Conditions affecting the genitalia are varied in nature and may therefore mimic each other in terms of its overall presentations and symptoms – making it increasingly difficult to determine what condition a person has from the assessment of one’s symptoms alone.

With the stigma and fear of talking about the field itself, it makes it even harder for many to seek help despite the fear of having complications plague the genitalia and causing complications that may include infertility and pain. As such, some are left with no option other than to self-medicate – only to end up with untoward effects due to either an improper treatment plan or the use of an ineffective regimen resulting in the worsening of the underlying condition.

To resolve these issues and encourage various individuals to seek help or at least remedy the gap between the public and the healthcare community, it is essential to educate everyone regarding the importance of a proper diagnosis and provide even laypersons the necessary information regarding conditions that may plague their genital area. While this does not equip the public with the ability to self-medicate, nor does this encourage self-medication, it does provide them with the understanding of what their disease might be, and what tests may be administered to obtain a more detailed insight as to what condition they might be suffering from.

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Pelvic Inflammatory Disease: Etiology

Pelvic Inflammatory Disease is a syndrome that essentially results from another underlying condition – making it secondary to common infections, effectively becoming a complication in many conditions that affect the genitalia of women. Concerning the previous points laid out, pelvic inflammatory disease is a condition that is often mistaken with many other diseases due to the symptoms that somehow overlap with other conditions, making it difficult to diagnose the disease with the help of a symptomatic analysis alone.

What is Pelvic Inflammatory Disease (PID)?

As previously mentioned, pelvic inflammatory disease or PID is a syndrome that is secondary to certain infections in the genitalia – primarily resulting from the ascension of microorganisms that have infested the cervical or external vaginal area to the upper genital tract. It is considered a severe complication of several sexually transmitted infections such as chlamydia and gonorrhea, and this is commonly misunderstood as its symptoms may coincide with the signs of the underlying infection. Essentially, its presentations are non-specific, and these may often be mistaken with the manifestations of another condition affecting reproductive, genitourinary, or gastrointestinal tracts.

In women with PID, the disease itself may present a plethora of signs and symptoms that may primarily present as pain along the pelvic region, thus the name PID. The range of symptoms can be classified between unnoticeable, subtle, mild, or severe symptoms. PID may often go unrecognized and may stay under the radar of many physicians if the symptoms are mild or even more subtle. As such, unless a person knows that they do have an underlying infection that could precipitate PID, the condition often goes unmanaged until a physician intentionally attempts to look for the disease itself.

It is crucial to note likewise that diagnosis for PID often involves ruling out a possible pregnancy case as well as it is widely known that pregnant women are more susceptible to PID or PID-like symptoms – making it a probable differential diagnosis when a patient tends to present symptoms that can be classified under the condition’s set of manifestations.

Prevalence and Spread

PID is known as a common condition among women of reproductive age – showing that there are around 2.5 million women in the United States with a previously reported diagnosis of PID. This value, however, only equates to approximately 4.4% of self-reporting prevalence rate among women of childbearing age according to the National Health and Nutrition Examination Survey during its 2013-2014 cycle, indicating that there might still be more within the population that remains undiagnosed due to the difficulty of its diagnosis. In the past, specifically during the early months of 2015, there was somehow a declining trend in the number of PID cases in the United States, but recent data are showing that the numbers are still climbing, and there seems to be no explanation as to why the count seemed to drop for a brief period. Some studies suggest that the strengthening of STD testing methods caused the reduction of complications such as PID, but the subsequent boost in the number of STD cases, particularly its underreporting, may have resulted later on in the increase of PID cases once again.

Persons at Risk for PID

Although PID appears as a complication among many individuals with an underlying condition or infection that could precipitate an ascension of pathogens towards the upper urinary tract, several risk factors can be used as an assessment point to determine whether you are at risk of developing either or both an infection within the genitourinary area and PID as a complication when the condition is left untreated for extended periods.

Sexual Activity

Sexual activity is perhaps the most significant risk factor as it essentially opens up the possibility of contracting an infection within the genital area. Essentially, when a person is sexually active, they are already susceptible to conditions such as sexually transmitted infections, and then they are already at risk of contracting certain complications of STIs such as PID. While this does not necessarily mean that they would automatically contract PID upon engaging in sexual intercourse, it does, however, put them at significant risk by being exposed in the first place.

