OCCURRENCE OF PELVIC INFLAMMATORY DISEASE
AND ASSOCIATED FACTORS AMONG
UNDERGRADUATES ATTENDING IRRUA SPECIALIST
TEACHING HOSPITAL, IRRUA
A DISSERTATION SUBMITTED TO THE NATIONAL
POSTGRADUATE MEDICAL COLLEGE OF NIGERIA IN
PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE
AWARD OF THE FELLOWSHIP OF THE COLLEGE IN
FAMILY MEDICINE
BY
OSENI, TIJANI IDRIS AHMAD
IRRUA SPECIALIST TEACHING HOSPITAL,
IRRUA, EDO STATE
MAY, 2016 DECLARATION
It is hereby declared that this research was done by me in the course of my training in Family
Medicine. This dissertation has not been presented to any other body for an award nor submitted elsewhere for publication. The discussions are original except where acknowledged to the contrary.
………………………………………………………..
OSENI, TIJANI IDRIS AHMAD
2
CERTIFICATION
This is to certify that this research titled; Occurrence of Pelvic Inflammatory Disease and
Associated Factors among Undergraduates Attending Irrua Specialist Teaching
Hospital, Irrua was done by Dr OSENI, Tijani Idris Ahmad during the period of his part
II training under our supervision. We also supervised the writing of the dissertation.
SUPERVISORS
Dr M. A. ODEWALE (FMCGP),
Head, Department of Family Medicine,
Irrua Specialist Teaching Hospital, Irrua.
Signature………………………………….
Date………………………………………..
Dr P. A. Imomoh (FWACP),
Consultant Family Physician,
Irrua Specialist Teaching Hospital, Irrua.
Signature………………………………….
Date………………………………………..
3
DEDICATION
This work is dedicated to Allah Almighty and to the memory of my father, Mallam Idris
Oboh Oseni for giving me a good start in life.
4
ACKNOWLEDGEMENTS
I express my sincere gratitude to my supervisor and head of unit, Dr M. A. Odewale whose support has been most invaluable to the success of this work. From the writing of the proposal to the completion of the work, he assisted me in every way imaginable, painstakingly reading through my work over and over and guiding me through the work until its completion. Words are not enough to thank you.
My co-supervisor, Dr P. A. Imomoh was no less remarkable in his support for me. He has indeed been a wonderful mentor, friend, adviser and benefactor. He has left an indelible impression in my mind and will guide me in reciprocating to others in similar manner in future.
I also thank Dr C. C. Affusim the deputy CMAC for his brotherly support and encouragement through the course of my training. Your support has been most invaluable and is highly appreciated.
My acknowledgement also goes to my other trainers among who are Dr M. O. Momoh and
DR N. F. Fuh for their guidance, support and patience in the course of my training. They painstakingly read through my work and their suggestions were most invaluable.
I also thank my colleagues in the Department of Family Medicine, Irrua Specialist Teaching
Hospital, particularly Dr Lawani Osagie and Dr Ochei of Community Health Department for their tremendous input into this work. I appreciate you all.
Lastly, I specially thank my wives and children and other members of my family for being there for me all through my work; Words cannot express my gratitude to them. To Nurah and
Maryam who read through my work and made useful suggestions and corrections, I say may
Allah reward you most abundantly.
5
TABLE OF CONTENTS
Content Page
TITLE PAGE i
DECLARATION ii
CERTIFICATION iii
DEDICATION iv
ACKNOWLEDGEMENTS v
TABLE OF CONTENTS vi
LIST OF ABBREVIATIONS x
LIST OF FIGURES xi
LIST OF TABLES xii
SUMMARY 1
CHAPTER 1: INTRODUCTION, AIMS AND OBJECTIVES 3
CHAPTER TWO: LITERATURE REVIEW 12
CHAPTER THREE: METHODOLOGY 41
CHAPTER FOUR: RESULTS 49
CHAPTER FIVE: DISCUSSIONS, CONCLUSION AND RECOMMENDATIONS 72
REFERENCES 83
APPENDICES 93
6
LIST OF ABBREVIATIONS
Abbreviations Meaning
A & E Accident and Emergency
AIDS Acquired Immune Deficiency Syndrome
CDC Centre for Disease Control and Prevention
CET Cervical Excitation Tenderness
CMV Cytomegalovirus
CRP C-Reactive Protein
CT Computerised Tomography
ESR Erythrocyte Sedimentation Rate
GOPD General Out-Patient Department
HIV Human Immunodeficiency Virus
ISTH Irrua Specialist Teaching Hospital
IUCD Intra Uterine Contraceptive Device
MRI Magnetic Resonance Imaging
NHIS National Health Insurance Scheme
OND Ordinary National Diploma
PEACH PID Evaluation And Clinical Health
PID Pelvic Inflammatory Disease
SES Socio-Economic Status
STI Sexually Transmitted Infections
USA United States of America
WBC White Blood Cells
WHO World Health Organisation
7
LIST OF FIGURES
Figures Page
Fig. 1 Common sites of infection in PID 3
Fig. 2 Laparoscopic visualisation of acute PID 28
Fig. 3 Socioeconomic Status of Parents of Respondents 55
Fig. 4 Association between SES of Parents and Occurrence of PID 71
8
LIST OF TABLES
Tables Title Page
TABLE 1: Sociodemographic Characteristics of the Respondents 50
TABLE 2: Educational History of the Respondents 52
TABLE 3: Socioeconomic Characteristics of Parents of the Respondents 54
TABLE 4: Sexual History of Respondents 57
TABLE 5: Symptoms of Pelvic Inflammatory Disease among Respondents 59
TABLE 6: Clinical Examination of the Respondents 61
TABLE 7: Frequency Distribution of the Clinical Diagnoses among Respondents 62
TABLE 8: Occurrence of PID by Sociodemographic Characteristics of Respondents 64
TABLE 9: Association between Sexual History and Occurrence of PID
among Respondents 67
TABLE 10: Association between Sexual History of Respondents and
Socioeconomic Status of their parents 70
9
SUMMARY
Background: Pelvic Inflammatory Disease (PID) is a major cause of gynaecological morbidity globally. It is a spectrum of infections that arise commonly from the lower genitalia (vagina and cervix) and ascending to the upper genital tract causing endometritis, salpingitis, oophoritis, tubo-ovarian abscess and/or pelvic peritonitis. Complications from
PID include infertility, ectopic pregnancy and chronic pelvic pain. Major risk factors for PID include low socioeconomic status, early coitarche, multiple sex partners, poor or no barrier contraceptive use, young age, history of induced abortion, low parity and past history of PID or Sexually Transmitted Infections.
Objective: The aim of this study was to determine the occurrence of PID and associated factors among undergraduates attending Irrua Specialist Teaching Hospital, Irrua.
Methodology: The study was a hospital based descriptive cross-sectional study. Three hundred and sixty undergraduates attending the General Out-Patient Department (GOPD),
Accident and Emergency (A & E) and the gynaecological clinics of the hospital, irrespective of what they presented with, were consecutively selected and clinically assessed for the presence of PID using the World Health Organisation (WHO) and the Centres for Disease
Control and Prevention (CDC) criteria for clinical assessment of PID. Respondents were classified as having PID if they had lower abdominal pain in addition to one or more of the following: cervical excitation tenderness, uterine tenderness or adnexal tenderness. They were also evaluated for the presence of risk factors for PID and their socioeconomic status was determined using Oyedeji’s social class tool. A semi-structured questionnaire was used to collect data. The data was analysed using epi-info statistical software and the results presented in tables, charts, frequency distribution and percentages. Chi-Square was used to test for association between occurrence of PID and presence of risk factors as well as
10 association between socioeconomic status of parents and presence of risk factors among the study participants.
Results: Of the 360 female undergraduates studied, 229 (63.6%) had PID. Risk factors identified by the study for the occurrence of PID were multiple sex partners (p < 0.001), previous history of STI/PID (p = 0.02), non/poor condom use (p < 0.001), and history of induced abortion (p = 0.01) particularly surgical abortion via dilatation and curettage (p =
0.03). There was no association between socioeconomic status of parents and occurrence of
PID (p = 0.14), though the study found PID to be highest among students in the middle socioeconomic class (67.4%). There was however a significant association between low socioeconomic class and multiple sex partners (p = 0.02), previous history of STI/PID (p =
0.05), low condom use (p < 0.001), history of induced abortion (p < 0.001) and history of repeated abortions (p < 0.001).
Conclusion: There was a high prevalence of PID among undergraduates attending Irrua
Specialist Teaching Hospital with students with multiple sex partners, previous history of
STI/PID, low condom use, history of induced abortion and surgical termination of pregnancy at significantly higher risk of developing the disease.
Recommendations: Efforts should be made to reduce the risk factors of PID in vulnerable groups through health education, promotion of safe sex and instituting measures aimed at improving living standards such as better education for the populace.
11
CHAPTER ONE
INTRODUCTION
1.1 Background of the Study
Pelvic Inflammatory Disease (PID) is a major clinical and public health problem globally accounting for 5 – 20% of hospital admissions for gynaecological problems worldwide.1,2 It is one of the most frequent and important infections that occur among non-pregnant women of reproductive age.2 It is a spectrum of infectious and inflammatory disorders of the upper female genital tract and includes endometritis, parametritis, salpingitis, oophoritis, tubo- ovarian abscess, and/or pelvic peritonitis.1,3
Fig. 1: Common sites of infection in PID
12
It is caused by an ascending spread of microorganisms from the vagina or uterine cervix into the upper genital tract.3,4 If untreated, lower genital tract infections commonly progress to
PID.5 It is commonly associated with sexually transmitted organisms especially Neisseria gonorrhoea and Chlamydia tracchomatis6 and is in fact one of the most common and serious complications of sexually transmitted infections (STIs) in women.1,2 It has however been associated also with microorganisms that comprise the vagina flora such as anaerobes, Gardnerella vaginalis, Haemophilus influenzae, enteric Gram-negative rods, and Streptococcus agalactiae.6 In some cases of PID, cytomegalovirus (CMV), Mycoplasma hominis, Ureoplasma urealyticum, and Mycoplasma genitalium have been implicated.6
When not promptly recognised and properly treated, it could lead to complications such as infertility; for example, more than 75, 000 women are reported to be infertile every year on account of PID in the United States of America (USA) accounting for 10 – 15% of infertility in the USA.1,3 It can also lead to ectopic pregnancy, menstrual disturbances, pregnancy wastage, low birth weight babies or chronic pelvic pain.7-9 Ovarian cancer has also been associated with PID.1,3
Inherent defence mechanism exists to protect the upper female genital tract against microbial colonisation.10,11 These mechanisms include the cervical mucus which serves as a mechanical barrier against ascending infection in addition to possessing antibacterial activity that protects against bacterial ascent.10,11 Endometrial and oviductal secretions also protects the upper genitalia by washing out bacteria from the endometrium and fallopian tube respectively.10
In spite of the above inherent defensive mechanisms, pathogens still ascend to the endometrium and other structures that make up the upper genitalia causing PID.10 This may be facilitated by passive transport and through the aid of vectors such as spermatozoa and trichomoniads. Retrograde menstruation also aids the transportation of pathogens into the
13 upper genitalia while uterine instrumentation and insertion of Intrauterine Uterine
Contraceptive Device (IUCD) can inoculate the endometrium.10
Long term morbidity is associated with salpingitis much more than endometritis and cervicitis.11 This is because inflammation of the fallopian tubes due to infection will lead to epithelial degeneration and deciliation of ciliated cells along the fallopian tube mucosa in association with sub mucosal inflammatory cell infilterates.11 There is also tubal oedema and intraluminal agglutination causing dysfunctionality, obstruction which may be partial or total, ultimately leading to infertility or ectopic pregnancy.11
Various risk factors have been associated with the occurrence of PID. These risk factors include young age,12-14 early coitarche,13 multiple sex partners,12 previous history of sexually transmitted infections (STI) or previous history of PID,10 inconsistent condom use,13,15 inappropriate insertion of Intra Uterine Contraceptive Device (IUCD),16 low socioeconomic status,6,15 induced abortion7 and being in school.17
Women of reproductive age are at increased risk of PID.12 This is because most sexual activity occur during this period. The risk of developing PID is however much higher in younger women particularly those younger than 25 years compared to women in other age group.3,12,13 It is estimated that one in five cases of PID occurs in women under the age of 19, and that one in eight adolescent females will develop PID compared to one in 80 for women older than 24 years of age.3
The high prevalence of PID among adolescents and young adults is attributable to behavioural anatomical and hormonal factors. They often engage in high-risk sexual behaviour such as having multiple sex partners, frequent and unprotected sexual intercourse and low contraceptive usage, particularly barrier contraceptive methods.3 They generally have higher number of sexual partners, higher number of concurrent partners and a higher frequency of partner change than older age groups.12 They also do not have the skills and
14 confidence to negotiate safer sex.12 In addition, adolescents and young women do not commonly consider the long term effect of their risky sexual behaviours.3,14 Most undergraduates fall into this age category.
Another factor that contributes to the high risk of acquiring PID among adolescents and young adults could be the anatomy of their developing cervix. The epithelium of their immature ectocervix is mainly columnar, exposing a relatively large surface area, which facilitates the attachment of microorganisms like C. trachomatis and N. gonorrhoeae.3 With increasing age, this columnar tissue undergoes squamous cell epithelisation which then covers the normal adult ectocervix or simply regresses into the endocervical canal.3
Hormonal factors have also been implicated in the development of PID among adolescents and young adults. Oral contraceptives, frequently used by adolescents, interfere with the columnar-squamous cell epithelisation process and are thus considered to be a risk factor for
C. trachomatis infection and PID.3 Anovulatory cycles, common after menarche, may be associated with high oestrogen levels, which facilitate cervical mucus penetration by microorganisms.3 In addition, low cervical secretory immunoglobulin A levels in the female adolescent genital tract, due to low prevalence of immunogenic triggers, may also contribute to the adolescent's susceptibility to PID.3
Another risk factor associated with PID among women of reproductive age is having sexual debut at a young age. Early coitarche has been shown to increase the occurrence of
PID.13,14,15 Those who had sexual debut before the age of 15 years are more likely to develop
PID compared to those who are 15 years and older.12 The association between younger age and first sexual intercourse and increased risk of PID may reflect biological factors and sexual behaviour over a substantial period of time.12,15 Young females were more likely to have their sexual initiation with significantly older partners.15 They do so seeking financial support or desiring intimate and emotional security.15 They are therefore more likely to
15 engage in risky sexual behaviours such as poor/non condom use due to high power imbalance, as the older male partners make the sexual decisions and are more likely to have sexually transmitted infections (STIs).15 Also, early sexual intercourse is commonly associated with a higher number of lifetime sexual partners which further predisposes them to developing PID.14,16,17
Multiple sex partners predispose women to the development of PID. The higher the number of sex partners a woman has, the higher the risk of developing PID. A higher number of concurrent partner as well as frequent partner change also significantly increase risk of PID.12
Adolescents and young adults, who constitute majority of undergraduates, commonly have multiple sex partners which predispose them to developing PID.3,12,18 They also have a higher number of concurrent partners as well as a higher frequency of partner change.12 Also women whose partners are not faithful to them are also at increased risk of developing PID, especially if their partners engage in unprotected sex with other women.12 It is important therefore that both partners must be faithful to each other as history of multiple sex partners by either the woman or her partner increases her risk of developing PID.3 Adolescents and young women from low socioeconomic backgrounds are more likely to have multiple sex partners as they succumb to unprotected sex through coercion, force, violence and transactional reasons.12
Similarly, those women with previous history of PID/STI are at greater risk of developing
PID.10,13 This may be due to poor treatment leading to chronicity of the infection. It could also be due to reinfection after treatment.2 Inaccurate information regarding PID and STIs among members of the public are also known risk factors for PID.12,19 Living in an area with a high prevalence of sexually transmitted infection (STI) has been shown to increase the risk of developing PID.5,10,12 This is because persons with PID and other STIs would easily transmit the infection to others. Thus, in a higher institution where prevalence of PID is high,
16 the rate of spread of the infection will be high. Consequently, uninfected ladies who engage in risky sexual behaviours will easily contact the disease in such an environment.
Inconsistent use of barrier contraceptive is also a major risk for the development of PID.12,13
Consistent condom use has been shown to significantly reduce the risk of developing PID as well as prevent unwanted pregnancy.15
Low socioeconomic status is a significant risk factor for PID.19 This is because students from poor family background are more likely to engage in risky sexual behaviour that predisposes them to PID. They do this in order to get money to augment whatever they get from their parents.18 On the other hand, students from high socioeconomic backgrounds whose financial needs are met by their parents may not engage in such activities.18 The higher incidence of
PID in women of lower socioeconomic status may be due in part to a woman's lack of education and awareness of health and disease and her accessibility to medical care.20,21 They may also engage more in sex with older men (so called “sugar daddies”) for gifts, pocket money and school fees6 as majority of such girls are often responsible for their fees and even send money to their poor parents from such proceeds. These men who make the decisions that affect sexual risk almost universally do not like to use barrier contraceptives, thus sex in this vulnerable group is most likely to be unprotected.6 Lack of access to good health care facilities for patients with STIs from low socioeconomic backgrounds may also facilitate progression to PID in this group. They would rather patronise patent medicine dealers and quacks. They are also at higher risks of unwanted pregnancies from unprotected sex, making them engage in criminal abortion in the hands of quacks and under unsanitary conditions further increasing their susceptibility to PID.18
The diagnosis of PID is primarily based on a history of abdominal or pelvic pain or cramping of varying intensity, new or abnormal vaginal discharge, fever or chills (which may be high grade), dyspareunia, heavy or prolonged menses or coital bleeding and clinical findings of
17 lower genital tract inflammation associated with pelvic organ tenderness (cervical motion tenderness, uterine tenderness and adnexal tenderness).9,19 Diagnosis of PID based on above clinical findings have been shown to have a positive predictive value of 65 – 90%.9,21 The diagnostic criteria for PID according to the World Health Organisation (WHO) and the
Centres for Disease Control and Prevention (CDC) include the presence of one or more of the following major criteria: cervical motion tenderness, uterine tenderness or adnexal tenderness with no other apparent cause.6,9,22
The following minor criteria are supportive but not required for the diagnosis: Fever greater than or equal to 38.3oC, abnormal discharge per cervix or vagina, WBCs on Gram stain or
Saline of cervical swab, Gonorrhoea or Chlamydia testing positive, increased Erythrocyte
Sedimentation Rate or C – reactive protein, and PID findings on diagnostic study.9
Most specific findings, though not required and rarely indicated unless refractory to management or unclear diagnosis: Laparoscopy findings consistent with PID which is the
Gold Standard for diagnosis, Endometrial Biopsy with histology suggestive of Endometritis,
Imaging such as Transvaginal Ultrasound or Magnetic Resonance Imaging with classic findings – Thickened, fluid filled tubes, Free pelvic fluid may be present, Tubo-ovarian complex, Tubal hyperaemia on Doppler Ultrasound.9 The differential diagnoses include ectopic pregnancy, appendicitis, cervicitis, urinary tract infection, and adnexal tumours.4
1.2 Statement of the Problem
Pelvic Inflammatory Disease is said to be high among undergraduates.5,23 This could be due to the fact that undergraduates are mostly adolescents and young adults and tend to engage in risky sexual behaviour such as having sex for pecuniary gains particularly with older partners who may be harbouring sexually transmitted infections,18,23 have multiple sex partners, higher number of concurrent partners, higher frequency of partner change and do not have the skills and confidence to negotiate safer sex.12 They are also less likely to use barrier contraceptives,
18 engage in unsafe abortions, and less likely to seek standard medical intervention.12,22 All these characteristics of the female undergraduate predispose them to the development of PID with its attendant complications later in life.
