J Am Board Fam Pract: first published as 10.3122/jabfm.7.2.110 on 1 March 1994. Downloaded from 1 Pelvic Inflammatory Disease: Diagnosis i And Management Martin Quan, MD Bacllground: Acute pelvic inflammatory disease (PID) is a major gynecologic health problem in the United States, aftlicting more than 1 million women each year and generating annual direct and indirect costs estimated at $4.2 billion. Family physicians aut play an important role in the prevendon, as well as diagnosis and treatment, of PID. Methods: A MEDLINE search for articles published from 1985 to the present was made using the key words "pelvic inflammatory disease," "endometritis," "salpingids," ''mho-ovarian abscess," "adnexids," "pelvic abscess," "parametrids," and "oophorids." The bibliographies of these articles and the author's personal files were also sources of information. Results and Conclusions: A number of risk factors have been linked to PID, including young age, age at first intercourse, muldple sex partners, the presence of bacterial vaginosis, vaginal douching, the use of an intrauterine contracepdve device, and a history of a sexually transmitted disease. The diagnosis of PID represents a major clinical challenge that requires a careful history and physical examination coupled with selective and knowledgeable use of the diagnostic tests and procedures currently available. Broad-spectrum antibiodcs, which represent the cornerstone of therapy, must adequately cover the polymicrobial spectrum of pathogens implicated in this infecdon, which includes Neisseria gonorrhoeae, Chlamydia traehomatis, and specific cervicovaginal anaerobic and aerobic bacteria. The numerous sequelae associated with PID, which include inferti1ity, ectopic pregnancy, and chronic pelvic pain syndromes, underscore the need for effective measures for preventing pelvic inflammatory disease. (J Am Board Fam Pract 1994; 7:110-23.) Acute pelvic inflammatory disease (PID) is an "pelvic inflammatory disease," "endometritis," ascending infection of the female genital tract "salpingitis," "tubo-ovarian abscess," "adnexitis," involving the uterus, fallopian tubes, and adjacent "pelvic abscess," "parametritis," and "oophoritis." http://www.jabfm.org/ pelvic structures. It is the most frequent serious The bibliographies of these articles and the author's infection encountered by United States womenl personal files were also sources of information. and is responsible for more than 250,000 hospital admissions and 2.5 million outpatient visits each Incidence year. Direct and indirect costs of PID were esti­ Acute PID is not a reportable disease, and thus mated at greate.r than $4.2 billion in 1990.2 precise incidence rates are unavailable. The inci­ In light of the medical and socioeconomic conse­ dence appears to be increasing, however, as evi­ on 23 September 2021 by guest. Protected copyright. quences associated with this disorder, it is impera­ denced by estimates of 850,000 cases per year3 in tive that the primary care physician be proficient in the mid-1970s rising to more than 1.4 million its recognition and treatment. This report reviews cases annually by the late-1980s.2 From a survey the clinical aspects of acute PID with a special focus conducted in 1988, Aral, et a1.4 found that nearly on its epidemiology, diagnosis, and management. 11 percent of United States women of reproduc­ tive age report having had PID in the past. Methods A MEDLINE search for articles published from Epidemiology 1985 to the present was made using the key words A number of epidemiologic risk factors are asso­ ciated with PID. Awareness of these factors is of Submitted, revised, 12 November 1993. value not only in assessing a patient's risk for From the Division of Family Medicine, School of Medicine, having PID but also when counseling female pa­ University of California, Los Angeles. Address reprint requests to Martin Quan, MD, UCLA Family Health Center, 220 UCLA tients regarding contraceptive methods and sex­ Medical Plaza, Room #220, Los Angeles, CA 90024-1683. ual practices. 110 JABFP March-April 1994 Vol. 7 No.2 J Am Board Fam Pract: first published as 10.3122/jabfm.7.2.110 on 1 March 1994. Downloaded from Age contraceptives were capable of inhibiting the Young women are at greatest risk for acute PIO, spread of inflammation into the upper genital tract and nearly 70 percent of cases occur in women in patients with chlamydial infections of the cervix. younger than 25 years. Scandinavian studies have determined the risk of PIO developing in sexually Vaginal Douching active adolescent girls to be 1 in 8 compared with In a multivariate analysis that controlled for a 1 in 80 in women older than 24 years of age.s number of potentially confounding variables (in­ cluding age, age at first intercourse, history of Age at First Intercourse Chlamydia trachomatis or Neisseria gonorrhoeae in­ A sexual debut before the age of 16 years was fection or PIO, current birth control method, and reported by Lidegaard and Helm6 to be associated presence of bacterial vaginosis), WoIner-Hanssen with a twofold increased risk of PIO compared and associates13 reported that women who with women whose age at first intercourse was 18 douched three or more times a month were 3.4- years or older. Similarly, Aral, et al.4 found that fold more likely to have acute PIO than women white women who were sexually active before the who douched less than once a month. This find­ age of 15 years were three times more likely to ing was corroborated by Scholes, et al. 14 in a have been treated for PIO than those who initi­ case-control study, which found that women who ated intercourse after 19 years of age. douched once or more a week had a 3. 