Multiple Sexual Partners

About the previous point regarding sexual activity, another risk factor that could further exacerbate your susceptibility to a potential infection is having multiple sexual partners, particularly sexual intercourse with numerous individuals you are not familiar with. By "familiar," we are referring to knowing a person’s sexual health status – a topic that might sometimes be considered taboo in certain cultures due to the growing stigma with the concept of sexual health. However, suppose you would like to be safe and know whether an infection causes your presentations or not. In that case, you should make sure that you know your partner’s health status and that you will be able to keep track of your partner’s status throughout your sexual encounters – a practice that may sometimes be disregarded in the case of having multiple sexual partners. This does not necessarily infer that having multiple partners is considered taboo, but the difficulty of keeping track and being informed might be the risk factor in this aspect.

Unprotected or Unsafe Sexual Practices

Although it is essential to know your partner’s sexual health status, it is also important to practice safe sexual practices that have been studied to provide a safer sexual practice and prevent, to the highest possibility that it can muster, any transmission of potential infections during contact with your partner. This may include using condoms that essentially serve as a barrier between the tissues in contact while likewise serving as a contraceptive method to prevent potential pregnancies from unexpected events.

Improper Sanitary Care

Contrary to the knowledge of many, washing the genital area, while beneficial if appropriately performed and sparingly, may result in the contraction of certain infections within the genitalia due to the imbalances caused by the removal of certain microorganisms within the area. The genitalia naturally contains several microorganisms within its environment – some of which are beneficial while some are pathogenic in certain instances. When you perform excessive douching or washing of the vaginal area, the process essentially removes some of the good bacteria present within the genitalia. If this happens, the balance that prevents the harmful bacteria from proliferating is now insufficient – allowing the bad bacteria to increase and cause an invasion of specific structures of the genitourinary tract.

History of PID or a Sexually Transmitted Infection (STI)

While having a history of PID or a previous case of STI does not necessarily automatically cause another PID case within your system, it does put you at a heightened risk for another episode as your genitourinary tract is essentially already compromised or you already have a bacterial invasion that may ascend towards your upper urinary tract if the infection becomes unmanaged. As such, when you have a history of either of these conditions, it is vital to have yourself routinely checked to ensure that you will not be contracting PID and that you will not develop any complications that commonly arise from an undiagnosed PID case in the background.

Usual Treatment Approach for PID

In most cases, the usual approach to resolve issues of PID is to address the underlying infection and eliminate the presence of pathogens within the patient’s system. This would commonly entail the administration of antibiotics, specifically broad-spectrum antibiotics that can clear a wide variety of pathogens, to remove the presence of any infection within your upper urinary tract. However, it is essential to note that no pharmacological treatment will address any structural damage such as tissue scarring within the genitalia, as these are essentially irreversible once the damage has been done. As such, it is highly recommended that anyone who develops symptoms of PID or is susceptible to the condition be routinely tested to ensure that any potential case of PID is urgently resolved before it causes any irreversible issues.

Pelvic Inflammatory Disease – a sexually transmitted condition?

In the most basic sense, Pelvic Inflammatory Disease is not sexually-transmitted as PID. PID is a condition caused by another underlying infection that would have initially infected the external regions of the genitalia. In most cases, these infections are sexually transmitted diseases such as chlamydia and gonorrhea – making it so that someone who does have sexual intercourse with a person who has PID could contract the underlying infection that they might have not the case of PID itself. PID develops as a complication to a disease and would only manifest if the condition is left untreated for extended periods.

Possible Complications of Pelvic Inflammatory Disease

Although PID is a complication in itself, it also does cause certain damages to the structures of the genitourinary tract that then causes further complications in a woman’s health.

Ectopic Pregnancy

Tubal or ectopic pregnancy is commonly caused by an underlying PID case in pregnant women. This is essentially a case when a patient’s PID causes the development of scar tissues within the fallopian tubes. When this happens, the egg cells cannot descend to the uterus and are therefore fertilized and implanted within the fallopian tube itself. When this happens, the embryo will develop within this area, causing a massive life-threatening and bleeding emergency that would have to require immediate medical attention to resolve.

Infertility

Due to the inherent mechanism of pelvic inflammatory disease to cause structural damages to the upper urinary tract upon the ascension of pathogenic microorganisms to these areas, it is always possible that an unmanaged case of PID may cause the affected person to develop infertility, especially when the damage reaches the fallopian tube and ovaries of the patient. With this, the rule of thumb would be that the more times you develop PID, the higher your risk of contracting structural damages and subsequently developing infertility in the long run.