From hospital records, a good number of the patients who present to Irrua Specialist
Teaching Hospital with features of PID were young undergraduates. This study therefore sought to determine the occurrence of pelvic inflammatory disease as well as determine the associated factors among undergraduates attending Irrua Specialist Teaching Hospital
(ISTH), Irrua, Edo State.
1.3 Aim and Objectives
1.3.1 Aim: The aim of this study is to determine the occurrence of pelvic inflammatory disease and associated factors among undergraduates attending Irrua Specialist Teaching
Hospital in order to institute preventive measures through health education that might lead to behavioural change among this vulnerable group to reduce the scourge of the disease and its attendant sequelae.
1.3.2 Specific Objectives: The specific objectives of the study were
1. To determine the prevalence of pelvic inflammatory disease among undergraduates
attending Irrua Specialist Teaching Hospital.
2. To identify risk factors for the development of pelvic inflammatory disease among
undergraduates attending ISTH from clinical assessment.
3. To ascertain if there is association between the identified risk factors and the
occurrence of pelvic inflammatory disease in the study population.
1.4 Justification of the Study
Edo State has one of the highest concentrations of young people in Nigeria with young adults and adolescents making up about 32.9% of its total population.24 There are high rates of unplanned pregnancies and unsafe abortions, sex trafficking and prostitution, STI/HIV/AIDS
19 and poor health seeking behaviour of youths in the state. There are also high levels of youth unemployment and breakdown of parent-child communications among young adults and adolescents in the state which is one of the highest in Nigeria.24
Pelvic Inflammatory Disease is a significant cause of morbidity which can lead to adverse events like infertility, ectopic pregnancy and chronic pelvic pain later in life. The occurrence of this disease and its associated factors among undergraduates has not been studied in this area (Edo Central). This has highlighted the need for reference data to ascertain the role of these risk factors in the occurrence of PID among undergraduates in the study area.
20
CHAPTER TWO
LITERATURE REVIEW
2.1 Definition
Pelvic Inflammatory Disease (PID) was defined by Sweet25 as a disease which manifests with a spectrum of upper genital tract infections that include endometritis, salpingitis, tubo-ovarian abscess and/or pelvic peritonitis and is associated with lower genital tract inflammation. This definition is in tandem with that of the Centre for Disease Control and Prevention (CDC)6 and that of Evans, Jaleel and Kinsella26 which defined PID as ascending infection of the upper genital tract from the vagina and cervix and includes endometritis, salpingitis, tubo- ovarian abscess and/or pelvic peritonitis.
Li and McDermott27 defined PID as inflammation of the upper genital tract including the endometrium, fallopian tubes and/or contiguous structures that follow infection from micro- organisms that ascend from the cervix and/or vagina.
Soper11 defined PID as an infection – caused inflammatory continuum from the cervix to the peritoneal cavity, which is most importantly, associated with fallopian tube inflammation which can lead to infertility, ectopic pregnancy and chronic pelvic pain.
Pelvic inflammatory disease has also been defined as a syndrome caused by the ascending spread of microorganisms from the vagina or the uterine cervix to the upper genital tract and including any combination of endometritis, salpingitis, tubo-ovarian abscess, or pelvic peritonitis.13
Bartlett, Levison and Munday28 described PID as due to infection of the upper female genital tract resulting in a wide range of pelvic pathology, from mild endometritis to pelvic peritonitis caused by organisms that are either sexually transmitted (such as C trachomatis, N gonorrhoeae, Mycoplasma genitalium) or endogenous vaginal organisms (for example,
21
Bacteroides species) that ascend into the pelvic area from the lower genital tract through the cervix.
Another definition of PID is that of Okon et al,1 who defined PID as an infection of the upper genital tract in women that include endometritis, parametritis, salpingitis, oophoritis, tubo- ovarian abscess and peritonitis.
For the purpose of this study, PID is defined based on Shepherd’s4 definition as infection of the upper female genital tract comprising of endometritis, salpingitis, parametritis, oophoritis, tubo-ovarian abscess and/or pelvic peritonitis commonly due to sexually transmitted infections with Chlamydia trachomatis and Neisseria gonorrhoea arising from an ascending infection from the vagina and cervix (commonly) or through lymphatic or haematogenous spread.
2.2 Epidemiology of PID
Pelvic Inflammatory Disease is a common cause of gynaecological morbidity worldwide.12,28,29 Over 800,000 cases of PID are diagnosed annually in the United States of
America.11,30 In the United Kingdom, PID was found to contribute to about 2% of annual visit to general practitioners.26 A Jamaican study reported a PID prevalence of 17% among women of reproductive age with majority of them from low socioeconomic status.31 The study also found PID to be higher among those who were sexually assaulted.31 This is supported by another study also in Jamaica which found PID to be higher among sexually assaulted women from low socio economic status.32
Prevalence of PID in Nigeria is high, particularly among young adults. A study done in Port
Harcourt, Nigeria put the prevalence among undergraduates at 11%.5 Prasad et al24 in a similar study reported a prevalence of 14% among young women in India. This is small compared to the study by Olowe, Alabi and Akindele10 in Osogbo, South-Western Nigeria which reported a PID prevalence of 70% and that of Okon et al,1 in Nguru, North-Eastern
22
Nigeria which reported a prevalence of 62.8%. The disparity may be due to the difference in location, Port Harcourt being an urban centre as opposed to Nguru and Osogbo which are semi urban areas. Also variation in health-seeking behaviour and increased management of
PID outside the hospital environment particularly in urban areas could also explain the variation as all the studies were hospital based.1
Occurrence of PID is common among sexually active women3 of childbearing age,33 particularly adolescents13 and young women.13,28 In the United States of America, however,
PID is most common among adolescent girls aged 15 – 19 years.3,34 This contrast with an
English study which found PID to be most common among young women aged 20 to 24 years followed by those aged 25 to 29 years.35 Okon et al,1 in Nguru, North-Eastern Nigeria found PID to be highest among women aged 21 to 30 years. Kennedy, John and Sunny5 also reported similar findings with PID highest among students aged 20 – 30 years in their study among undergraduates in Port Harcourt. These findings are in line with the English study35 above but differs from the American studies3,34.
The cost of treating patients with PID is very high especially in resource poor settings like
Nigeria as confirmed by a study done in Lagos, Nigeria by Suleiman and Tayo.36 The study found that most of the patients with PID are in low socioeconomic status and cannot afford the high cost of treatment.
2.3 Classification of PID
2.3.1 Subclinical PID – PID can occur in women without any obvious symptom or signs classically associated with the disease. Asymptomatic PID is a major problem as the damage continues despite showing no obvious symptom or sign. Sweet25 in a study noted that subclinical PID is as common as acute PID and a major contributor to the complications of
PID as its lack of symptoms implies non-recognition or treatment causing unhindered progression. The study also found subclinical PID responsible for most cases of post infection
23 tubal factor infertility.25 The findings are similar to those of Raya et al,3 whose study found subclinical PID accounting for about 60% of all cases of PID.
According to Sweet’s study, PID is difficult to diagnose clinically as none of the socio- demographic predictors are clinically useful in identifying women with subclinical PID.25
Raya et al,3 however highlighted the symptoms of subclinical PID to include dyspareunia, irregular menstrual bleeding, urinary and gastrointestinal symptoms. The study also identified the gold standard of diagnosis as endometrial biopsy demonstrating endometritis.25 In a study by Jaiyeoba and Soper,37 laparoscopy demonstrating salpingitis was found to be diagnostic of subclinical PID.
From these studies, subclinical PID is an important cause of morbidity and complication requiring prompt diagnosis and management,3,25,37 however the present study did not consider it. Only clinical cases were considered.
2.3.2 Mild-to-moderate symptomatic PID – The study by Raya et al,3 also classified PID as mild to moderate symptomatic which, according to the study, occurred in 36% of all PID cases and presented with cramping lower abdominal or pelvic pain, cramping, intermittent or post coital vaginal bleeding, vaginal discharge, urinary symptoms, fever and uterine, adnexal and/or cervical motion tenderness.
2.3.3 Severe PID – The third category of PID in Raya et al’s3 classification was severe PID which occurred in approximately 4% of cases with patients presenting with fever, chills, purulent vaginal discharge, nausea, vomiting and elevated inflammatory markers.
According to Jaiyeoba and Soper,37 PID could be classified into mild and severe PID based on the severity of symptoms. This is similar to the classification of PID by Sweet25 into subclinical and acute, and Raya et al’s3 classification into subclinical, mild-to-moderate symptomatic and severe with subclinical equivalent to mild and acute equivalent to severe (in
Sweet’s classification) and mild-to-moderate and severe (in Raya et al’s classification). It has
24 also been classified into acute, acute on chronic, recurrent and chronic depending on the duration.
2.4 Risk factors for PID
2.4.1 Young Age: The risk of developing PID is highest among adolescents and young adults.5,12,35 This is because this period is characterised by physical and psychological transformation and behavioural experimentation such as engaging in risky sexual behaviour.34,38
Biologically, adolescents and young adults are more at risk of developing PID owing to increased cervical ectopy.38 The finding by Ekpenyong and Etukumana38 in Uyo, Nigeria is similar to that of Chinsembu39 in Windkoek, Namibia and Barret and Taylor34 in London,
UK. All three studies ascribed the increased cervical ectopy in young women to the fact that the cervix has an increased amount of ectropion (columnar epithelium that extrudes over the exocervix and into the vaginal vault) that makes adolescent girls more susceptible to gonorrhoea and Chlamydia, Columnar epithelium being more vulnerable than squamous epithelium to infection byChlamydia.34,38,39
Also, considerable physical and tissue changes resulting from reproductive hormones during adolescence and young adulthood further increase the vulnerability of adolescents and young ladies to PID/STI.38 In the study by Raya et al,3 PID was also attributed to the increased susceptibility of adolescents to PID to anovulatory cycles which are common after menarche and associated with high oestrogen levels and facilitates cervical mucus penetration by microorganisms. The study further ascribed the increased susceptibility to PID in adolescents to low cervical secretory immunoglobulin A levels in the female adolescent genital tract, due to low prevalence of immunogenic triggers.3
Also, lack of knowledge of PID and STIs, lack of communication and negotiation skills and lack of power to negotiate sex with their partners who are commonly older adults particularly
25 make the age group most vulnerable to PID according to Ekpenyong and Etukumana38 in their study among female undergraduates in Uyo, South – South Nigeria.
A study by Okon et al1 in Nguru, North-Eastern Nigeria found PID to be highest among young women aged 21 to 30 years. Similar findings were reported by Kennedy, John and
Sunny5 who found PID to be highest among women in their 20s in Port Harcourt, Nigeria and
French et al35 in England. These findings however differed from findings by studies done by
Raya et al3 and Barrett and Taylor34 which both found PID to be commonest among
American girls aged 15 to 19.
2.4.2 Early Coitarche: Early coitarche is another risk factor for PID.12,13,17 A study by
Dhont et al,40 in Rwanda found tubal abnormality to be high among women who attained coitarche when they were less than 20 years. Another study by Ugboma, Nwagwu and
Jeremiah13 among undergraduates in the University of Port Harcourt found it to be highest among girls less than 15 years followed by those aged 15 to 19 years. This is similar to the findings of Simms et al,12 in their study among women attending selected clinics and hospitals in London and Liverpool which showed that younger age at first intercourse was associated with increased risk of PID.
Early coitarche is commonly associated with a higher number of lifetime sexual partners,17 frequent sexual intercourse3 and decrease barrier contraceptives use3 all of which increase the risk of developing PID.3,17 The columnar epithelium of the immature ectocervix exposes a relatively large surface area that facilitates attachment of microorganisms like C. trachomatis and N. gonorrhoea further predisposing ladies who have early sexual debut to PID.3
2.4.3 Multiple Sex Partners: Multiple sex partners is another major risk factor for PID and the higher the number of sex partners, the higher the risk.12,13,40 In a study by Ugboma and colleagues,13 the number of sexual partners was found to be significantly associated with
Chlamydia infection, a major cause of PID. Dhont et al,40 in a study among infertile women
26 and their partners in Kigali, Rwanda found PID to be higher among women who had multiple sex partners, were unmarried or married in a polygamous setting. In another study by Urasa et al,15 among youth attending a sexually transmitted infection clinic in Dar es Salaam,
Tanzania, a significant number of young females had multiple sex partners as well as older sex partners. Young ladies had multiple sex partners particularly with older partners for financial gains and social support.15 Such ladies are more likely to engage in risky sexual behaviours such as unprotected sex and generally lack the power to negotiate condom use with their older partners further predisposing them to the development of PID which significantly increased their risk of STIs.15
2.4.4 Previous STI/PID: Past history of STI/PID has been shown to increase susceptibility to PID.23,27,41 Previous infection impairs host defences, thus placing the individual at increased risk of PID.41 Also, untreated or poorly treated STI will progress to PID through ascending infection of the microorganisms to involve the endometrium, fallopian tubes and other structures that make up the upper female genitalia.6,25 Infection from unsafe abortion leads to post abortal PID from previous uterine instrumentation via dilatation and curettage further increases PID susceptibility.42-44 A study in Australia found a direct relationship between previous STI and PID among young women less than 25 years.27
2.4.5 Parity: Low parity has been associated with increased risk of PID.12,40 A study done by Ehigiegba and Okosun43 in Benin found a preponderance of low parity among patients presenting with pelvic abscess majority of which were as a result of PID and post abortal sepsis. This is similar to findings by Adesiyun and Ameh44 in Zaria. In the study, half of the patients with pelvic abscess mainly from post abortal PID were nulliparous.44
2.4.6 Marital Status: Occurrence of PID is higher in ladies who are single compared to those who are married.17,42 A study by Lamina in Ogun state South Western Nigeria among women seeking repeat induced abortion found that most women presenting for repeat induced
27 abortion were less than 25 years and single.42 This high prevalence of abortion including multiple abortions among single young ladies compared to married ones significantly increases their risk of developing PID.42 Also, Adesiyun and Ameh44 in Zaria found post abortal PID from unsafe abortion to be higher in single young ladies compared to married ones. This is coupled with the fact that young single ladies tend to engage in other risky sexual behaviours such as having multiple sexual partners compared to married ones.
2.4.7 Contraceptive Use: Inconsistent use of condom are major risk factors for the development of PID.12,13,15 Poor condom use have been reported among young females including students.15,17 Poor condom use, in addition to being an independent risk factor for the development of PID also results in a high number of unplanned pregnancies, most of which end up in induced abortions, which are illegal in Nigeria (unless medically intended to save a mother’s life)42 and hence procured commonly from unskilled medical personnel and under poor sanitary conditions further increasing the risk of PID.15,42
Intra Uterine Contraceptive Device (IUCD) insertion and removal has also been associated with an increased risk of developing PID.34,45, The endometrium could be inoculated with microorganisms during insertion or removal of IUCD if aseptic condition is not maintained or contaminated IUCD is used.34 This is more common when the procedure is done by non- professionals or under unsanitary conditions. Alteration of cervico-vaginal milieu and compromise of host defence against pathogens, predispose to vaginitis and cervicitis.
Infection then ascends through the thread of the IUCD to the uterus leading to PID.34
2.4.8 Induced Abortion: Termination of pregnancy has been associated with increased risk of iatrogenic PID.45 However, a study in North America showed that termination of pregnancy is not a risk factor for the development of PID.12 This could be due to the fact that in North America where termination of pregnancies is legal and therefore done in standard clinical setting and prophylactic antibiotics routinely given12 as opposed to the Nigerian
28 setting and other developing countries where it is illegal and therefore done mainly by unskilled personnel in unprofessional way and under unhygienic conditions predisposing patients to PID.42 Hence findings of the above study contrasts with findings of another study done in Nigeria, where recent termination of pregnancy was identified as a risk factor for the development of PID.43 The findings also contrasted with the findings of a Swedish study that demonstrated a significant relationship between termination of pregnancy and development of PID.45
The rate of induced abortion is high in Nigeria, even though it is illegal.7,42 An estimated 1.5 million unplanned pregnancies occur every year in Nigeria with 50% of these pregnancies resulting in induced abortions.42 Some women use abortion as a means of child spacing rather than modern contraception for fear of adverse effect of modern contraceptives on fertility.42
They therefore see abortion as an immediate solution to unplanned pregnancy.42 These abortions are done clandestinely, commonly under unsterile conditions and by unskilled medical personnel leading to increased risk of iatrogenic PID.7,42 Post abortion contraceptive use is also very poor leading to repeat abortions which was found to be common among young females less than 25 years further increasing their risk of developing PID.42 The high rate of abortion in Nigeria is worrisome considering the fact that maternal mortality remain high in Nigeria with abortion playing a significant role in the high maternal morbidity and mortality rate in the country. A study in Benin showed that post abortal PID was a major cause of pelvic abscess among patients seen in the University of Benin Teaching Hospital.43
This finding is corroborated by a similar study in Ahmadu Bello University Teaching
Hospital, Zaria, Northern Nigeria by Adesiyun and Ameh44 which also identified post abortal
PID from unsafe abortion as a major cause of pelvic abscess. The Benin study as well as the
Zaria study highlighted the important role of unsafe abortion and the resulting PID in the
29 pathogenesis of pelvic abscess in this environment.43,44 Most deaths from induced abortion are due to infection.7
2.4.9 Socioeconomic Status: Another recognised risk factor for PID is low socioeconomic status.12,18,23 Young women from low socioeconomic backgrounds seek support from men who pay their school fees, buy them gifts and offer inducements.18 These poor women lack the power to negotiate safe sex with their “sugar daddies” and commonly have multiple sex partners; practices which expose them to the risk of developing PID.15,18 Two studies done by
Bourne in Jamaica both reported low socioeconomic status as a major risk factor in the development of PID,31,32 particularly among young women who are also exposed to sexual assault and rape.32 Findings in this Jamaican study that low socioeconomic status is a risk factor of PID agrees with another study conducted by Suleiman and Tayo36 in Lagos, Nigeria.