9-fold increase in risk. Possible mechanisms for this in­ Number ofSex Partners creased risk include flushing of cervicovaginal The risk of acute PIO is increased two- to three­ bacteria into the uterus by the act of douching, as fold for those women who have multiple sex well as a douching-induced alteration of the vagi­ partners.4,7 nal environment to one less protective against vaginal pathogens. 13,14 History ofPID Four to 23 percent of patients who have had one Bacterial Vaglnosls episode of PIO have a subsequent episode.8 A positive Gram stain for bacterial vaginosis was found by Eschenbach, et a1. 1S to be significantly History ofa Sexually transmitted DIsease associated with the clinical diagnosis of acute A self-reported history of gonococcal, chlamydial, PIO. Corroboration of this finding was provided http://www.jabfm.org/ or herpesvirus infection was reported by Aral and by Paavonen, et al. 16 who reported a strong asso­ associates4 to increase a woman's likelihood of ciation between bacterial vaginosis and patients PIO by 2.5-fold. with histopathologic evidence ofPIO. Method ofContraception Other It is well established that the use of contraceptives Nonwhite groups are generally regarded as being influences the risk of development of PIO. The at increased risk for PIO, as are women of a low on 23 September 2021 by guest. Protected copyright. presence of an intrauterine contraceptive device socioeconomic class. An increased risk has also (IUD) is associated with a 1.5- to 2.6-fold in­ been observed in women never married, divorced, creased risk of developing acute PIO.1,9 Barrier or separated. 17,18 Marchbanks, et al. 19 recently re­ methods of contraception afford protection ported a twofold increased risk of PIO among against PIO, and the Women's Health Study current and former cigarette smokers. found a 40 percent reduction of risk in users of diaphragms or condoms.9 The use of combined Microbiology oral contraceptives has generally been shown to Studies relying on advanced microbiological have a protective effect, reducing the risk of PIO techniques and upper genital tract cultures have by up to 50 to 80 percent.9,10 Although concerns clearly established the polymicrobial causation of have been expressed regarding the possible en­ acute PIO.16,17,20-23 Moreover, these studies have hancement of Chlamydia trachomatis infections also demonstrated the lack of concordance be­ among oral contraceptive users,l1 a study by tween findings on cervical cultures and findings Wolner-Hanssen, et al. 12 suggested that oral on the microbiologic investigation of upper geni- Pelvic Inflammatory Disease 111 J Am Board Fam Pract: first published as 10.3122/jabfm.7.2.110 on 1 March 1994. Downloaded from tal tract infections. Organisms most frequently species, Bacteroides bivius, Bacteroides disiens, and 1 implicated in PID, individually as well as some­ Bacteroides fragilis. Facultative aerobes are iso­ times in combination, include Neisseria gonorrhoeae, lated less frequently than anaerobes and include Chlamydia trachoma tis, endogenous cervicovaginal gram-negative bacilli (including Escherichia colt)' bacteria, and the genital mycoplasmas. group B streptococcus, Gardnerella vaginalis, and Haemophilus injluenzae. 20,21,23,25 Neisseria gonorrboeae I N gonorrhoeae is a strictly aerobic, gram-negative Genital MycoplllSmllS diplococcus that has long been recognized as an Mycoplasma hominis and Ureapiasma urealyticum important pathogen in acute PID. Although the are the two genital mycoplasmas linked to PID. number of cases reported to the Centers for Dis­ Although commonly recovered from the lower ease Control (CDC) in 1991 was 700,000, an genital tract of patients with PID, they have been additional one to two cases are thought to occur infrequently isolated from the upper genital for every reported case. 24 Ten to 17 percent of tract. 17,23 \Vhether they represent true pathogens women with untreated gonococcal infections of or are simply commensal or~isms (whose pres­ the cervix develop PID, with 66 to 77 percent of ence is simply a marker of the sexual activity of the these women becoming symptomatic during patient) remains an area of controversy that awaits or within 7 days of the onset of menses.25 further elucidation.