intravenously.

Abscesses that persist despite treatment with antibiotics may be drained. Often, a needle can be used. It is inserted through a small incision in the skin, and an imaging test, such as ultrasonography or computed tomography (CT), is used to guide the needle into the abscess. A ruptured abscess requires emergency surgery.

Women should refrain from sexual intercourse until antibiotic therapy is completed and a doctor confirms that the infection is completely eliminated, even if symptoms disappear. All recent sex partners should be tested for gonorrhea and chlamydial infection and treated. If pelvic inflammatory disease is diagnosed and treated promptly, a full recovery is more likely.

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