Sexually transmitted infections

Pelvic inflammatory disease (PID)

What is pelvic inflammatory disease?

Although it refers to an infection of a woman's upper reproductive organs (including the uterus, fallopian tubes, cervix and ovaries), pelvic inflammatory disease (or PID) can also occur as a lower abdominal infection. Pelvic inflammatory disease usually begins at the vagina and cervix and spreads from there into the uterus and fallopian tubes. Pelvic inflammatory disease can also occur outside of the female reproductive organs, in the tissues surrounding these organs.

As its name suggests, pelvic inflammatory disease causes inflammation. Inflamed tissues become swollen, hot, red and painful. The infection and inflammation can damage tissues, leaving permanent scars. It is the scarring that leads to the long-term complications of PID—complications such as chronic pelvic pain, ectopic pregnancy, and infertility.

What causes PID?

Because PID is caused by bacteria—some of which are also known to cause other sexually transmitted infections including chlamydia and gonorrhea—your risk of developing PID is increased if you are infected with another sexually transmitted infection and don't seek treatment.

Although some types of PID are caused by the same bacteria that cause other sexually transmitted infections, a diagnosis of PID doesn't necessarily mean you have another STI. The bacteria responsible for your PID may have spread from your rectum or from a pad or tampon in place too long. Sexually transmitted infections, however, remain the leading cause of PID.

Who gets PID?

Although PID can affect all women, you are at higher risk if:

• you're younger (18 to 24);
• you've had unprotected sex with an infected partner—usually a person infected with either chlamydia or gonorrhea
• you've had PID before (some studies suggest that up to 25 percent of PID cases recur)
• you've undergone pelvic surgery
• you developed complications during childbirth
• you have a new sex partner(s)
• you've had more than two sex partners in the past six months

Using an IUD (intrauterine device) has been shown to increase the risk of developing pelvic inflammatory disease (particularly if you have an infection), while the use of oral contraceptives (the Pill) has been shown to decrease the risk.

What are the signs and symptoms of PID?

Canadian statistics suggest that one in ten women will experience at least one episode of PID. Women affected by pelvic inflammatory disease often show no symptoms. Those who do experience symptoms typically complain of pain or pressure in the lower stomach belly, which they describe as constant and dull. Some women liken this pain to the pain of a bladder infection, appendicitis, or menstrual cramps. This pain may increase during bowel movements, sexual activity, or while urinating. Occasionally, the pain caused by PID may be so acute that it requires hospitalization.

Other symptoms may include:

• fever
• abnormal vaginal bleeding or discharge, sometime accompanied by pain
• chills
• nausea
• lower back pain
• vomiting

These symptoms often start at the end of a woman's menstrual period.

How is PID diagnosed?

As mentioned, a woman may have pelvic inflammatory disease and not know it unless long-term consequences develop (see below). If you have symptoms that may be linked to PID, you must be examined by a doctor or nurse. He or she will check your abdomen for tenderness and will also conduct a pelvic exam to check for pelvic tenderness. Laboratory tests such as a urine test, cervical swab and vaginal swab will be done to determine which specific bacteria caused the infection. In some cases, a blood test may be useful to identify PID: measuring a your white blood cell count can help determine whether you have an infection.

How is PID treated?

Because early treatment is of the utmost important and because delay in treatment can cause PID to become much more serious, doctors usually start treatment right away.

Mild to moderate pelvic inflammatory disease is usually treated through the prescription of antibiotics taken by mouth. In some cases, however, PID can be severe enough that patients need to be admitted to hospital in order to receive antibiotics intravenously. Early treatment reduces the risk of serious, even life-threatening complications.

What are the complications associated with PID?

Complications of PID may include:

• tubo-ovarian abscess (a swollen are full of pus inside an ovary, the fallopian tubes or both) which can break and spread the infection throughout the abdomen, resulting in:
  • peritonitis, a condition that requires emergency surgery
• scarring of the pelvic organs including the ovaries, fallopian tubes, bowel and bladder which can lead to:
  • adhesions, a condition in which scar tissue joins two organs, causing pain when a woman moves
  • long-lasting, chronic, or permanent pelvic pain
  • infertility
  • Increased risk of a pregnancy in which the fertilized egg attaches to either the fallopian tube or to an area outside the uterus

If prescribed antibiotics to treat pelvic inflammatory disease and to prevent future PID, be sure to take all medication as directed and to rest in bed for one to three days or until the pain is lessened. Return to your doctor or clinic within two to four days, again a week to ten days later, and then again for a follow-up visit between six to eight weeks after completing treatment to ensure the infection is completely cleared. Avoid sexual activity until you have finished taking all of your medication.

Does PID require surgery?

Scar tissue can be removed surgically if it has joined two organs together or if it is causing pain or other complications. During surgery, the doctor will cut the adhesion, separating organs that are joined together. Depending on the size and location of the scar tissue, two surgical techniques may be used.

Laparoscopy uses a tiny camera mounted on a telescope. The laparoscope is inserted through a tiny incision in a patient's belly button and is used to guide the surgery. Small amounts of scar tissue can be removed through the telescope. Done as a day procedure, laparoscopic surgery is performed under general anesthetic. Women undergoing laparoscopic surgery can expect three to five days of abdominal pain.

The second option, a laparotomy, is open surgery usually reserved for extensive adhesions or scar tissue. The procedure—major surgery requiring general anesthetic—is performed through an incision made in the abdominal wall. Women undergoing laparotomy can expect a hospital stay of two to four days and a recovery time of four to six weeks.