A study by Isibor et al,46 in Irrua, South-South Nigeria also found PID to be worse with women from low socioeconomic background. Suleiman and Tayo36 attributed the high prevalence of PID among women with low socioeconomic status to their inability to access standard medical care when they have sexually transmitted infections.
2.4.10 Being in School: Another risk factor of PID is being in school.17,19,23 A study by
Prasad et al,23 in India and findings by WHO19 revealed a high prevalence of sexual intercourse among school going adults. This is similar to findings by another study conducted by Omoteso18 among university undergraduates in South-Western Nigeria. The study found that young undergraduates particularly those from poor socioeconomic backgrounds engaged in risky sexual behaviours such as engaging in sex for monetary and social gains as well as having multiple sex partners. Chinsembu39 in his study of sexually transmitted infections in
Windhoek, Namibia observed a high prevalence of sexual intercourse among school going adolescents in Namibia using data from the Namibia Global School-Based Health survey.
These students with poor parental supervision, had sexual debut at a very young age (some as
30 low as 10 years), majority of them had multiple sex partners in the preceding six months and did not use condom consistently.
The increased risk of PID among undergraduates may be due to the fact that most undergraduates are young,17 single17 ladies who engage in risky sexual behaviours such as having multiple sex partners, engaging in sex for monetary gains and social support as well as having poor contraceptive use, high incidence of unwanted pregnancy and engage in repeated abortion all of which predispose to the occurrence of PID.
2.5 Aetiology of PID
Pelvic Inflammatory Disease commonly arises from ascending infection from the lower genital tract. Lower genital tract infection, if not properly treated, will lead to cervicitis from ascension of the organisms to the cervix. Further spread will affect the uterus, fallopian tubes and peritoneum causing leading to endometritis, salpingitis and peritonitis respectively.30
This is made worse by the fact that the infection could go undetected (asymptomatic) causing significant damage without the patient knowing.3,46,47
It is a polymicrobial infection with a wide variety of organisms involved.3,25,33 According to
Dayan,48 STls such as gonorrhoea and chlamydia account for one-third to one-half of PID infections. This is similar to the findings of Barrett and Taylor,34 Risser and Risser49 as well as Tukur, Shittu and Abdul50 who found the commonest cause of PID to be Chlamydia trachomatis34,49 and Neisseria gonorrhoe.34,50 Ugboma, Nwagwu and Jeremiah13 in their study to determine the prevalence of chlamydia among undergraduates in Port Harcourt further stated that infection with Chlamydia accounted for over 50% of cases of salpingitis as well as infertility. This claim was also supported by Okoror and colleagues51 as well as
Enwuru and Umeh52 in separate studies done in South-Eastern Nigeria.
Jaiyeoba, Lazenby and Soper30 reported that Neisseria gonorrhoea, Chlamydia trachomatis and Mycoplasma genitalium were recovered from the cervix, endometrium and fallopian
31 tubes of women with laparoscopically proven acute salpingitis. In a study conducted by
Barrett and Taylor,34 other microbial agents causing PID were found to include genital tract mycoplasmas (particularly M. genitalium), anaerobic and aerobic bacteria which comprise the endogenous vaginal flora (eg, Prevotella species, black-pigmented Gram-negative anaerobic rods, Peptostreptococci sp., Gardnerella vaginalis, Escherichia coli, Haemophilus influenzae, and aerobic streptococci). Barrett and Taylor’s findings compare with those of
Okon et al,1 in Nguru, North-Eastern Nigeria in which Escherichia coli, anaerobes,
Streptococci and Staphylococci were among organisms isolated from patients with PID alongside Neisseria gonorrhoea.
Bacterial vaginosis has also been commonly isolated from patients with PID.34,48,53 A study by Ness et al,53 among young African – American women found that infection with Bacteria vaginosis increased the risk of development of PID. This compared with the findings of
Barrett and Taylor34 and Dayan.48
Non-sexually transmitted pathogens such as tuberculosis, also play a role in endometritis, salpingitis and tubal factor infertility, particularly in developing countries.33 Dayan48 reported that non sexually transmitted organisms are commonly introduced through procedures such as Intra Uterine Contraceptive Device (IUCD) insertion, dilatation and curettage as well as operative termination of pregnancy that breach the protective cervical barrier and directly introduce bacteria and other microorganisms into the endometrium.
2.6 Pathophysiology
Typically, acute PID is caused by ascending spread of microorganisms from the vagina and/or endocervix to the endometrium, fallopian tubes, and/or adjacent structures.25,33,47
Infection of the cervix leads to damage to the endocervical canal and breakdown of the mucus plug promoting the ascension of infection.33 Haggerty and Ness33 in their study on the epidemiology, pathogenesis and treatment of pelvic inflammatory disease reported that, in
32 addition to Endocervical damage by microorganisms as mentioned above, microorganisms like Neisseria and Chlamydia also adhere to spermatozoa, potentially promoting their ascension. The study also reported that the loss of mucus plug associated with the onset of menses and retrograde menstruation increases the ascension of microorganisms and infection from the vagina and cervix into the upper genital tract.33 This is in addition to younger women having a larger cervical ectopy due to increased hormonal levels at menarche that produces a larger attachment area for bacterial pathogens.33 All these contribute to increased susceptibility to infection leading to PID.
According to Soper,11 Bacterial vaginosis elaborates a variety of mucolytic proteinases which degrades the cervical mucus plug and the naturally occurring antimicrobials potentiating cervical inflammation which facilitates the ascension of cervical and vaginal microorganisms resulting in endometritis and salpingitis.11 Jaiyeoba and Soper47 in another study stated that once infection-induced inflammation reached the fallopian tube, epithelial degeneration and deciliation of ciliated cells occurred along the fallopian tube mucosa in association with a submucosal inflammatory cell infiltrate. This with the associated oedema of the fallopian tube leads to clubbing of the involved tube producing a dysfunctional, partially or totally obstructed tube causing infertility or ectopic pregnancy.47
2.7 Symptoms and signs of PID
Symptoms of PID vary from mild to severe necessitating a high index of suspicion among clinicians to facilitate diagnosis.47,54 Soper11 identified symptoms of PID to include abdominal pain, abnormal vaginal discharge, inter-menstrual bleeding, post-coital bleeding, fever, urinary frequency, low back pain and nausea/vomiting. The findings are similar to those of Jaiyeoba and Soper37 who reported same symptoms. Some patients may present with secondary dysmenorrhoea which is indicative of an underlying disease condition55 like PID.
33
Further assessment of patients with suspected PID include general and pelvic examination including bimanual examination.47 A study conducted by Jaiyeoba and Soper37 identified the signs of PID to include fever with temperature greater than 38.3oC, abnormal vaginal or cervical mucopurulent discharge, abdominal tenderness which may/may not be present particularly if there is no peritonitis or patient is having endometritis or cervicitis without salpingitis. This is similar to the findings of Haggerty and Ness,33 and Risser and Risser.56
Risser and Risser,56 in addition, noted that the presence of cervical mucopus is an indication of cervical infection though some studies cast doubt on its use in the diagnosis of PID.
Jaiyeoba and Soper37 further added that bimanual examination would reveal pelvic tenderness such as uterine tenderness in endometritis and adnexal tenderness in salpingitis. Bartlett,
Levison and Munday,28 in their study, while agreeing with findings by Jaiyeola and Soper37 added that there may also be cervical motion tenderness in patients with PID. The current study assessed undergraduates with PID using the above symptoms and signs.
2.8 Investigations
Risser and Risser49 noted that laboratory investigations to confirm diagnosis of PID include endocervical swab for N. gonorrhoea and using nucleic acid amplification test for C. trachomatis where available. This agrees with the findings of Bartlett, Levison and Munday28 in a separate study.
Full blood count will show elevated white blood cell count; this is not very reliable as only
60% of patients with PID have elevated white blood cell count.37 Elevated erythrocyte sedimentation rate (ESR) of greater than 15mm/hr is also seen in patients with PID, though only 75% of PID patients will have elevated ESR.33,37 C – Reactive Protein (CRP) is also elevated in patients with PID and can be used as a monitoring tool as its levels decreases to normal sooner than ESR following effective antibiotic therapy.37 Above findings by Jaiyeoba and Soper37 agrees with findings of Haggertty and Ness.33 Bartlett, Levison and Munday28
34 however added that pregnancy test could be done to exclude ectopic pregnancy, which is a strong differential of PID.
Endometrial biopsy showing neutrophils and plasma cells in the endometrium is indicative of endometritis and has been suggested for use in the diagnosis of PID.37 It is not as invasive as laparoscopy but useful in diagnosing endometritis and predicting salpingitis, as studies show that 54 – 92% of patients with endometritis on biopsy also have laparoscopically confirmed salpingitis.37
Ultrasonography has been reported as the imaging study of choice followed by magnetic resonance imaging (MRI) and computerised tomographic (CT) scan.37 Ultrasonography is non-invasive and widely available. Transvaginal is preferred to abdominal approach and
Doppler increases its sensitivity in diagnosing PID.37 Transvaginal sonography or MRI will show thickened, fluid filled tubes with or without free pelvic or tubo-ovarian complex while
Doppler studies will show tubal hyperaemia.29 Ultrasonography is useful in excluding other diagnostic possibilities28 such as ectopic pregnancy, ruptured or infected ovarian cyst. The use of MRI, though more accurate than ultrasonography,37 is expensive and not widely available in our setting.
2.9 Diagnosis of PID
Sweet25 reported that no single symptom or sign could reliably diagnose PID as most of the symptoms and signs overlap and may also be present in other disease condition. He therefore concluded that diagnosis of PID should be entertained and treatment instituted in patients who are young and sexually active with lower abdominal/pelvic pain in whom pelvic tenderness (Cervical motion tenderness, uterine tenderness or adnexal tenderness) is elicited on examination.25 This is in line with the guidelines by the American Centres for Disease
Control and Prevention (CDC)6 and the World Health Organisation (WHO).19 Doxanakis et al,29 also reported similar findings and arrived at same conclusion that the threshold for
35 diagnosing PID should be low in view of the significant morbidity and complications associated with it when left untreated. Bartlett, Levison and Munday28 in a separate study also had similar findings and arrived at the same conclusion as Sweet25 and Doxanakis et al.29
Sweet,25 and Jaiyeoba and Soper37 in separate studies gave additional diagnostic criteria to include fever with temperature greater than or equal to 38.3oC, abnormal cervical or mucopurulent discharge, presence of abundant white blood cells on saline microscopy of vaginal secretions, elevated erythrocyte sedimentation rate, elevated C-reactive protein and laboratory documentation of N. gonorrhoea or C. trachomatis infection.
Jaiyeoba and Soper47 however reported that the most specific diagnostic criteria were endometrial biopsy with histologic evidence of endometritis and/or laparoscopy showing evidence of salpingitis.47 Sweet25 also noted that Transvaginal sonography, magnetic resonance imaging (MRI) or Doppler studies suggesting pelvic infection were also useful.25
Laparoscopy was identified by various studies as the gold standard for diagnosis of salpingitis, however it was neither recommended nor feasible for it to be routinely used in the diagnosis of PID29,37 as it missed out endometritis and cervicitis37 and was invasive and expensive and required expertise, factors all lacking in resource poor setting like ours.
Doxanakis et al,29 Bartlett, Levison and Munday,28 and Risser and Risser56 in separate studies found laparoscopy to accurately diagnose salpingitis, though not 100% sensitive. The procedure did not aggravate the inflammatory process according to a study by Jaiyeoba and
Soper.37 Laparoscopic findings included pronounce hyperaemia of the tubal surface, oedema of the tubal wall, and sticky exudate on the tubal surface and from the fimbriated ends when patent according to Jaiyeoba and Soper.37 The drawback of laparoscopy in the diagnosis of
PID is its inability/difficulty in diagnosing PID in patients with endometritis without salpingitis.37 Evans, Jaleel and Kinsella26 as well as Bartlet, Levison and Munday28 therefore
36 concluded that laparoscopy should be done for patients who fail to respond to treatment for
PID to confirm the diagnosis or make alternative diagnosis.26,28
Fig 2: Laparoscopic visualization of acute salpingitis.
Emphasis is however less placed on the accurate determination of the site of infection, whether cervicitis, endometritis, salpingitis or peritonitis. Instead all suspected cases should be treated empirically with appropriate antibiotics to ameliorate the adverse outcome of PID such as tubal infertility and ectopic pregnancy when it is not treated or poorly treated.37
Clinical diagnosis of PID is however not precise.48,54,57 No single historical, physical or laboratory finding is diagnostic of PID.29,37 Only about 65% of clinical PID is confirmed by
37 laparoscopy.37 This makes the diagnosis of PID challenging as clinicians are faced with the dilemma of undertreating patients therefore exposing them to the risk of developing adverse sequelae or over treating them with the attendant risk of antibiotics resistance.29 This should be balanced; not all patients presenting with pelvic pain or genital pathology should be placed on treatment for PID. However history of pelvic pain in addition to physical examination revealing cervical motion tenderness, uterine tenderness or adnexal tenderness should be assessed and treated as PID.25
This conforms with the CDC 2010 guidelines which recommended that empiric treatment for
PID be initiated in sexually active young women and other women at risk for STDs if they are experiencing pelvic or lower abdominal pain, if no cause for the illness other than PID can be identified, and if one or more of the following minimum criteria are present on pelvic examination: cervical motion tenderness or uterine tenderness or adnexal tenderness.6
2.10 Complications of PID
Pelvic inflammatory disease can lead to various complications such as infertility, ectopic pregnancy, chronic pelvic pain and recurrent infection/PID.33,48,58 Tubal disease following
PID is the commonest cause of infertility in Africa.40,50,59 Umeora, Mbazor and Okpere59 in a retrospective review of patients with tubal infertility managed over a five year period (1998 –
2002) in the University of Benin Teaching Hospital found that 764 out of the 1181 patients
(64.7%) studied had clinically suspected tubal infertility though 13.5% were confirmed.59
This was because majority of the patients could not afford the test of tubal patency.59 Of the confirmed cases, PID was noted in 11% of the patients.59 However, 60% of the study population had history of infection.59 They noted that the low prevalence could be due to the possibility of sub clinical (silent) PID.59 Subclinical PID has been shown to account for 60% of PID.25
38
The above study in Benin compared favourably to another study by Tukur, Shittu and
Abdul50 in a teaching hospital in Zaria, North-Central Nigeria which found a significant association between PID and tubal infertility reporting a prevalence of 38.3% of confirmed chlamydial infection among patients with tubal infertility.50
A study done by Sule, Erigbali and Eruom60 among patients attending four major hospitals in
Osun state, South-Western Nigeria found that tubal factor infertility accounted for 39.5% of infertility in the area with PID identified as a major cause of tubal infertility in the study. This was also corroborated by the findings of Enwuru and Umeh52 in Owerri, south-eastern
Nigeria,52 Dhont et al,40 in Kigali, Rwanda and Doxanakis et al,29 in Melbourne, Australia.
