OVERVIEW

In an era where sexually transmitted infections are prevalent among the youth, there are several complications that may arise which can compromise the fertility of a woman.

The female reproductive system is prone to a range of microbes due to its proximity to the anus and the prevalence of inappropriate sexual practices. The most common disease condition which is the main cause of infertility in developing countries is Pelvic Inflammatory Disease (PID). What then is PID?

DEFINITION

Pelvic inflammatory disease is an infectious and inflammatory disorder of the upper female genital tract (the cervix, uterus, fallopian tubes, and ovaries) above the internal os of the cervix.

It usually involves the lining of the uterus (endometritis), the fallopian tubes (salpingitis), the cervix (cervicitis), the ovaries (oophoritis) and the peritoneum (peritonitis). It is commonly an ascending lower urinary tract infection (UTI) and less commonly from gynaecological procedures and intra-abdominal origin.

ETIOLOGY

Pelvic inflammatory disease is usually a polymicrobial infection (an infection implicated by a wide range of different organisms).

PID can also arise from a monoclonal infection (infection caused by a single species of organism) with gonorrhoea and chlamydia being the most common organisms. The bacteria could be from the vagina or transmitted during sexual intercourse with a partner having a sexually transmitted infection.

The most common sexually transmitted bacteria are:

• Neisseria gonorrhoeae (causes gonorrhoea)
• Chlamydia trachomatis (causes chlamydial infection)
• Mycoplasma genitalium
• Gardnerella vaginalis
• Mycoplasma hominis
• Trichomonas vaginalis
• Escherichia coli
• Haemophilus influenzae
• Herpes simplex virus 2
• Cytomegalovirus
• Enterococcus
• Anaerobes

It rarely affects girls before their first menstrual period (menarche) or women during pregnancy or after menopause. PID is termed a menstruating disease because it is commonly diagnosed in menstruating age women.

The following increases the risk of PID in women:

• Sexually active and younger than 35 years.
• Sexual intercourse with a partner who does not use a condom.
• Having many or new sexual partners.
• Having a sexually transmitted disease or bacterial vaginosis.
• A previous history of pelvic inflammatory disease.
• Low socioeconomic status.
• Menstruation woman.
• Illegal abortion.

EPIDEMIOLOGY

According to the Center for Disease Control and Prevention, it estimated that more than 1 million women experience an episode of PID every year. The disease leads to approximately 125,000 – 150,000 hospitalizations.

Currently, there is no specific international data available for PID incidence. However, the World Health Organization in 2005, estimated that approximately 448 million new cases of curable STIs occur annually in individuals aged 15-49 years.

Women in developing countries, especially sub-Saharan Africa and Southeast Asia, experience an increased rate of complications and sequelae from PID.

PATHOPHYSIOLOGY

The disease normally occurs in two stages. The first stage involves the acquisition of a vaginal or cervical infection. These infections are often sexually transmitted and may occur without symptoms. The second stage involves the direct ascent of microbes from the vagina or cervix to the upper genital tract, leading to inflammation and infection of these structures.

The mechanism of ascension of the microbes is still unknown. However, studies suggest the functional barrier provided by the cervical mucus is decreased in efficacy due to the vaginal inflammation and hormonal changes which occur during ovulation and menstruation.

During menstruation. the cervical os is opened and that creates a route for vaginal bacteria to ascend into the upper genital tract.

Intercourse contributes to the ascent of the infection through rhythmic uterine contractions during orgasm. This rhythmic contractions of the uterus open the cervix and bacteria is then carried along with the sperm into the upper genital tract.

SIGNS AND SYMPTOMS

Symptoms of pelvic inflammatory disease normally occur toward the end of the menstrual period or during a few days after. The early onset of PID is usually asymptomatic but below are the symptoms which appear as the infection worsens:

• Pain in the lower abdomen and pelvis.
• Irregular vaginal bleeding (normally between periods).
• Painful sexual intercourse (dyspareunia).
• Heavy vaginal discharge with an unpleasant odour (normally pus-like and yellow-green).
• Pain when urinating (dysuria).
• Low-grade fever (38.9).

The late-onset symptoms of PID normally include the following:

• Severe pain in the lower abdomen, normally worse at one side.
• Signs of shock such as fainting.
• Nausea and vomiting.
• Fever greater than 38.9.
• Epigastric pain.

DIAGNOSIS

A health practitioner can make a diagnosis of PID in a woman through the following:

• A pelvic examination to check for signs of tenderness in the cervix, uterus or surrounding organs (ovaries and fallopian tubes).
• Inspection of fluid present in the vagina or cervix which appears abnormal.
• Inquires about your symptoms and your medical and sexual history.
• Cervical or vaginal swab samples to test for microbes.
• Pregnancy test to confirm or rule out a tubal pregnancy.
• Ultrasound scan of the pelvis to detect the presence of abscesses in the fallopian tubes, ovaries or tubal pregnancy.

TREATMENT

In treating pelvic inflammatory disease, antibiotic therapy is given for the first 2 weeks. Normally symptoms improve within 3 days during the 2 weeks course of antibiotics.

Drainage of an abscess is indicated when there is a presence of an abscess in the fallopian tubes or ovaries. Most commonly, antibiotics are taken orally but can be administered via intravenous injection if the patient’s symptoms do not improve on oral antibiotics.

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

• Infection does not resolve within 48 hours of antibiotic therapy.
• Presence of severe symptoms or a high fever.
• A pregnant woman.
• Suspected abscess formation.
• Presence of vomiting.
• Temperature above 38.
• A confirmed diagnosis of PID cannot be made and disorders that require surgery (such as appendicitis) cannot be ruled out.

In the hospital setting, antibiotics are given intravenously. Abscesses that persist despite treatment with antibiotics are drained. The drainage is guided by an ultrasound scan or a CT (computed tomography) scan.

Sexual intercourse is prohibited until antibiotic therapy is completed or the physician confirms that infection is completely eliminated.

It is important to have recent sexual partners tested and treated for sexually transmitted infections.

PREVENTION

Prevention of PID is pre-requisite in maintaining the health and fertility of a woman. Abstaining from sex is an assured way of avoiding sexually transmitted pelvic inflammatory disease.

However, if a person is sexually active, the use of condoms during sexual intercourse can help prevent pelvic inflammatory disease.

In order to be effective, condoms must be worn correctly each time a person has sexual intercourse.

COMPLICATIONS

Pelvic inflammatory disease can cause a variety of problems including the following:

• Blocked fallopian tubes.
• Peritonitis (a serious abdominal infection).
• Fitz-Hugh-Curtis syndrome (a serious infection of tissues around the liver)
• Turbo-ovarian abscess.
• Adhesions (bands of scar tissue).
• Ectopic pregnancy (tubal pregnancy).
• Infertility.

KEYPOINTS

• The most common preventable cause of infertility in women is pelvic inflammatory disease.
• Pelvic inflammatory disease is sexually transmitted.
• PID is not common among young adolescent girls having their first menarche and postmenopausal women.
• If you have a sexually transmitted disease, you are at risk of PID.
• Having sexual intercourse without a condom increases your risk of PID.