Infertility was the commonest cause of gynaecological consultation accounting for a third of all gynaecological consultations in a study by Umeora, Mbazor and Okpere.59 Majority of the cases of infertility in the study and the other studies above were secondary infertility with tubal infertility being the leading cause, further stressing the importance of PID as a major cause of infertility. Tubal infertility may result from tubal occlusion which has been associated with chlamydial or gonococcal antibodies with the rate of tubal factor infertility doubling for every subsequent PID episode.33,48 Increasing rate of infertility has also been reported with increase in the severity of the infection and delay in treatment with rates as high as 2.6 times in those who delay seeking healthcare for 3 or more days after the onset of abdominal pain.47
Another complication from PID is ectopic pregnancy.52,58,61 A case-control study done in
Lagos, Nigeria among 100 consecutive women who had laparotomy for ectopic gestation in 3 major hospitals in the city found PID to be a significant risk factor for the development of ectopic pregnancy.8
This is similar to findings of a retrospective review of 73 women with tubal ectopic pregnancy who had exploratory laparotomy in Papua New Guinea which found most of the
39 patients that had open surgery (salpingectomy) for ectopic pregnancy had macroscopic evidence of PID.62
Also patients with untreated or poorly treated PID are at risk of developing chronic pelvic pain.28,29 Chronic pelvic pain is defined as menstrual or non-menstrual pain of at least six months duration.47 Chronic pelvic pain following PID account for up to 12% of hysterectomies done in the USA annually.33 It has also been associated with significant reduction in physical and mental health.33 Recurrent PID is also a known complication of the disease.3,33 These complications occur as a result of damage to the cilia lining the fallopian tubes, tubal blockage or occlusion or adhesion formation among pelvic organs.33
Patients with PID are also at higher risk of developing cervical cancer.63 Abdul, Shittu and
Randawa63 in a case-control study in Zaria, north central Nigeria found that women with chronic PID had a significantly higher prevalence of cervical dysplasia on pap smear compared to those without chronic PID suggesting that chronic PID is a risk factor for cervical dysplasia. This is of significant clinical importance in view of the fact that cervical cancer is the commonest gynaecological cancer in Nigeria and the polymicrobial aetiology of
PID and the role of infection (Human Papilloma Virus infection) in cervical cancer are well established.63
2.11 Treatment of PID
Jaiyeoba, Lozenby and Soper30 recommend in their study that treatment of PID should be with broad spectrum antibiotics covering the likely organisms implicated in PID. The treatment must cover for N. gonorrhoea or C. trachomatis25 which are the commonest organisms implicated in PID.29
The recommended outpatient treatment for PID as contained in the Centre for disease Control and Prevention (CDC) guideline include intramuscular Ceftriaxone 250mg in a single dose plus oral doxycycline 100mg twice daily for 14 days with or without oral metronidazole
40
500mg twice daily for 14 days.12,29 Ceftriaxone could be replaced with Cefoxitin 2g intramuscularly in a single dose followed by Probenecid 1g orally administered or other third generation cephalosporin (eg ceftizoxime or cefotaxime) parenterally administered.30 This is also the recommendation of the Pelvic Inflammatory Disease Evaluation and Clinical Health
(PEACH) study.11
Treatment with quinolones (Ciprofloxacin, Ofloxacin or Moxifloxacin) alone or in combination with other agents has been shown to be effective in the treatment of PID according to a review by Jaiyeoba, Lazenby and Soper.30 They however noted that ciprofloxacin appeared less effective in clearing Bacteria vaginosis associated microorganisms from the endometrium despite clinical cure, hence its use as primary monotherapy is discouraged as the possibility of relapse is high.30
Combination of metronidazole and Doxycycline was suggested to provide comprehensive coverage of anaerobic bacteria, though clinical and microbiological cure has remained low with the combination (75% and 71%, respectively). This necessitated the inclusion of
Ceftriaxone (or other cephalosporin as above) which increased the cure rate significantly.30
Haggerty however reported a clinical cure rate of 96% and a microbiological cure rate of
94% with ciprofloxacin.33
An alternative regimen proposed for the treatment of acute PID is Azithromycin administered orally at a single dose of 2g. This has been shown to be more effective than Doxycycline against Chlamydia. Its ability to reduce inflammation effectively as well as its single dosing which increases compliance also puts it at an advantage over Doxycycline. Its drawback however, is that increased resistance by N. gonorrhoea have been reported and the high dose is associated with gastrointestinal symptoms. The review therefore proposed Azithromycin as an effective alternative to Doxycicline.30 The CDC also recommended a single oral dose of
41
Azithromycin 2g to a quinolone-based regimen for 14 days as also effective in the treatment of PID.6
Dayan48 in a study in Australia recommended the use of Azithromycin as a single oral dose of
1g plus Doxycycline 100mg twice daily for 14 days in addition to Metronidazole 400mg twice daily for 14 days in young sexually active women with PID with no predisposing factor. The study also recommended the addition of Ceftriaxone 250mg given intramuscularly as a single dose or ciprofloxacin 500mg orally as a single dose to the above regimen.48 This the study found to successfully treat PID both clinically and microbiologically.
Soper11 recommended a regimen that include Azithromycin 1g orally in a single dose plus
Doxycycline 100mg orally twice daily for 7 days plus ceftriaxone 125mg intramuscularly or
Cefixime 400mg orally single dose (if gonorrhoeal prevalence is 55 or higher in the population) plus metronidazole 500mg twice daily for 7 days (if bacterial vaginosis is present).
In the author’s centre (ISTH) where this study was carried out, ciprofloxacin 500mg twice daily, doxycycline 100mg twice daily and metronidazole twice daily for 14 days are used in the outpatient treatment of PID. This is in line with the CDC guideline which recommended that ciprofloxacin could be used in place of ceftriaxone.6 This has given us significant clinical as well as microbiological cure in our patients.
During treatment, it is important that all current partners are screened and treated and recent partners (from the previous 6 months) are screened for sexually transmitted infections.28 This prevents the risk of reinfection and further transmission.
Treatment of PID is usually on outpatient basis (About 90% of women with PID are treated as outpatients11).33 However, hospitalisation should be considered if tubo-ovarian abscess is suspected; the patient is pregnant; patient is nonresponsive to oral antibiotic treatment; patient
42 is unable to tolerate or follow outpatient oral regimen; patient is suffering severe illness; or surgical emergencies such as appendicitis cannot be excluded.30,48
Parenteral treatment according to the CDC guideline include Cefotetan 2g intravenously every 12 hours or Cefoxitin 2g intravenously every 6 hours plus Doxycycline 100mg orally every 12 hours or intravenously every 12 hours.6 Another parenteral regimen is Clindamicin
900mg intravenously every 8 hours plus gentamicin intravenously or intramuscularly at a dose of 2mg/kg loading dose and 1.5mg/kg maintenance dose every 8 hours.6 An alternative regimen is Ampicilin/Sulbactam 3g intravenously every 6 hours plus Doxycycline 100mg orally every 12 hours or intravenously every 12 hours.6,30 CDC recommended that parenteral treatment be discontinued 24 hours after clinical improvement while oral medications be continued to complete 14 days of therapy.6
2.12 Prognosis
When treatment is instituted early in line with CDC and WHO guidelines above, prognosis is good with studies reporting clinical and microbiological cure rates close to 100%.6,30,33
Dayan48 reported that prompt diagnosis and treatment of PID was shown to significantly reduce the morbidity and complications associated with it whereas those cases that were untreated or poorly treated were more likely to lead to adverse sequelae of PID. This finding was corroborated by Bartlett, Levison and Munday,28 Soper11 and Haggerty and Ness33 among others.
2.13 Prevention of PID
Prevention of PID could be done at the primary, secondary or tertiary level. Raya3 identified primary prevention as important in reducing the disease burden and preventing further spread. Primary prevention includes health education on abstinence, faithfulness to uninfected partner and use of contraceptive, particularly barrier contraceptive like condom. Prevention of PID is also achievable by preventing the risk factors of the disease. Simms12 advocated
43 behavioural change as a key factor in the primary prevention of PID. Abstinence or delay in the initiation of sexual activity will reduce the incidence of STIs,3 and in turn PID. Also screening programmes for Chlamydia trachomatis targeted at high-risk groups (sexually active young women of 25 years and younger as well as high risk women over the age of 25 years) would facilitate early detection of subclinical PID.3 These screening programmes though well established in most advanced countries,3 are not routinely done in our environment due to lack of awareness and paucity of resources and facilities.
Increase awareness and use of contraceptives particularly barrier methods should also be advocated. Nigeria presently has a low prevalence of contraceptive usage. In a study done by
Oye-Adeniran et al,64 to assess the prevalence of contraceptive usage among young women in
Nigeria, only 11.1% of the study population have ever used contraceptive while 7.3% were using at the time of the study. Non usage or poor usage of contraceptives would predispose the individual to unwanted pregnancy.
Instrumental termination of pregnancy which results when unwanted pregnancy occurs due to unprotected sex would increase the risk of genital infection including PID. This is made worse in our setting where abortion is illegal and therefore procured from quacks and in settings far from being ideal.
Barrier contraceptives will in addition to preventing unwanted pregnancies give the added benefit of preventing sexually transmitted infections. This will further reduce the incidence and prevalence of PID. Oye-Adeniran et al,64 in their study also found Education and marital status to significantly affect usage of contraceptives. They found ignorance of the various contraceptive methods, their effectiveness and safety profile as some of the reasons why young women refused contraceptives.64
Secondary prevention of PID requires early diagnosis and prompt treatment with appropriate anti-microbial.25,33 This also prevent complications of PID from setting in as the damage to
44 the endometrium/tubes is halted/reversed with appropriate treatment.33 Instituting the above measures will guard against morbidities and disabilities arising from PID thus negating the tertiary level of prevention (rehabilitation).
2.14 Sexual Problems of Female Undergraduates
Most undergraduates are adolescents and young adults. Adolescents often engage in high-risk sexual behaviour including multiple sex partners and frequent and unprotected sexual intercourse.3,65 Owolabi et al65 in a study done in Ife, South-Western Nigeria among adolescents found that 30.1% of respondents admitted being pregnant in the past and all of them terminated the pregnancies. 16.3% of the girls also admitted having 2 or more partners.65
They are also vulnerable to sexual violence such as rape.32 Bourne reported that 85.8% of women who were raped were aged 5 to 29 years with 93% of them reporting that the act occurred when they were between the ages of 15 and 19.32 Rape predisposed victims to PID as offenders seldom used barrier contraceptive and the process is most often traumatic.32
Adolescents and young women are also exposed to exploitation by older and richer men who give them money and other material things in exchange for sex.39,65 Sexual behaviour among undergraduates is influenced mainly by family background; peer pressure; media influence; economic situations as well as educational background of parents.18 Students from low socioeconomic background tend to involve more in sexual activities for monetary benefit compared to those from high socioeconomic background according to a study by Omoteso18 in south-western Nigeria. The study also revealed that 63% of female undergraduates have had sexual intercourse.18 Also, a Jamaican study revealed that adolescents from low socioeconomic status are more susceptible to sexual assault especially those between the ages of 15-19 years.32 This is of grave consequences as the study further revealed that most of the
45 assault is on their sex debut32 with attendant medico-social problems predisposing them to
PID, STIs and unwanted pregnancies among others.32
Adolescent girls in sub-saharan Africa, including many undergraduates, have been shown to be highly vulnerable to engage in trans-generational sex for cash or material things due to poverty. They may also engage in sex with their age mates for cash and material gifts.66 Other reasons for engaging in such practice according to the study by Adogu et al,66 included the transactional nature of it, a means of improving their social status, pleasure, love, material comfort, security, life maintenance, school fees, books, housing and fear of harm. One of the problems with having sex for money is that the lady has little power to negotiate sex and such practice are usually associated with less condom use and greater sexual coercion,66,67 both of which will predispose her to greater susceptibility to unwanted pregnancies, unsafe abortions,
STIs including HIV and AIDS as well as increase her likelihood of developing PID.66
Adolescents (including undergraduates) also engage in sex with multiple partners which may be sequential or concurrent,66 a condition that further increase their susceptibility to PID. The practice of having multiple sex partners was also more common among those in the low socioeconomic status with economic reasons being the major reason among girls.66,67
Above behaviours expose the female undergraduate to great risks. For instance, adolescent girls make up half of those having abortions, both outside or within marriages.68 They are also more likely to die of childbirth related problems.68 premarital sex is relatively common in our environment especially in urban areas.68
Contraceptive use in this category of persons is also very low with Muyibi et al,68 reporting condom use of 18.8% among sexually active adolescents in Nigeria. A study done in London among undergraduates showed that the sexual behaviour of undergraduates is not different from those of non-students.69 Both categories engaged in risky sex behaviour irrespective of
46 educational background implying that education alone may not be sufficient in modifying risk-taking behaviour in young adults.69
Abortion is also high among female students. Adogu et al,66 reported in their study that 60% of abortions in Nigeria was done by adolescents with 55% of all the abortions done been unsafe. They found that the reason why adolescents terminate pregnancies include; pregnancy from incest or sexual abuse, contraceptive failure, fears of upsetting parents or bringing shame to the family, fears of expulsion from the family home, school or jobs, fears of difficulty in finding a marriage partner, lack of financial means to care for a child, desire to complete education or achieve other goals, dislike for the man responsible for the pregnancy.66
Abortion in Nigeria is highly restricted by law; the procedure is often performed clandestinely and under unsafe conditions. Such procedures pose serious health and social risks. A study done in Nigeria estimates that 50% of the Nigerian women who die from unsafe abortion each year are adolescents, and abortion complications are responsible for
72% of all deaths among teenagers below the age of 19 years.66
2.15 Socioeconomic status of parents and its effect on their undergraduate daughters
Socioeconomic status (SES) is an economic and sociological combined total measure of a person’s work experience and of an individual’s or family’s economic and social position in relation to others, based on income, education and occupation. It is classified into high, middle and low.20 Classification into any of these classes can be done using any of the variables mentioned above (income, education and occupation). The classification in this work used that recommended by Oyedeji which has been pre-tested and widely accepted.70 It is based on the occupation and educational level of the parents.20
Socioeconomic status is increasingly being used to characterise inequality in healthcare and other sectors.70,71,72 Its indices have been used in the integrated management of childhood
47 illnesses, ownership and purchase of mosquito nets, payment mechanisms for primary health care services, formulating of policies and programmes targeted at the poor as well as monitoring achievement of the millennium development goals.71
Parents in middle to high socioeconomic class are mostly educated and do such jobs like engineering, medicine, law, banking, business and civil service jobs,73 while those in low socioeconomic status are petty traders, farmers, artisans, drivers or unemployed.73 The importance of the home in the development of the child cannot be over emphasized. The home has a great influence on the students’ psychological, emotional, social and economic state.74 Students from high socioeconomic status tend to be more stable physically, socially, academically and emotionally while those from low socioeconomic background tend to perform less academically, are more vulnerable to crime and are more likely to engage in sex for money.74
Also students brought up by both parents tend to perform better in school than those from single parents according to a study by Uwaifo74 in Ekpoma South-Southern Nigeria. Such students also show a greater emotional stability as opposed to students brought up by single parents.74 They therefore are less likely to be sexually abused or engage in other risky sexual behaviour that will predispose them to PID.
Low socioeconomic status also predispose to lower genital tract infection such as trichomoniasis.75 A study by Adeoye75 found the prevalence of genital tract infection to be higher in patients with low SES as compared to those with high SES. This is also true for PID as evidenced by studies by Simms et al6 and Suleiman and Tayo.36
Studies by WHO reveal that adolescents and young ladies from low socioeconomic background engage in sex for monetary and material gains.6 The study further reveal that these young girls from low socioeconomic backgrounds engage in sex with older men who most times do not use condom further exposing them to PID.6 The high level of youth
48 unemployment coupled with the breakdown of parent – child communication was identified by a study in Benin among young adults and adolescents in Edo state as another factor that predisposes them to engaging in risky sexual behaviours further increasing their risk of developing PID.24
49
CHAPTER THREE
METHODOLOGY
3.1 Study Area
This study was conducted at Irrua Specialist Teaching Hospital, Irrua, Edo State. The hospital is situated along Benin-Abuja expressway in Irrua, a semi urban area and headquarters of
Esan Central Local Government Area of Edo State. It was commissioned in 1991 as a Federal
Medical Centre with 260 beds and later backed up by decree 92 of 1993. It is presently a 375 bed hospital. It serves the northern, central and parts of the southern senatorial districts of the state. In addition, it receives students from neighbouring Delta, Ondo and Kogi states. The people of the region are predominantly farmers and traders from low and medium income settings. There are also civil servants as well as business men in the region served by the hospital.
The hospital offers residency training programmes in Family Medicine, Internal Medicine,
Paediatrics, Surgery, Obstetrics and Gynaecology, Community Health, Psychiatry,
Anaesthesia, Ophthalmology, Radiology, Otorhinolaryngology and Pathology. It is also the
Centre of Excellence for Lassa Fever Research and Control. Furthermore, it serves as a teaching hospital to Ambrose Alli University Medical School which is a state owned institution.
The hospital receives students from the three major tertiary institutions in Edo Central and
Edo North Senatorial Districts – Ambrose Alli University, Ekpoma and College of Education,
Igueben both in Edo Central Senatorial District and Auchi Polytechnic, Auchi in Edo North
Senatorial District.
Patients with PID are usually seen in the Family Medicine Clinic (commonest), gynaecological clinic and the Accident and Emergency unit of the hospital, thus patients used for the study were recruited from these three units of the hospital. The Family Medicine
50
Clinic consists of the General Out Patient Department (GOPD) and the Staff/NHIS Clinic.
All patients presenting to the hospital other than accidents and emergencies are first seen in these clinics. Patients are treated and discharged from the family medicine clinics by family physicians or referred to other specialties for those requiring referrals.
The clinics are equipped with facilities such as angle poise lamps, cuscos and sims speculums. Patients with suspected PID are examined in the presence of a Chaperon and endocervical swabs and high vaginal swabs collected under direct vision using angle poise lamps and cuscos speculum. The samples are then sent to the microbiological laboratory for microscopy, culture and sensitivity.
3.2 Study Design
The study was a descriptive cross-sectional study.
3.3 Study Population
Sexually active female undergraduates of reproductive age (15 – 49 years) presenting to Irrua
Specialist Teaching Hospital, Irrua.
3.3.1 Inclusion Criteria
1. Female undergraduates aged 15 to 49 years,
2. who are sexually active,
3. who present to ISTH and
4. have consented to participate in the study.
3.3.2 Exclusion Criteria
1. Students who were too ill to participate in the study.
2. Students with other competing diagnoses such as ectopic pregnancy. Patients with
greater than four weeks’ history of amenorrhea were subjected to pregnancy test, and
51
where positive, were excluded from the study. Patients with clinical findings that were
highly suggestive of appendicitis or urinary tract infection were also excluded.
3. Students with history of pelvic surgeries such as myomectomy, salpingectomy,
caesarean section.
4. Students who did not consent to participate in the study.
4.3.3 Selection of Subjects
1. Patients presenting to the General Out-Patient Department, Accidents and Emergency
Unit and gynaecological unit of ISTH who met the above criteria were selected for the
study.
2. Patients were considered to have PID if they had pelvic or lower abdominal pain and
on examination had one or more of the following: i. cervical motion tenderness, ii. uterine tenderness or iii. adnexal tenderness.12
3. Those who did not meet the above criteria for PID were, for the purpose of this study,
categorised as not having PID.
4. All the patients (those with PID and those without PID) were evaluated and treated for
their ailment.
52
3.4 Sample Size and Sampling Technique
3.4.1 Sample Size Determination
The sample size was determined using the formula for single proportion:76
N = Z2pq/d2 where
N = estimated sample size
Z = standard normal deviate corresponding to a confidence interval of 95% (1.96) p = prevalence of PID (Olowe, Alabi and Akindele reported a PID prevalence of 70% among patients attending a tertiary hospital in Osogbo, South western Nigeria)10 q = the proportion of those without PID in the population = 1 – p = 1 – 0.70 = 0.30 d = allowable relative error (5%)
N = (1.96)2 X 0.70 X 0.30/(0.05)2 = 0.806736/0.0025 = 323
Response Rate: A response rate of 90% was anticipated and so the sample size to be selected
(ns) was calculated using the formula ns = n/0.9 where ns = sample size to be selected,
n = calculated sample size and
0.9 = anticipated response rate of 90% ns = n/0.9 = 323/0.9 = 359.
The total sample size used was 360
3.4.2 Sampling Technique
Consecutive sampling was employed in the study. Female undergraduates who met the inclusion criteria and agreed to participate in the study were recruited consecutively and interviewedand examined until the required sample size of three hundred and sixty (360) was achieved. An average of eight students was seen weekly. These patients were seen in the
53
Family Medicine clinic, gynaecological clinics and Accident and Emergency units of Irrua
Specialist Teaching Hospital, Irrua.
3.5 Study Instruments
The study instruments used included:
1. Semi structured interviewer administered questionnaire (Appendix III)
2. Oyedeji’s questionnaire for socioeconomic class assessment (Appendix IV)
3. Digital thermometer to determine the temperature of respondents
4. Cuscos speculum for exposure of the vagina and cervix
5. Angle poise lamp for illumination and visualisation of the vagina and cervix
3.6 Pretesting
The questionnaire and devices were pretested in the staff/NHIS clinic of the hospital. A total of thirty students had questionnaire administered to them, their axillary temperatures taken, abdominal as well as vaginal examination including speculum examination with the aid of an angle poise lamp as well as digital bimanual examination done on them. Examination was done in the presence of a chaperon.
3.7 Methods of Data Collection
The semi structured questionnaire which was developed by the author had both close-ended and open-ended questions and was sub-divided into five sections:
A. Sociodemographic Characteristics
B. Medical history
C. Sexual history
D. Family history and
E. Examination findings.
54
The socio-demographic characteristics included age, marital status, institution type, educational level, source of funding, ethnic group and religion.
Medical history included presence of lower abdominal pain, menstrual history (including last menstrual period to rule out ectopic pregnancy), presence of menstrual abnormalities such as menorrhagia, metrorrhagia, dysmenorrhoea, oligomenorrhoea or inter menstrual bleeding.
The students were also evaluated for presence of vaginal discharge, and the nature of the discharge, including colour and odour, if present. Other aspects of the medical history included vulvo-vaginal irritation, itching, presence of genital ulcers and where present, ascertain whether they were painful or not. They were also evaluated for dyspareunia.
The sexual history of the students was also taken and the age at coitarche, number of sex partners student has ever had and the reason for engaging in sex activities. They were also evaluated for previous history of PID or other STIs as well as history of contraceptive use and the type of contraceptive, where used. Their parity and history of termination of pregnancy
(TOP), and method of termination (whether medical or surgical) were also taken from each of the respondents.
The family history included the parents’ level of education as well as their occupation. Their average monthly income, family size, whether the parents were both alive or not, and whether they were living together or not, were also assessed.
Oyedeji’s Classification of Social Class instrument20 which has been validated was used to determine the socioeconomic status of parents of the study participants (female undergraduates). It classified socioeconomic status into high, medium and low based on the occupation and level of education of the parents. It is graded on a score of 1 to 5, 1 being the highest and 5 the least. Each score has two variables, occupation and level of education with each of the variable assigned the score for that level as in Appendix IV. A person with a score
55 of 1 to 2 belonged to high socioeconomic status, 2.1 to 3 and 3.1 to 5 belonged to medium and low socioeconomic status, respectively.
The clinical examination done included
i. general examination including assessment for fever using the digital thermometer to
check axillary temperature,
ii. abdominal examination for pelvic tenderness and/or masses,
iii. speculum vaginal examination with the aid of an angle poise lamp to visualise muco-
purulent discharge if present and
iv. bimanual digital vaginal examination to elicit cervical excitation tenderness, adnexal
tenderness and bimanual palpation to assess the uterine size and tenderness.
The questionnaire was interviewer administered. The author saw and examined all the study participants.
3.8 Study Duration
The study was carried out over a period of eighteen months. Proposal writing and approval lasted for a period of six months. Data collection and analysis were carried out over a period of ten months (February to November, 2014). The final write up of the dissertation was done in two months.
3.9 Data Analysis:
Data from the questionnaire was coded and entered into an electronic spread sheet. The analysis was done with the aid of Epi info statistical software version 3.5.4 designed by the
American Centres for Disease Control and Prevention (CDC), Atlanta, USA for epidemiological studies. Results were presented using tables, charts, frequency distribution and simple percentages. Chi-square test was used to test for association between the occurrence of PID and associated risk factors and p ≤ 0.05 was considered statistically significant. Chi-square test was also used to test for association between the socioeconomic
56 status of parents and presence of risk factors for PID as well as test for association between socioeconomic status of parents and occurrence of PID. The prevalence of PID among undergraduates attending Irrua Specialist Teaching Hospital, Irrua during the period of the study was determined using the formula for calculating prevalence.77
Prevalence = Number of cases of the disease present at a particular point in time Number of persons at risk of the disease at the particular time
The result was then multiplied by 1,000 or 10,000 to yield statistics that could be easily interpreted.
3.10 Ethical Considerations
Ethical approval was obtained from the Ethics and Research Committee of Irrua Specialist
Teaching Hospital, Irrua (Appendix I), while written informed consent was obtained from patients after details of the study including the aim and objective have been explained to them
(Appendix II). They were told that the study did not pose any health risk to them and the study will benefit them on the long run by increasing the body of knowledge on the subject matter which will help prevent and manage PID better. They were also assured of confidentiality and given the option to opt out of the study at any time they wished.
57
CHAPTER FOUR
RESULTS
Occurrence of Pelvic Inflammatory Disease and associated factors among undergraduates attending Irrua specialist Teaching Hospital, Irrua was studied. A total of 372 female undergraduates were recruited out of which 360 consented to participate in the study. Twelve did not agree, giving a response rate of 96.8%. The 360 students who met the eligibility criteria and gave consent to participate were recruited for the study over a ten month period.
4.1 Sociodemographic Characteristics of the respondents
The Sociodemographic characteristics of respondents are as shown in table 4.1 below. The ages of the respondents ranged from 16 to 35 years with a mean age of 23 ± 3.6 years.
Majority of the respondents were 20 to 24 years amounting to 196 (54.4%). However, 29
(8.1%) respondents were 30 years and above.
As regard marital status, 338 (93.9%) were single while 22 (6.1%) of them have been married at one time one of which was divorced at the time of the study.
The ethnic group of the respondents were diverse with majority of them coming from the immediate environment and nearby places. “Esan” constituted the largest ethnic group among the study population 163 (45.3%).
A total of 283 (78.6%) of the respondents were Christians while the rest 77 (21.4%) were
Muslims.
58
TABLE 4.1: Sociodemographic Characteristics of the Respondents (N=360)
Sociodemographic Frequency Percentage
Characteristics
Age (Years)
15 – 19 37 10.3
20 – 24 196 54.4
25 – 29 98 27.2
30 and above 29 8.1
Marital Status
Single 338 93.9
Ever Married 22 6.1
Ethnic Group
Esan 163 45.3
Afemai 124 34.4
Bini 25 6.9
Ibo 24 6.7
Others 24 6.7
Religion
Christianity 283 78.6
Islam 77 21.4
59
4.2: Educational History of Respondents
Out of the 360 respondents studied, 199 (55.3%) were university students, 110 (30.6%) attended polytechnic and 51 (14.2%) were in the College of Education.
Majority of the respondents 321 (89.2%) were sponsored by their parents while the rest were either sponsored by their husbands 16 (4.4%) or self-sponsored 23 (6.4%).
Apart from the main sponsors, 65 (18.1%) of the respondents had additional sponsors while the remaining 295 (81.9%) relied solely on the allowances they got from their parents or what they earned themselves. For those who had extra sponsors, 55 (15.3%) of them was their boyfriend.
Most respondents 210 (58.3%) got less than ten thousand naira (N10, 000) as monthly allowance from their sponsors. A total of 8 (2.2%) respondents however got at least fifty thousand naira (N50, 000) as monthly allowance from their sponsor.
This is illustrated in table 4.2 below.
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TABLE 4.2: Educational History of the respondents (N=360)
Characteristics Frequency Percentage Institution Type University 199 55.3 Polytechnic 110 30.5 College of Education 51 14.2
Main Sponsor Parents 321 89.2 Self-sponsored 23 6.4 Husbands 16 4.4
Additional Sponsor Boyfriend 55 15.3 Husband 5 1.4 Other relatives 5 1.4 None 295 81.9
Average Monthly Allowance (Naira) 0 – 9,999 210 58.3 10,000 – 19,999 88 24.5 20,000 – 29,999 33 9.2 30,000 – 39,999 18 5.0 40,000 – 49,999 3 0.8 50,000 – 59,999 8 2.2
61
4.3: Socioeconomic Characteristics of Parents of the Respondents
Table 4.3 shows the socioeconomic characteristics of parents of respondents. Most of the respondents had fathers who were educated; 95 (31.7%) of them had secondary education and
94 (31.3%) had tertiary education.
Among their mothers, 95 (27.5%) of them had no formal education while 89 (25.7%) had primary education only. A total of 75 (21.7%) mothers had tertiary education.
The fathers of the students engaged in various occupations; 106 (35.3%) were public servants, 89 (29.7%) were farmers, 56 (18.7%) were artisans and the remaining 49 (16.3%) were traders.
Majority of the mothers were traders, 153 (44.2%). Others were public servants, 78 (22.5%), farmers, 78 (22.5%) and artisans, 37 (10.7%).
The family sizes ranged from 2 to 34 with a mean of 8 and standard deviation of 3.97. Most of the respondents 232 (64.4%) had families whose sizes ranged from 5 to 9. The result is illustrated in table 4.3 below.
62
TABLE 4.3: Socioeconomic Characteristics of Parents of the Respondents
Characteristics Frequency Percentage Level of Education of Fathers (N=300) None 38 12.7 Primary 73 24.3 Secondary 95 31.7 Tertiary 94 31.3 Level of Education of Mothers (N=346) None 95 27.5 Primary 89 25.7 Secondary 87 25.1 Tertiary 75 21.7 Occupation of Fathers (N=300) Civil servant 106 35.3 Farming 89 29.7 Artisan 56 18.7 Trading 49 16.3 Occupation of Mothers (N=346) Trading 153 44.2 Farming 78 22.5 Civil Servant 78 22.5 Artisan 37 10.7 Family Size (N=360) 0 – 4 34 9.4 5 – 9 232 64.4 10 – 14 70 19.4 15 – 19 20 5.6 20 and above 4 1.1
63
The Socioeconomic statuses of the parents were as follows: Low – 192 (53.3%; 95% CL
48.0% - 58.6%), Middle – 92 (25.6%; 95% CL 21.2% - 30.4%) and High – 76 (21.1%; 95%
CL 17.1% - 25.8%). This is illustrated below:
High, 76 (21.1%)
Low, 192 Middle, 92 (53.3%) (25.6%)
Fig. 3: Socioeconomic Status of Parents of Respondents (N=360)
4.4 Sexual History of Respondents
The age at sexual debut ranged from 13 to 30 years with a mean age of 18 ± 2.2 years. Most of the respondents 261 (72.5%) attained coitarche between the age of 15 and 19 years. This was followed by those aged 20 years and above with 96 (26.7%). However, 3 (0.8%) respondents attained coitarche before the age of 15 years.
Majority of the respondents 249 (69.2%) have had two sexual partners since they became sexually active, though 19 (5.3%) of them have had only one partner.
The reason given for engaging in sexual activity varied. Most respondents, 183 (50.8%), said they had sex for pleasure, while some 55 (15.3%) admitted engaging in sex for pecuniary gains and 7 (1.5%) respondents said they were raped.
A large number of the respondents, 268 (74.4%) have had PID or STI in the past. The remaining 92 (25.6%) have never had PID or STI in the past.
64
The contraceptive use among the respondents was low. Only 104 (28.9%) respondents used any form of contraception. Of this number, 69 (66.3%) respondents regularly used a barrier contraceptive.
Majority of the respondents 337 (93.6%) were nulliparous while 16 (4.4%) of them had one child. Of the remaining, 5 (1.4%) and 2 (0.6%) had two and three or more children, respectively.
A good number of the respondents, 251 (69.7%), have had at least one abortion. 32 (8.9%) respondents have had up to four abortions in the past.
Most, 195 (77.7%), of the respondents who have had induced abortion, had surgical termination only through dilatation and curettage (D & C). Of the remaining respondents, 31
(12.4%) had medical termination using drugs to induce abortion and 25 (9.9%) used both medical and surgical either together or for different pregnancies for those who have had more than one abortions.
This is illustrated in table 4.4 below.
65
TABLE 4.4: Sexual History of Respondents
Sexual History Frequency Percentage Age at Coitarche (Years) (N=360) 10 – 14 3 0.8 15 – 19 261 72.5 20 and above 96 26.7 No of Sex Partners ever had (N=360) 1 19 5.3 2 249 69.2 3 54 15.0 4 and above 38 10.5 Reasons for engaging in sex (N=360) Pleasure 183 50.8 Marriage/Engagement 96 26.7 Monetary Gains 55 15.3 Peer pressure 19 5.3 Raped 7 1.9 Previous STI/PID (N=360) Yes 268 74.4 No 92 25.6 Contraceptive use (N=360) Yes 104 28.9 No 256 71.1 Method of Contraceptive (N=104) Condom 69 66.3 Natural 22 21.2 Pills 5 4.8 Injectables 5 4.8 IUCD 3 2.9 Parity (N=360) 0 337 93.6 1 16 4.4 2 5 1.4 3 and above 2 0.6 No of induced abortion (N=360) 0 109 30.3 1 122 33.9 2 60 16.6 3 37 10.3 4 and above 32 8.9 Method of abortion (N=251) Surgical (D & C) 195 77.7 Medical 31 12.4 Both 25 9.9
66
4.5 Symptoms of Pelvic Inflammatory Disease among Respondents
Respondents reported various menstrual abnormalities. Menorrhagia was reported by 72
(20%) of the 360 respondents and Metrorrhagia was reported by 49 (13.6%) respondents.
Dysmenorrhea was reported by 195 (54.2%) of respondents while oligomenorrhea and inter- menstrual bleeding was present in 22 (6.1%) and 10 (2.8%) respondents respectively.
Less than a third, 109 (30.3%), of the respondents had vaginal discharge. The discharge was purulent among 70 (64.2%), brown in 18 (16.5%), milky/creamy in 15 (13.8%) and white in
6 (5.5%) respondents respectively. The odour of the discharge was foul smelling in 103
(94.5%) respondents with the remaining 6 (5.5%) respondents reporting odourless discharge.
Vulval itching was reported by 25 (6.9%) respondents while lower abdominal pain was reported by 229 (63.6%) respondents. Dyspareunia was present in 192 (53.3%) respondents as shown in table 4.5 below.
67
TABLE 4.5: Symptoms of Pelvic Inflammatory Disease among Respondents Symptoms Frequency Percentage Menstrual abnormality (N=360) Menorrhagia Present 72 20.0 Absent 288 80.0 Metrorrhagia Present 49 13.6 Absent 311 86.4 Dysmenorrhoea Present 195 54.2 Absent 165 45.8 Oligomenorrhea Present 22 6.1 Absent 338 93.9 Inter-menstrual bleeding Present 10 2.8 Absent 350 97.2
Vaginal discharge (N=360) Present 109 30.3 Absent 251 69.7
Colour of Discharge (N=109) Purulent 70 64.2 Brown 18 16.5 Milky/Creamy 15 13.8 White 6 5.5
Odour of Discharge (N=109) Foul Smelling discharge 103 94.5 No Smell 6 5.5
Vulval itching (N=360) Present 25 6.9 Absent 335 93.1
Lower abdominal pain (N=360) Present 229 63.6 Absent 131 36.4
Dyspareunia (N=360) Present 192 53.3 Absent 168 46.7
68
4.6 Clinical Examination of the Respondents
Table 4.6 shows the findings on clinical examination of the respondents. Fever (axillary temperature greater than or equal to 38.3oC) was present in 92 respondents (25.6%).
Pelvic examination revealed that 228 (63.3%) had lower abdominal tenderness. Pelvic masses were felt in 34 (9.4%) respondents and 61 (16.9%) respondents had inguinal lymphadenopathy.
On vaginal examination, 94 (26.1%) respondents were found to have vaginal discharge; 223
(61.9%) had positive Cervical Excitation Tenderness (CET); 84 (23.3%) had uterine tenderness; 198 (55%) had adnexal tenderness and 7 (1.9%) had genital ulcers.
69
TABLE 4.6: Clinical Examination of the Respondents (N=360) Examination findings Frequency Percentage Fever (T ≥ 38.3oC) Present 92 25.6 Absent 268 74.4 Lower Abdominal Tenderness Present 228 63.3 Absent 132 36.7 Pelvic Mass Present 34 9.4 Absent 326 90.6 Inguinal Lymphadenopathy Present 61 16.9 Absent 299 83.1 Genital Ulcers Present 7 1.9 Absent 353 98.1 Vaginal Discharge Present 94 26.1 Absent 266 73.9 Cervical Excitation Tenderness Present 223 61.9 Absent 137 38.1 Adnexal Tenderness Present 198 55.0 Absent 162 45.0 Uterine Tenderness Present 84 23.3 Absent 276 76.7
70
4.7 Clinical Diagnoses among Respondents
Out of the 360 respondents, 229 (63.6%) of them had PID. The other diagnoses were malaria
66(18.3%), gastritis 23 (6.4%), respiratory tract infection 19 (5.3%), urinary tract infection 13
(3.6%), gastroenteritis 4 (1.1%), candidiasis 4 (1.1%), incomplete abortion 1 (0.3%) and
Bartholin cyst 1 (0.3%). This is illustrated in table 4.7 below.
TABLE 4.7: Frequency Distribution of the Clinical Diagnoses among Respondents
(N=360)
Diagnoses Frequency Percentage
PID 229 63.6
Malaria 66 18.3
Gastritis 23 6.4
Respiratory Tract Infection 19 5.3
Urinary Tract Infection 13 3.6
Gastroenteritis 4 1.1
Candidiasis 4 1.1
Incomplete abortion 1 0.3
Bartholin cyst 1 0.3
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4.8 Prevalence of PID among Undergraduates attending ISTH during the period of the study
Overall prevalence of PID among undergraduates attending ISTH during the period of the study = 229 X 1000/360 = 636 per 1000 = 63.6%
The monthly prevalence is as shown in table 4.8 below:
TABLE 4.8: Monthly Prevalence of PID among Undergraduates attending ISTH during the period of the study
S/N Month Undergraduates Female Undergraduates Prevalence (%)
with PID of Reproductive Age
1. February 34 53 64.2
2. March 31 47 66.0
3. April 18 29 62.1
4. May 14 22 63.6
5. June 12 28 42.9
6. July 15 28 53.6
7. August 20 31 64.5
8. September 33 51 64.7
9. October 23 30 76.7
10. November 29 41 70.3
11. Total 229 360 63.6
72
4.9 Association between Sociodemographic Characteristics of Respondents and
Occurrence of PID
The association between Sociodemographic characteristics of the respondents and the occurrence of PID is as illustrated in table 4.9 below. Majority 129 (56.3%) of the respondents who had PID were aged 20 to 24 years followed by 57 (24.9%) in the 25 to 29 years age group and least, 16 (7.0%), among those aged 30 years and above. The proportion of those with PID was however highest among those aged 15 to 19 (73%), followed by those in 20 to 24 years age group (65.8%). The difference between the ages of respondents and occurrence of PID was not found to be statistically significant (χ2 = 4.05, df = 3, p = 0.20)
Most of the respondents with PID were single. There were 214 (63.3%) respondents with PID compared to 124 (36.7%) of respondents without PID who were single. There were 15
(68.2%) married respondents with PID compared to 7 (31.8%) of married respondents without PID. The proportion of PID among married women was higher (71.4%) than that of single ladies (63.3%). There was however, no statistically significant difference between single and married respondents who had PID and those who did not (χ2 = 0.67, df = 1, p = 0.72).
There was a higher number of respondents 124 (54.1%) who were university students with
PID compared to 76 (33.2%) from the Polytechnic and 29(12.7%) from College of Education.
There were however more university students that participated in the study 199 (55.3%). The proportion of patients with PID was however, highest among Polytechnic students (69.1%) followed by University Students (62.3%) and least among students of College of Education
(56.9%). The difference was however not statistically significant (χ2 = 2.57, df = 2, p = 0.28).
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Table 4.9: Occurrence of PID and Sociodemographic Characteristics of Respondents
(N=360)
Sociodemographic PID (%) No PID (%) Total (%) χ2 Test
Characteristics N=229 (63.6) N=131 (36.4) N=360 (100)
Age group (Years)
15 – 19 27 (73) 10 (27) 37 (100) χ2 = 4.05
20 – 24 129 (65.8) 67 (34.2) 196 (100) df=3
25 – 29 57 (58.2) 41 (41.8) 98 (100) p = 0.20
30 and above 16 (55.2) 13 (44.8) 29 (100)
Marital Status
Single 214 (63.3) 124 (36.7) 338 (100) χ2 = 0.67
Ever Married 15 (71.4) 7 (28.6) 21 (100) df = 1,
p = 0.72
Institution
University 124 (62.3) 75 (37.7) 199 (100) χ2 = 2.57
Polytechnic 76 (69.1) 34 (30.9) 110 (100) df = 2
College of Education 29 (56.9) 22 (43.1) 51 (100) p = 0.28
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4.10 Association between Sexual History and Occurrence of PID among Respondents
The association between sexual history and occurrence of PID among respondents is as illustrated in table 4.10 below. The number of respondents with PID was highest, 164
(71.6%), among those who attained coitarche between the ages of 15 to 19 years and least
3(1.3) in respondents who attained coitarche when they were less than 15 years of age. The proportion of respondents with PID was highest (100%) in those less than 15 years. There was no statistically significant relationship between age at coitarche and the occurrence of
PID among respondents (χ2 = 1.80, df = 2, p = 0.40).
Most of the respondents with PID 147 (64.2%) have had two sex partners. Only 7 (3.1%) respondents who have had only one sexual partner had PID. There was a steady rise in proportion in the number of respondents with PID with rise in the number of sex partners with 36.8%, 59%, 70.4% and 97.4% of respondents with one, two, three and four or more partners having PID respectively. There was a statistically significant difference between the number of sex partners in those with PID compared to those without the disease (χ2 = 27.93, df = 3, p < 0.001).
The reasons for engaging in sexual activity among respondents varied. Occurrence of PID was highest, 7 (100%) among rape victims. This was followed by respondents who admitted engaging in sex for monetary gains, 42 (76.4%). It was least among respondents who were either married or engaged to be married 51(53.1%) and therefore had sex with their partner on account of that. There was a significant association between the reason for engaging in sexual activity and occurrence of PID among respondents (χ2 = 12.62, df = 4, p = 0.01).
Most of the respondents 179 (66.8%) who have had PID or STI in the past currently have PID compared to 50 (54.3%) without STI or PID in the past. The difference was found to be statistically significant (χ2 = 4.58, df = 1, p = 0.02).
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The contraceptive usage was low as only 69 (5.9%) of respondents used a barrier contraceptive anytime they had sex. Of these respondents, 18 (26.1%) of them had clinical
PID. Of those who did not use a barrier contraceptive consistently, 211 (72.5%) of them had
PID. The difference in occurrence of PID between those who used barrier contraceptive consistently and those who did not was found to be statistically significant (χ2 = 19.55, df = 1, p < 0.001).
Out of the 360 respondents studied, 251 (69.7%) have had at least one induced abortion.
Among respondents who have had an induced abortion in the past, 171 (68.1%) of them had
PID. Of the remaining 109 respondents who have never had induced abortion, 58 (53.2%) of them had PID. There was a statistically significant relationship between history of induced abortion and occurrence of PID (χ2 = 7.30, df = 1, p = 0.01).
Among the respondents that have had 0, 1, 2, 3 and 4 or more induced abortions, 80 (73.4%),
71 (58.2%), 35 (58.3%), 22 (59.5%) and 21 (65.6%) of them had PID respectively. There was however, no statistically significant difference between those with PID and those without PID in relation to the number of induced abortion done (χ2 = 7.11, df = 4, p = 0.14).
Majority, 132 (57.4%), of the respondents with PID have had at least one surgical termination of pregnancy while 12 (82.2%) respondents with PID had medical termination of pregnancy.
There was a statistically significant difference in the method of abortion used when matched with the occurrence of PID (χ2 = 5.04, df = 1, p = 0.03) with respondents with surgical termination of pregnancy more likely to develop PID than those with medical termination.
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Table 4.10: Association between Sexual History and Occurrence of PID among
Respondents
Sexual History PID Present (%) PID Absent (%) Total (%) Test Statistics N=229 (63.6) N=131 (36.4) N=360 (100) χ2 Test Coitarche (Years) (N=360) 10 – 14 3(100) 0 (0.0) 3 (100) χ2 = 1.8 15 – 19 164 (62.8) 97 (37.2) 261 (100) df = 2 20 and above 62 (64.6) 34 (35.4) 96 (100) p = 0.4 Sex Partners (N=360) 1 7 (36.8) 12 (63.2) 19 (100) χ2 = 27.93 2 147 (59) 102 (41) 249 (100) df = 3 3 38 (70.4) 16 (29.6) 54 (100) p < 0.001 4 and above 37 (97.4) 1 (2.6) 38 (100) Reasons for Engaging in Sex (N=360) Pleasure 116 (63.4) 67 (36.6) 183 (100) χ2 = 12.62 Marriage/Engagement 51 (53.1) 45 (46.9) 96 (100) df = 4 Monetary Gains 42 (76.4) 13 (23.6) 55 (100) p = 0.01 Peer Pressure 13 (68.4) 6 (31.6) 19 (100) Raped 7 (100.0) 0 (0.0) 7 (100) Previous STI (N=360) Yes 179 (66.8) 89 (33.2) 268 (100) χ2 = 4.58 No 50 (54.3) 42 (45.7) 92 (100) df = 1 p = 0.02 Persistent Barrier Contraceptive Use (N=360) Yes 18 (26.1) 51 (73.9) 69 (100) χ2 = 19.55 No 211 (72.5) 80 (27.5) 291 (100) df = 1 p < 0.001 Parity (N=360) 0 215 (63.8) 122 (36.2) 337 (100) χ2 = 0.14 1 10 (62.5) 6 (37.5) 16 (100) df = 2 2 and above 4 (57.1) 3 (42.9) 7 (100) p = 0.93 History of Induced Abortion (N=360) Yes 171 (68.1) 80 (31.9) 251 (100) χ2 = 7.3 No 58 (53.2) 51 (46.8) 109 (100) df = 1 p = 0.01 No of Induced Abortion (N=360) 0 80 (73.4) 29 (26.6) 109 (100) χ2 = 7.11 1 71 (58.2) 51 (41.8) 122 (100) df = 4 2 35 (58.3) 25 (41.7) 60 (100) p = 0.14 3 22 (59.5) 15 (40.5) 37 (100) 4 and above 21 (65.6) 11 (34.4) 32 (100) Method of Abortion Used (N=251) Medical 12 (38.7) 19 (61.3) 31 (100) χ2 = 5.04 Surgical 132 (57.4) 88 (42.6) 220 (100) df = 1 p = 0.03
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4.11: Association between Sexual History of Respondents and Socioeconomic Status of their Parents
The association between sexual history of respondents and socioeconomic status of their parents is as shown in table 4.11 below. The proportion of respondents with low SES decreased with increasing age at coitarche. The three who had sexual debut when they were less than 15 years were all from low socioeconomic backgrounds. This was followed by 138
(52.9%) in those aged 15 to 19 years and 51 (53.1%) in respondents aged 20 years and above.
The difference in age at coitarche among the various SES was however not statistically significant (χ2 = 2.90, df = 4, p = 0.40)
The number of sex partners among respondents from the various SES showed that there was a statistically significant higher proportion of respondents from low SES with multiple sex partners compared to respondents from middle and high socioeconomic classes (χ2 = 15.87, df = 6, p = 0.02).
Of the 268 (74.4%) respondents with previous history of STI or PID, 175 (65.3%) of them were from low socioeconomic backgrounds while 50 (18.7%) and 43 (16%) of them were from middle and high socioeconomic backgrounds respectively. This difference was found to be statistically significant (χ2 = 3.69, df = 2, p = 0.05)
A total of 69 respondents used barrier contraceptive (condom) anytime they had sex. Of this number 19 (27.6%), 21 (30.4%) and 29 (42%) were from low, middle and high socioeconomic backgrounds respectively. There was a statistically significant difference in barrier contraceptive usage among responds from various socioeconomic classes (χ2 = 29.13, df = 2, p < 0.001).
Those in the low socioeconomic class had the highest proportion of induced abortion compared to those in other social classes. This difference was statistically significant (χ2 =
26.28, df = 8, p < 0.001).
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Surgical termination of pregnancy through dilatation and curettage was used more by respondents in the various socioeconomic classes. There was however no statistically significant difference in the method used by respondents in the various socioeconomic classes
(χ2 = 1.55, df = 2, p = 0.22).
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TABLE 4.11: Association between Sexual History of Respondents and Socioeconomic
Status of their Parents
Sexual Socioeconomic Status of Parents χ2 Test History Low (%) Middle (%) High (%) Total (%) N=192(53.3) N=92(25.6) N=76(21.1) N=360(100) Age at Coitarche (Years) (N=360) 10 – 14 3 (100) 0 (0) 0 (0) 3 (100) χ2= 2.90 15 – 19 138 (52.9) 69 (26.4) 54 (20.7) 261 (100) df = 4 20 and above 51 (53.1) 23 (24.0) 22 (22.9) 96 (100) p = 0.40
No of Sex Partners (N=360) 1 10 (52.6) 5 (26.3) 4 (21.1) 19 (100) χ2=15.87 2 118 (47.4) 72 (28.9) 59 (23.7) 249 (100) df = 6 3 41 (75.9) 8 (14.8) 5 (9.3) 54 (100) p= 0.016 4 and above 23 (60.5) 7 (18.4) 8 (21.1) 38 (100)
Previous History of STI (N=360) Yes 175 (65.3) 50 (18.7) 43 (16) 268 (100) χ2=3.69 No 17 (18.5) 42 (45.6) 33 (35.9) 92 (100) df = 2 p = 0.05
Persistent Barrier Contraceptive Use (N=360) Yes 19 (27.6) 21 (30.4) 29 (42) 69 (100) χ2=29.13 No 173 (59.5) 71 (24.4) 47 (16.1) 291 (100) df = 2 p<0.001
History of Induced Abortion (N=360) Yes 149 (59.4) 62 (24.7) 40 (15.9) 251 (100) χ2=16.40 No 43 (39.5) 30 (27.5) 36 (33) 109 (100) df = 2 p<0.001
No of Induced Abortion (N=360) 0 43 (39.5) 30 (27.5) 36 (33) 109 (100) χ2=26.28 1 67 (54.9) 32 (26.2) 23 (18.9) 122 (100) df = 8 2 33 (55) 20 (33.3) 7 (11.7) 60 (100) p<0.001 3 28 (75.7) 3 (8.1) 6 (16.2) 37 (100) 4 and above 21 (65.6) 7 (21.9) 4 (12.5) 32 (100)
Method of Abortion Used (N = 251) Medical 18 (58.1) 6 (19.3) 7 (22.6) 31 (100) χ2=1.55 Surgical 132 (60) 56 (25.5) 32 (14.5) 220 (100) df = 2 p = 0.22
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4.12 Association between SES of Parents and Occurrence of PID
Of the 192 respondents from low socioeconomic class, 126 (65.6%) had PID while the remaining 66 (34.4%) did not have PID. Of the 92 and 76 respondents from middle and high socioeconomic classes, 62 (67.4%) and 41 (53.9%) had PID respectively. Those without PID in the middle and high socioeconomic classes were 30 (32.6%) and 35 (46.1%) respectively.
There was however no significant association between socioeconomic status of parents and the occurrence of PID among respondents (χ2 = 3.97, df = 2 and p = 0.14).
80
70 65.6 67.4 (%) 60 53.9 50 46.1
40 34.4 32.6 PID 30 No PID 20
10 Presence/Absence PID of Presence/Absence
0 Low SES Middle SES High SES Socioeconomic Status of Parents of Respondents
Fig 4: Association between SES of Parents and Occurrence of PID
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CHAPTER FIVE
DISCUSSIONS, CONCLUSION AND RECOMMENDATIONS
This study looked at the occurrence of Pelvic Inflammatory Disease and associated factors among undergraduates attending Irrua Specialist Teaching Hospital (ISTH), Irrua, Edo State.
It was a hospital based study conducted at the General Out-Patient Department (GOPD),
Accidents and Emergency (A & E) unit and gynaecological clinic of ISTH. A total of 360 respondents who were all female undergraduates from Ambrose Alli University, Ekpoma,
Auchi Polytechnic, Auchi and College of Education, Igueben participated in the study.
5.1 Sociodemographic Characteristics of Patients
Majority of the respondents studied (54.4%) were aged 20 to 24 years followed by those aged
25 to 29 years who made up 27.2% of the respondents. Occurrence of PID was highest among respondents aged 15 – 19 years with 73% of them having PID followed by respondents aged 20 to 24 years and 25 to 29 years with 65.8% and 58.2% of them having
PID respectively. The difference between the age of respondents and occurrence of PID was however not statistically significant. The findings of this study agree with findings of other studies that PID is highest among adolescents and young adults.1,3,5,34,35 A study by Raya et al3 in Israel also found PID to be highest among girls aged 15 to 19 years. This is also similar to findings by Barrett and Taylor34 that PID was commonest among girls 15 to 19 years in the
UK. The study done in Nguru, North eastern Nigeria by Okon1 found PID to be highest among young women aged 21 to 30 years. Similar findings were reported by Kennedy et al,5 who found PID to be highest among women in their 20s in Port Harcourt. French35 in
England also found PID to be highest among women aged 20 to 24 years.
Most of the respondents were single (93.9%). This is due to the fact that most female undergraduates are adolescents and young women. In Edo state, like most parts of Southern
Nigeria, women commonly marry after graduation from the tertiary institution. Most
82 undergraduates are therefore unmarried in this part of the country. The proportion of married women with PID (71.4%) was more than the proportion among those who were single
(63.3%). The difference was not statistically significant. This however differed from a study by Simms et al,12 which found PID to be significantly higher in single ladies than married ones. It however agreed with findings of Prasad et al,23 who found PID to be higher among young married women in India compared to single ladies. The difference may be due to extra marital affairs on the part of either of the partners,23 or the practice of polygamy which is accepted by most cultures in Nigeria and therefore a common practice in the country.16
Majority of the respondents were of “Esan” tribe (45.3%) followed by Afenmai (34.4%). This is due to the fact that the hospital and two of the schools (Ambrose Alli University, Ekpoma and College of Education, Igueben) are in Esan land while the third (Auchi Polytechnic,
Auchi) is in Etsako. Students from other parts of Edo state and Nigeria also attend these institutions as can be seen in the ethnicity of the patients.
Most of the students were from Ambrose Alli University, Ekpoma. The high number of respondents with PID among university undergraduates compared to those from Polytechnic and College of Education may be due to the fact that, of the three schools, it is the closest to the hospital hence patients from the school will access care more from this hospital compared to students from the other institutions who will have to consider cost and will therefore come to the hospital when it becomes really necessary. However, the proportion of PID from
Polytechnic students was higher than those from the University and College of Education.
The increase, like that of the Muslims, could be due to the distance of the polytechnic from the study location compared to the other schools, necessitating presentation of serious or chronic cases that could not be managed in Auchi among other reasons. There was, however, no statistically significant relationship between occurrence of PID and type of institution attended (p = 0.28).
83
Sponsorship was mainly from parents (89.2%). However, respondents were more among students who got less money from their parents (less than N10, 000) (58.3%) compared to those who got more. These students with less allowance are more likely to engage in sex for monetary gains as a way of supplementing what they got from their parents.6
5.2 Socioeconomic Characteristics of Parents
Half of the respondents were from parents with low socioeconomic status (53.3%). Simms et al12 and Dehne21 in separate studies found PID to be highest among ladies with low socioeconomic status. The World Health Organisation19 also recognises low socioeconomic status as a risk factor for PID. Suleiman36 and Isibor46 in separate studies in Lagos and Irrua, respectively found PID to be highest among women of low social class. The increased prevalence of PID among women of low social class have been attributed to, among other things, their inability to access standard medical care when they have sexually transmitted infection thus aiding its progression to PID.36
This study was however at variance with the above studies as it did not find any significant association between the occurrence of PID and the socioeconomic status of parents of the respondents (p = 0.14). The study also found PID to be highest among respondents whose parents were of middle socioeconomic status (67.4%) followed by those of low (65.6%) and high (53.9%) socioeconomic status respectively. The findings of this study showed that female undergraduates with PID cut across the various socioeconomic classes. This therefore means that socioeconomic status of parents cannot be used as an independent risk factor in predicting the occurrence of PID among undergraduates attending Irrua Specialist Teaching
Hospital.
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5.3 Clinical Features
All the respondents with PID complained of lower abdominal pain. They had varying degrees of menstrual irregularity such as dysmenorrhoea (54.2%), menorrhagia (20%), metrorrhagia
(13.6%), oligomenorrhea (6.1%) and inter-menstrual bleeding (2.8%). Some of the respondents (30.3%) reported abnormal vaginal discharge while 53.3% of them experienced dyspareunia.
The examination findings were also consistent with those of clinical PID. Fever was present in 25.6% of the respondents. Fever here is defined as body temperature greater than or equal to 38.3oC.6 Jaiyeba and Soper37 in their study recognised a temperature greater than or equal to 38.3oC as one of the signs of PID. This is similar to the findings of Haggerty and Ness33 as well as the CDC guidelines6 for the diagnosis of PID.
Most of the respondents (63.3%) had abdominal tenderness, cervical excitation tenderness
(61.9%), adnexal tenderness (55%) and uterine tenderness (23.3%). In a study by Bartlett,
Levison and Munday,28 diagnosis of PID was based on the presence of abdominal tenderness with or without cervical excitation tenderness or adnexal tenderness on bimanual examination. They also reported that the sensitivity of abdominal tenderness, cervical motion tenderness and adnexal tenderness when compared with diagnostic laparoscopy was 61.2%,
79.9% and 90.3% respectively.28
The 229 respondents in whom diagnosis of PID was made all presented with abdominal pain and had one or more of the above clinical signs. This is in line with the recommended guidelines by CDC for clinical diagnosis of PID which states that empirical treatment for PID should be initiated in sexually active young women and other women at risk for STDs if they are experiencing pelvic or lower abdominal pain, if no cause for the illness other than PID can be identified, and if one or more of the following minimum criteria are present on pelvic examination: cervical motion tenderness or uterine tenderness or adnexal tenderness.6,24
85
The other 131 patients had other clinical conditions including malaria, gastritis, respiratory tract infection, urinary tract infection, gastroenteritis, candidiasis, incomplete abortion and bartholin cyst.
5.4 Prevalence of PID
The prevalence of PID among undergraduates attending Irrua Specialist Teaching Hospital,
Irrua was found to be 63.6%. This compares favourably with the findings of Olowe et al,10 in
Osogbo, South-western Nigeria and Okon et al,1 in Nguru, North-Eastern Nigeria who reported PID prevalence of 70% and 62.8%, respectively. It is however at variance with the findings of Kennedy et al,5 in Port Harcourt and Bourne31 in Jamaica who reported low PID prevalence of 11% and 17%, respectively. The difference may be due to the fact that Osogbo and Nguru are semi-urban areas unlike Port Harcourt that is a big city with several health facilities. Patients with PID may not present to the teaching hospital due to the desire for privacy which is often lacking in a teaching hospital setting where patients are evaluated by several cadre of doctors and other health professionals and used for teaching during rounds and clinics. There are also several alternatives in the cities as opposed to rural and semi urban centres like ours where there are dearth of standard heath care facilities outside the teaching hospital. Another reason may be the increased awareness and therefore improved health seeking behaviour. This is also the opinion expressed in the study by Okon.1
5.5 Risk factors of PID in respondents
The age at sexual debut in this study ranged from 13 to 30 years with a mean age of 18 years.
All the respondents who had sexual debut when they were younger than 15 years all had PID
(100%). Majority of the patients attained coitarche between the ages of 15 and 19 years
(72.5%). Those in the low socioeconomic status attained coitarche earlier than those in the higher socioeconomic classes, for instance those who had their sexual debut before the age of
15 years were all in the low socioeconomic class (100%). There was no significant
86 relationship between the age at coitarche and the occurrence of PID (p = 0.40). This is contrary to the findings of a study by Simms et al,12 where age at first intercourse was found to be a significant risk factor for the occurrence of PID, and another study by Ugboma et al,13 in Port Harcourt. Both studies also found most of the women with PID attaining coitarche between the ages of 15 and 19 years.12,13
Most of the respondents had two sex partners (69.2%). Occurrence of PID was highest among respondents with 4 or more partners. An increase in the occurrence of PID with increase in the number of sexual partners was also noted in the study. There was an association between the occurrence of PID and multiple sex partners among respondents studied (p < 0.001). This is similar to findings of Simms et al12 in England and Ugboma et al13 in Port Harcourt
Nigeria. Both studies found multiple sex partners to significantly increase the risk of PID.12,13
Respondents engaged in sexual activity for various reasons. Most of the subjects in this study
(50.8%) said they engaged in sex to derive pleasure. However, some of them (15.3%) admitted engaging in sex for monetary gains. Others ((20.6%) said they had sex with their partners anticipating marriage, their partners having promised to marry them.
Majority of respondents (74.4%) have had PID/STI in the past. Occurrence of PID was higher in respondents with previous history of PID/STI (66.8%). Previous history of PID/STI was found to be a statistically significant risk factor for the occurrence of PID (p = 0.02). This compare with the study of Prasad, et al23 which found previous history of PID/STI as a significant risk factor for the occurrence of PID.23
Contraceptive use was low among the study population (28.9%). Of the respondents that used any form of contraceptive, 66.3% consistently used condom. There was a higher occurrence of PID (72.5%) among those respondents who did not use condom consistently compared to those who used (26.1%). The difference between the occurrence of PID among respondents who used condom consistently and those who did not was found to be statistically significant
87
(p < 0.001). This compares with a study by Oye-Adeniran64 which found a low contraceptive prevalence (11.1%) among Nigerian women of child-bearing age. There was also a significantly lower condom use among respondents from low socioeconomic class (p <
0.001). The low level of contraceptive use especially among those in low socioeconomic class may be due to their inability to negotiate condom use with their older sexual partners who usually give them money for sex.6 It could also be due to low level of awareness considering the fact that most subjects from low socioeconomic backgrounds have parents who are mostly illiterate or barely literate.73
Parity did not significantly affect the occurrence of PID in the study subjects (p = 0.93). A study by Simms12 identified low parity as a risk factor for the occurrence of PID. Findings in this study may be due to the fact that most of the study subjects were single, nulliparous ladies.
A good no of the respondents (69.7%) have had at least one induced abortion in the past.
Occurrence of PID was higher among respondents who have had an induced abortion in the past (68.1%). There was a statistically significant difference in occurrence of PID between respondents with history of previous abortion and those without (p = 0.01). History of induced abortion was also significantly higher among respondents from low socioeconomic backgrounds (p < 0.001). This is a dangerous trend as abortion has been shown to be associated with increased risk of developing PID.43,44
This study however did not find a statistically significant association between the number of induced abortion and PID (p = 0.14). This implies that even one induced abortion is enough to significantly increase the risk of PID.
Most of the respondents that had induced abortion used the surgical method (Dilatation and
Curettage) (77.7%) with another 9.9% using both medical and surgical methods. There was a statistically significant difference between the method of abortion used and the risk of
88 developing PID (p = 0.03). This agrees with the findings of Ehigiegba and Okosun43 in Benin where dilatation and curettage was the commonest mode of induced abortion. Another study by Adesiyun and Ameh44 in Zaria found a significant relationship between unsafe abortion and post abortal PID in their study of pelvic abscess complicating unsafe abortion.
5.6 Limitations
The study was hospital-based and most patients with symptoms of PID/STIs commonly resort to self-medications, present to patent medicine dealers, nurses and herbal homes or go to spiritualist. Such patients were therefore missed in this study as only patients who presented to Irrua Specialist Teaching Hospital during the period of the study participated in the study.
Diagnosis of PID was on clinical grounds. Thus patients with subclinical PID were missed in the study. Such patients despite not meeting the criteria for clinical diagnosis of PID could proceed to develop complications of PID later in life.
The study was restricted to undergraduates. Therefore, secondary school students, school leavers, artisans and other non-undergraduates were excluded from the study.
5.7 Relevance of the Study to Family Medicine
Pelvic inflammatory disease is a major cause of morbidity among teenagers and young adults, including undergraduates. The occurrence of PID leads to adverse sequelae such as infertility, ectopic pregnancy and chronic pelvic pain. Highlighting the risk factors as well as their role in the development of PID will help stimulate stakeholders to come up with measures that will mitigate it. Such measures include advocacy and health education to undergraduates on the risk factors of PID and its sequelae. This can be done when they present to health facility for treatment as well as outreach to educational institutions and the community. The Family
Physician is best positioned to play this role.
The study will help family physicians who are usually the first point of contact to increase their index of suspicion for PID and its sequelae in vulnerable groups when they present to
89 them. This will make them institute measures to prevent occurrence or address promptly when present. These measures include advocacy, counselling and early diagnosis and treatment.
Findings from this study could be used to plan appropriate intervention such as health education, advocacy and other measures geared towards behavioural change among vulnerable population. Behavioural change is a key factor in the primary prevention of PID.
Potential modifiable risk factors have been shown to be associated with PID, including early coitarche and not using barrier contraception. Interventional strategies targeted at young persons including students will help in preventing and reducing the burden of PID and its attendant consequences in our environment. Such strategies include promotion of safe sex including abstinence, faithfulness to spouse/partner and correct use of condom to prevent infections and/or unwanted pregnancies among high risk populations. Prevention of PID through the above measures as well as prompt identification and treatment constitute primary and secondary levels of care respectively, both of which are of paramount importance to the family physicians. These measures would also protect against complications thus halting progression to the third level of care which is rehabilitation.
5.8 Conclusion
This study found a PID prevalence of 63.6% among undergraduates attending Irrua Specialist
Teaching Hospital. Majority of these students were from low socioeconomic background with their parents mostly illiterates and mostly engaged in farming and petty trading. This was followed by those in the middle socioeconomic class whose parents had mainly secondary education and were mostly artisans, traders and intermediate civil servants. Those from high socioeconomic class whose parents were graduates and mostly civil servants were least in the study.
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The study identified risk factors for the occurrence of PID to include multiple sex partners, previous history of PID/STI and low barrier contraceptive (condom) use. History of induced abortion, multiple induced abortion as well as dilatation and curettage as preferred method of abortion were also identified as risk factors.
5.9 Recommendations
1. As family physicians, we should, as major stakeholders in the healthcare setting
educate adolescent and young ladies on the dangers of PID (infertility, ectopic
pregnancy and chronic pelvic pain) as well as the risk factors for the occurrence of
PID with a view to helping them avoid these risk factors in order to prevent PID from
occurring. Our role as educators has already prepared us for this task.
2. Behavioural change with regard to engaging in sexual activities should be encouraged
particularly among high risk populations. Such behavioural changes include the
power to say no to sexual overtures, delaying sexual debut and using barrier
contraception. These measures will go a long way in preventing the occurrence of PID
as well as unwanted pregnancies.
3. Promotion of safe sex (abstinence, faithfulness to partner as well as use of barrier
contraception) should be done whenever the opportunity present itself such as during
consultations even if the patient presents with another ailment other than PID. The
family physician should use every opportunity to educate the people particularly the at
risk population and promote safe sex.
4. Women of reproductive age, particularly young undergraduates should also be
advised to present early to the hospital whenever they have symptoms of sexually
transmitted infections as they commonly progress to PID if not promptly and properly
treated. Prompt diagnosis and treatment of clinically suspicious PID should be
instituted in line with the CDC guidelines to prevent complications from setting in.
91
5. Further studies that will include laboratory diagnosis should be done among the study
population to identify patients with subclinical PID missed by this study.
92
REFERENCES
1. Okon KO, Ayilara R, Bello K, Uba A, Aniesona TA. Microbial Spectrum of
Pelvic Inflammatory Diseases in Nguru, Nigeria. Afr. J. Cln. Exper. Microbiol.
2008; 9(3): 157-165
2. Mahon BE, Wang J, Rosenman MB, Katz BP. Pelvic inflammatory disease during
the post-partum year. Infectious diseases in obstetrics and gynaecology. 2005;
13(4): 191-196.
3. Raya BA, Bamherger E, Kerem NC, Kessel A, Srugo I. Beyond “safe sex” – can
we fight adolescent pelvic inflammatory disease? Eur J Pediatr 2013; 172: 581-
590
4. Shepherd, SM. Pelvic Inflammatory Disease. Medscape. Updated: 10 April,
2013. Accessed 26 January, 2015.
5. Kennedy TW, John O, Sunny E. Prevalence of Chlamydia Trachomatis Infection
among Female Undergraduates of the University of Port Harcourt Using Strand
Displacement and Amplification [SDA] Technique The Nigerian Health Journal,
2012; 12(2): 35-38
6. Centre for Disease Control and Prevention. Sexually Transmitted Diseases 2010
Treatment Guidelines. MMWR 2010: 59(No.-RR12): 63-67
7. Rabiu KA, Adewunmi AA, Akinlusi FM, Akinola AI. Female reproductive
tract infections: Understandings and care seeking behaviour among women of
reproductive age in Lagos, Nigeria BMC Women’s Health 2010. Available online
at: http://www.biomedcentral.com/1472-6874/10/8. Accessed 26 January, 2015.
8. Anorlu RI, Oluwole A, Abudu OO, Adebajo S. Risk factors for ectopic pregnancy
in lagos, Nigeria. Acta Obstet Gynecol Scand 2005; 84: 184-188
93
9. Moses S. Pelvic Inflammatory Disease. Family Practice Notebook. Updated 15
April, 2012. Available at www.fpnotebook.com. Accessed 26 January, 2015.
10. Olowe OA, Alabi A, Akindele AA. Prevalence Pattern of Bacterial Isolates in
Cases of Pelvic Inflammatory Disease Patients at a Tertiary Hospital in Osogbo,
Nigeria. Environmental Research Journal 2012; 6(4): 308-311
11. Soper DE. Pelvic inflammatory disease. Obstet Gynecol 2010; 116: 419-428
12. Simms I, Stephenson J M, Mallinson H, Peeling R W, Thomas K, Gokhale R, et
al. Risk factors associated with pelvic inflammatory disease. Sex Transm Infect.
2006; 82(6): 452-457.
13. Ugboma HAA, Nwagwu VO, Jeremiah I. Genital chlamydia trachomatis infection
among female undergraduate students of university of Port Harcourt, Nigeria.
Nigerian Medical Journal 2014; 55(1): 9-13
14. Fatusi A, Blum R. Predictors of early sexual initiation among a nationally
representative sample of Nigerian adolescents. BMC public health. 2008; 8(1): 136.
15. Urassa W, Moshiro C, Chalamilla G, Mhalu F, Sandstrom E. Risky sexual practices
among youth attending a sexually transmitted infection clinic in Dar es Salaam,
Tanzania. BMC infectious diseases. 2008; 8(1): 159.
16. Ebisi NT. The impacts of culture on the transmission of infectious diseases in Nigeria:
The case of Awka south, Anambra state. African Journal of Social Sciences. 2012;
2(4): 173-190.
17. Olasode OA. Sexual behaviour in adolescents and young people attending a sexually
transmitted disease clinic, Ile Ife, Nigeria. Indian J Sex Transm Dis [serial online]
2007; 28: 83-86. Available from: http://www.ijstd.org/text.asp. Accessed 9th
December, 2015.
94
18. Omoteso BA. A study of the sexual behaviour of university undergraduate
students in south western Nigeria. J. Soc. Sci. 2006; 12(2): 129-133
19. WHO [World Health Organization]. Global strategy for the prevention and
control of sexually transmitted infections: 2006-2015. Geneva: WHO 2007.
Available from: http://www.who.int/reproductivehealth. Accessed 26 January,
2015.
20. Oyedeji GA. Socio-economic and cultural background of hospitalized children in
Ilesa. Nig J Paediatr. 1985; 12: 111-117.
21. Dehne, KL. Sexually transmitted infections among adolescents: The need for
adequate health services. World Health Organization and Deutsche Gesellschaft
fuer Technische Zusammenarbeit (GTZ) GmbH 2005. Accessed 26 January,
2015.
22. Aladeselu N. Draft Strategic Plan for Improving the Reproductive Health of
Young Adults and Adolescents in Edo State Nigeria. Youth Reproductive Health
Policy Database. 2002. Available at www.youth-policy.com. Accessed 26
January, 2015.
23. Choudhry S, Ramachandran VG, Das S, Bhattacharya SN, Mogha NS. Pattern of
sexually transmitted infections and performance of syndromic management
against etiological diagnosis in patients attending the sexually transmitted
infection clinic of a tertiary care hospital. Indian Journal of Sexual Transmission
Diseases, 2010; 31: 104-108.
24. Prasad JH, Abraham S, Kurz KM, George V, Lalitha MK, John R, et al.
Reproductive Tract Infections Among Young Married Women in Tamil Nadu,
India. International Family Planning Perspectives, 2005, 31(2): 73-82
95
25. Sweet RL. Pelvic Inflammatory Disease: Current concepts of diagnosis and
management. Curr Infect Dis Rep 2012; 14: 194-203
26. Evans DTP, Jaleel H, Kinsella MT. A retrospective audit of the management and
complications of pelvic inflammatory disease. International Journal of STD and
AIDS 2008; 19: 123-124
27. Li M, McDermott R. Smoking, poor nutrition, and sexually transmitted infections
associated with pelvic inflammatory disease in remote North Queensland
Indigenous communities, 1998-2005. BMC women's health. 2015; 15(1): 31.
28. Bartlett EC, Levison WB, Munday PE. Easily missed? Pelvic inflammatory
disease. BMJ 2013; 346: f3189. Accessed 26 January, 2015.
29. Doxanakis A, Hayes RD, Chen MY, Gurrin LC, Hocking J, Bradshaw CS, et al.
Missing pelvic inflammatory disease? Substantial differences in the rate at which
doctors diagnose PID. Sex Trans Infect 2008; 84: 518-523
30. Jaiyeoba O, Lazenby G, Soper DE. Recommendations and rationale for the
treatment of pelvic inflammatory disease. Expert Rev. Anti Infect. Ther. 2011;
9(1): 61-70
31. Bourne PA. Urinary tract infections, pelvic inflammatory disease, hepatitis B and
diabetes mellitus among women of the reproductive ages in a developing nation.
Journal of Clinical and Diagnostic Research 2011; 5(2): 331-339
32. Bourne PA. Sexually assaulted females on their sexual debut: Reproductive health
matters. Journal of Clinical and Diagnostic Research 2010; 4: 3513-3523
33. Haggerty CL, Ness RB. Epidemiology, pathogenesis and treatment of pelvic
inflammatory disease. Expert Rev. Anti Infect. Ther. 2006; 4(2): 235-247
34. Barrett S, Taylor C. A review on pelvic inflammatory disease. International
Journal of STD and AIDS 2005; 16: 715-721
96
35. French CE, Hughes G, Nicholson A, Yung M, Ross JD, Williams T, et al.
Estimation of the rate of pelvic inflammatory disease diagnoses: Trends in
England, 2000-2008. Sex Transm Dis 2011; 38: 158-62.
36. Suleiman IA, Tayo F. comparative costs of antibacterial usage in sexually
transmitted infections in a Nigerian teaching hospital. Trop J Pharm Res, 2010;
9(6): 549-555
37. Jaiyeoba O, Soper DE. A practical approach to the diagnosis of pelvic
inflammatory disease. Infectious diseases in Obstetrics and Gynecology 2011;
753037
38. Ekpenyong CE, Etukumana E. Ethnicity, family socioeconomic inequalities and
prevalence of vaginal douching among college students: The implication for
health. Journal of American College Health 2013; 61(4): 221-230
39. Chinsembu KC. Sexually transmitted infections in adolescents. The Open
Infectious Diseases Journal. 2009; (3): 107-117.
40. Dhont N, Wijgert JVD, Vyankandondera J, Busasa R Gasarabwe A, Temmerman
M. Results of infertility investigations and follow-up among 312 infertile women
and their partners in Kigali, Rwanda. Tropical Doctor 2011; 41: 96-101
41. Ness RB, Smith KJ, Chang CC, Schisterman EF, Bass DC. Prediction of pelvic
inflammatory disease among young, single, sexually active women. Sexually
transmitted diseases. 2006; 33(3): 137-142.
42. Lamina MA. Prevalence of abortion and contraceptive practice among women
seeking repeat induced abortion in western Nigeria. Journal of Pregnancy. 2015
43. Ehigiegba AE, Okosun EE. Management challenges of pelvic abscess in a tertiary
health institution in Nigeria. Trop J Obstet Gynaecol. 2010; 27(2): 57-62.
97
44. Adesiyun AG, Ameh C. An Analysis of Surgically Managed Cases Of Pelvic Abscess
Complicating Unsafe Abortion. J Ayub Med Coll Abbottabad 2006; 18(2): 14-16
45. Viberga I, Odlind V, Lazdane G. Characteristics of women at low risk of STI
presenting with pelvic inflammatory disease European Journal of Contraception &
Reproductive Health Care; 2006; 11(2): 60-68
46. Isibor JO, Samuel SO, Nwaham CI, Amanre IN, Igbinovia O, Akhile AO.
Prevalence of bacterial and Candida albicans infection amongst women attending
Irrua Specialist Teaching Hospital, Irrua, Nigeria. Afr. J Micrbiol. Res. 2011;
5(20): 3126-3130
47. Jaiyeoba O, Soper DE. Cervicitis and Pelvic Inflammatory Disease. In: Beigi RH,
ed. GIP – Gynaecology in Practice: Sexually Transmitted Disease. Hoboken, NJ,
USA: Wiley-Blackwell. 2012; 14-25
48. Dayan L. Pelvic inflammatory disease. Australian Family Physicians 2006;
35(11): 858-860
49. Risser WL, Risser JMH. The incidence of pelvic inflammatory disease in
untreated women infected with Chlamydia trachomatis: a structured review.
International Journal of STD and AIDS 2007; 18: 727-731
50. Tukur J, Shittu SO, Abdul AM. A case control study of active genital Chlamydia
trachomatis among patients with tubal infertility in Northern Nigeria. Tropical
Doctor 2006; 36: 14-16.
51. Okoror LE, Agbonlahor DE, Esumeh FI, Umolu PI. Prevalence of chlamydia in
patients attending gynaecological clinics in south eastern Nigeria. African Health
Sciences. 2007; 7(1): 18-24
98
52. Enwuru CP, Umeh SI. Asymptomatic carriage of Chlamydia trachomatis among
young adults in Owerri, South East Nigeria. IOSR Journal of Nursing and Health
Sciences 2014; 3(2): 49-53.
53. Ness RB, Kip KE, Hillier SL, Soper DE, Stamm CA, Sweet RL, et al. A cluster
analysis of bacterial vaginosis-associated microflora and pelvic inflammatory
disease. Am J Epidemiol 2005; 162: 585-590
54. Liu B, Donovan B, Hocking JS, Knox J, Silver B, Guy R. Improving adherence to
guidelines for the diagnosis and management of pelvic inflammatory disease: A
systemic review. Infectious Diseases in Obstetrics and Gynaecology 2012;
325108
55. Loto OM, Adewumi TA, Adewuya AO. Prevalence and correlates of
dysmenorrhea among college women. Australian and New Zealand Journal of
Obstetrics and Gynaecology 2008; 48: 442-444
56. Risser JMH, Risser WL. Purulent vaginal and cervical discharge in the diagnosis
of pelvic inflammatory disease. International Journal of STD and AIDS 2009; 20:
73-76
57. Taylor-Robinson D, Jensen JS, Svenstrup H, Stacey CM. Difficulties experienced
in defining the microbial cause of pelvic inflammatory disease. International
Journal of STD & AIDS 2012; 23: 18-24
58. Igberase GO, Ebeigbe PN, Igbekoyi OF. Ectopic pregnancy: An 11-year review in
a tertiary centre in the Niger Delta. Tropical Doctor 2005; 39: 175-177
59. Umeora OUJ, Mbazor JO, Okpere EE. Tubal factor infertility in Benin City,
Nigeria – sociodemographics of patients and aetiopathogenic factors. Tropical
Doctor 2007; 37: 92-94
99
60. Sule JO, Erigbali P, Eruom L. Prevalence of infertility in women in a
southwestern Nigerian community. Afr. J. Biomed. Res. 2008; 11: 225-227
61. Karaer A, Avsar FA, Batioglu S. Risk factors for ectopic pregnancy: A case-
control study. Australian and New Zealand Journal of Obstetrics and
Gynaecology 2006; 46: 521-527.
62. Hamura NN, Bolnga JW, Wangnapi R, Horne AW, Rogerson SJ, Unger HW. The
impact of tubal ectopic pregnancy in Papua New Guinea – A retrospective case
review. BMC Pregnancy and Childbirth 2013; 13:86
63. Abdul MA, Shittu SO, Randawa JA, Shehu MS. The cervical smear pattern in
patients with chronic pelvic inflammatory disease. Nigerian Journal of Clinical
Practice 2009; 12(3): 289-293
64. Oye-Adeniran BA, Adewale IF, Odeyemi KA, Ekanem EE, Umoh AV.
Contraceptive prevalence among young women in Nigeria. Journal of Obstetrics
and Gynaecology 2005; 25(2): 182-185
65. Owolabi AT, Onayade AA, Ogunlola IO, Ogunniyi SO, Kuti O. Sexual behaviour
of secondary school adolescents in Ilesa, Nigeria: implications for the spread of
STIs including HIV/AIDS. Journal of Obstetrics and Gynaecology 2005; 25(2):
174-178
66. Adogu P, Udigwe I, Udigwe G, Ubajaka C. Review of problems of adolescent
sexual behaviour and the role of millennium development goals 4, 5 and 6 in
Nigeria. International Journal of Clinical Medicine 2014; 5: 940-948
67. Durojaiye OC. Knowledge, attitude and practice of HIV/AIDS: Behaviour change
among tertiary education students in Lagos, Nigeria. Ann Trop Med Public Health
2011; 4: 18-24
100
68. Muyibi AS, Ajayi IO, Irabor AE, Ladipo MAA. Relationship between
adolescents’ family function with socio-demographic characteristics and
behaviour risk factors in a primary care facility. Afr J Prm Health Care Fam Med.
2010; 2(1): Art 177
69. Vivancos R, Abubakar I, Hunter PI. Sex, drugs and sexually transmitted
infections in British university students. Int. J STD AIDS 2008; 19: 370
70. Jacob T. Growth and Pubertal Development in Children with sickle cell anaemia at
Muhimbili National Hospital 2010 (Dissertation). Muhimbili University of Health and
Allied Sciences; 2011; 16
71. Onwujekwe O, Hanson K, Fox-Rushby J. Some indicators of socio-economic
status may not be reliable and use of indices with these data could worsen equity.
Health Econ. 2006; 15: 639-644
72. Mbade CE, Adedoyin RA, Odejide AS. Relationship between socioeconomic
status and body mass index among adult Nigerians. AJPARS 2009; 1(1): 1-6
73. Ofuya ZM. The age at menarche in Nigerian adolescents from two different
socioeconomic classes. Online J Health Allied Scs. 2007; 4:3
74. Uwaifo VO. The effect of family structure and parenthood on the academic
performance of Nigerian university students. Stud Home Comm Sci, 2008; 2(2):
121-124
75. Adeoye GO, Akande AH. Epidemiology of Trichomonas vaginalis among women
in Lagos metropolis, Nigeria. Pakistan Journal of Biological Sciences 2007;
10(13): 2198-2204
76. Patrickar SR. Sample size determination. In: Bhalwar R editor. A test book of
public health and community medicine. New Delhi: AFMC; 2008: 251-253.
101
77. Rajvir B. Measures of information in epidemiology. In: Bhalwar R editor. A test
book of public health and community medicine. New Delhi: AFMC. 2008; 89.
102
APPENDIX I
ETHICAL APPROVAL
103
APPENDIX II SOCIOECONOMIC STATUS OF PARENTS AND OCCURRENCE OF PELVIC INFLAMMATORY DISEASE AMONG UNDERGRADUATES ATTENDING IRRUA SPECIALIST TEACHING HOSPITAL, IRRUA
INFORMED CONSENT FORM This study, “Socioeconomic status of parents and Occurrence of Pelvic Inflammatory Disease among Undergraduates attending Irrua Specialist Teaching Hospital, Irrua”, is a descriptive study aimed at determining the relationship between the socioeconomic status of parents and the occurrence of Pelvic Inflammatory Disease (PID) among Undergraduates with a view to reducing the scourge and preventing the complications of PID. Participation in this study is at your discretion and you have the right to withdraw at any stage. This will not in any way hinder the care you require in the clinic. You are assured that no information published will identify you as a participant; hence your name and address will not be included. Information collected from you in the questionnaire will be kept from the reach of a third party and the data when computed will be pass worded to restrict assess. Dr OSENI, Tijani Idris Ahmad has explained the nature, risks and benefits of the research project to me as contained above. I am willing to participate in this study. I consent [ ] do not consent [ ] Date: …………………………….. Time: …………………………….. Sign: ……………………………..
I confirm that I have explained to you the purpose, risks and benefit of this study as stated above. I know the consequence of any false declaration of this and any other form. Signature and Date: ………………………….. (Dr. OSENI, Tijani I. A.)
104
APPENDIX III
SOCIOECONOMIC STATUS OF PARENTS AND OCCURRENCE OF PELVIC INFLAMMATORY DISEASE AMONG UNDERGRADUATES ATTENDING IRRUA SPECIALIST TEACHING HOSPITAL, IRRUA A. SOCIO-DEMOGRAPHIC CHARACTERISTICS
1. HOSPITAL NO [ ]
2. AGE LAST BIRTHDAY [ ]
3. MARITAL STATUS: (a) Single [ ] (b) Married [ ] (c) Divorced [ ] (d) Separated [ ]
(e) Widowed [ ]
4. INSTITUTION TYPE: (a) University [ ] (b) Polytechnic [ ] (c) College of Education
[ ]
5. LEVEL OF STUDY
a. University: (a) 100L [ ] (b) 200L [ ] (c) 300L [ ] (d) 400L [ ] (e) 500L [ ] (f)
600L [ ]
b. Polytechnic: (a) OND I [ ] (b) OND II [ ] (c) HND I [ ] (d) HND II [ ]
c. College of Education (a) NCE I [ ] (b) NCE II [ ] (c) NCE III [ ]
6. SOURCE OF FUNDING
a. Main Sponsor
b. Additional Sources
c. Average income per month from
i. Sponsor
ii. Additional Sources
7. ETHNIC GROUP:
8. RELIGION: (a) Islam [ ] (b) Christianity [ ] (c) Others [ ] Specify ………………….
9. Phone Number of Respondent: ………………………………………………………...
105
B. MEDICAL HISTORY
10. Presence of
a. Lower Abdominal Pain Yes [ ] No [ ]
b. Last Menstrual Period
c. Menstrual Abnormality:
i. Menorrhagia Yes [ ] No [ ]
ii. Metrorrhagia Yes [ ] No [ ]
iii. Dysmenorrhea Yes [ ] No [ ]
iv. Oligomenorrhoea Yes [ ] No [ ]
v. Inter menstrual bleeding Yes [ ] No [ ]
d. Vaginal Discharge Yes [ ] No [ ]
e. Nature of Discharge (If present) :
i. Colour: White [ ], Milky/Creamy [ ], Purrulent [ ], Brown [ ] Others
[ ] Specify…………………………..
ii. Odour: Foul Smelling [ ] Fishy [ ] Others [ ] Specify
………………………
f. Vulvo vaginal irritation: Yes [ ] No [ ]
g. Vulvo vaginal itching: Yes [ ] No [ ]
h. Presence of Genital Ulcers: Yes [ ] No [ ]
i. Are ulcers painful? Yes [ ] No [ ]
i. Dyspareunia: Yes [ ] No [ ]
j. Inguinal Bubo: Yes [ ] No [ ]
C. SEXUAL HISTORY:-
11. Age at coitarche [ ]
12. No of Sex Partners ever had [ ]
106
13. Reasons for Engaging in Sexual Activity
14. Previous history of PID/STI Yes [ ] No [ ]
15. Contraception use Yes [ ] No [ ]
16. Method of Contraception used: Condom [ ], Natural (Withdrawal, Safe Periods etc) [
] Pills [ ], Injectables [ ], IUDs [ ], Others [ ], Specify…………………
17. Parity [ ]
18. No of Induced Abortions [ ]
19. Method of Abortion: Medical [ ], Surgical (D & C or MVA) [ ] Others [ ] Specify
………………………..
D. FAMILY HISTORY:-
20. Level of Education of Father: (a) Primary [ ] (b) Secondary [ ] (c) Tertiary [ ]
21. Level of Education of Mother: (a) Primary [ ] (b) Secondary [ ] (c) Tertiary [ ]
22. Occupation of Father: (a) Farmer [ ] (b) Trader/Businesswoman [ ] (c) Civil Servant
[ ] (d) Artisan (Self Employed) [ ] (e) Unemployed [ ]
23. Occupation of Mother: (a) Farmer [ ] (b) Trader/Businesswoman [ ] (c) Civil Servant
[ ] (d) Artisan (Self Employed) [ ] (e) Unemployed [ ]
24. Average Income of Parents:
25. Family Size:
26. Are both parents alive? Yes [ ] Father only [ ] Mother only [ ] None Alive [ ]
27. Are both parents together? Yes [ ], Separated [ ], Divorced [ ], Widowed [ ]
28. Socioeconomic Class (a) Low [ ] (b) Middle [ ] (c) High [ ]
E. EXAMINATION FINDINGS
29. Fever Yes [ ] No [ ]
30. Lower Abdominal Tenderness Yes [ ] No [ ]
31. Pelvic Masses Yes [ ] No [ ]
107
32. Inguinal Lymphadenopathies or bubos Yes [ ] No [ ]
33. Cervical Excitation Tenderness Yes [ ] No [ ]
34. Adnexal Tenderness Yes [ ] No [ ]
35. Uterine tenderness Yes [ ] No [ ]
36. Genital Ulcers Yes [ ] No [ ]
37. Vaginal Discharge Yes [ ] No [ ]
108
APPENDIX IV
OYEDEJI CLASSIFICATION OF SOCIAL CLASS
Points Occupation Level of Education
1 Senior Public Servants, University graduates and
Professional, Managers, Large equivalent
scale traders, Businessman
contractors
2 Intermediate grade public servant Secondary School Certificate (A
and Senior School Teachers level) with teaching or other
professional training
3 Junior School Teacher, Drivers Secondary School Certificate (O
Artisan level) or Grade II teachers
Certificate holders or equivalent.
4 Petty traders, Labourers, Primary School education
messengers and similar grades
5 Unemployed Can just read and write or illiterate
The sum of father’s occupation and education scores plus mother’s occupation and education scores divided by 4 gives the social class.
Scores 1 to 2 – High socioeconomic class
2.1 to 3 – Middle Socioeconomic class
3.1 to 5 – Low socioeconomic class
109