This is likewise the rationale why it is crucial to have yourself tested and treated immediately as prolonged conditions would most often than not result in irreversible structural damages that could again cause severe complications.

Chronic Pain

Regarding the previous point that has been put forward, i.e., repetitive conditions causing damages to the urinary tract structure through the formation of scar tissues, pelvic inflammatory disease is likewise known to cause chronic pain that would often be located near the pelvic area. The pain usually lasts for months to years, depending on the severity of the patient’s condition. This is primarily due to the scarring that develops within the fallopian tube and other organs within the pelvic region of a patient affected by PID. This may likewise cause intermittent pain that comes and goes during specific periods, such as when a patient participates in sexual intercourse or when the patient is ovulating and releasing egg cells through their fallopian tube and ovaries.

Tubo-Ovarian Abscess Accumulation

Due to the damages caused by PID to specific structures of the urinary tract, sometimes the injuries may cause an accumulation of pus, causing the formation of an abscess within either the ovaries or the fallopian tube – coining it with the name tubo-ovarian abscess. This abscess formation may be harmless during its initial accumulation, but the presence of pus within a systemic location may, later on, result in the development of an infection that, if left untreated, may result in a life-threatening condition due to the proximity of the organs to the body’s systemic circulation. While this is not necessarily always the case, primarily when the situation is managed immediately and before any pus accumulation ensues, it does pose a significant warning because its subsequent effects may be more severe than some people might expect from such a common condition.

PID Preventive Measures

Similar to how other conditions affecting the genitourinary tract are managed, there are likewise several preventive measures that you can utilize to prevent the development of PID, or better yet, avoid the development of an infection that could precipitate a PID complication when left undiagnosed and untreated.

Safe Sex Practices

The primary preventive measure for any condition that primarily involves the genitourinary tract and whose primary transmission method is through sexual contact is to employ safe sex practices. Sexual intercourse is sometimes inevitable for the modern population – making it not surprising that the number of STI cases in the United States is climbing by the hour. However, you could always choose to be responsible for how you partake in the activity and ensure that you will not unknowingly expose yourself to unnecessary risk during your ventures. Using condoms or even employing hygiene habits such as washing or urinating after sex will go a long way in preventing possible infections.

Regular Testing for STIs

The common enemy of most physicians when it comes to non-specific conditions is the prevalence of underreporting – resulting in complications that could have been prevented if the disease had been diagnosed early on. To ensure that you do not have any underlying infection that may result in the development of PID - if you are sexually active - try to at least have yourself tested every few months by a broad-spectrum panel to ensure that you are safe from any STIs that might cause problems, or be transmitted to your partner during intercourse.

Testing for Partners

While it is crucial that you know your health status and whether you have an underlying condition that might cause complications in the long run, it might also be essential to have your partners tested for the same conditions as they are also potential sources of infection that they could then transmit to you. Although it is not necessarily a direct cause of disease since your partner’s condition would not involve your well-being in any way, making sure that all potential sources of infection are covered is one step towards ensuring that both you and your partner are safe from any ugly consequences that may arise from a minor lapse in judgment. After all, it will always be better to be safe than sorry.

Avoid Harsh Washing Techniques

It is common among many women to wash their genital region as many might notice a particular smell or be concerned that their area will be dirty or accumulate sweat after a long hard day at work – and that is completely fine and understandable from all perspectives. It is OK to wash your area, and it is also advisable to wash your genital region properly to ensure that it will not cause the growth of any fungal infections that tend to increase in sweaty and unclean areas.

However, one should note that washing the vagina excessively may cause an infection due to the imbalance that results from the washing off of the good bacteria that holds back the proliferation of pathogenic microorganisms within the area. The natural flora of the vagina contains both good and bad bacteria that balance themselves out to prevent the accumulation of one or the other. When excessive douching is applied, the balance is skewed, resulting in the overgrowth of a certain pathogenic species, subsequently resulting in the ascension of specific strains to the upper urinary tract, thus developing PID when the imbalance is left to persist.

Pelvic Inflammatory Disease: Pathogenic Mechanism

Pelvic inflammatory disease or PID is a complication that is often caused by the ascendance of a particular pathogenic microorganism towards the upper urinary tract of the patient – causing issues within the organs around the pelvic region and manifesting non-specific symptoms that would often be confused with other conditions if the diagnosis was performed using the manifestations alone.

Infection Acquisition

The initial development of PID starts with the contraction of an infection within the patient’s genitalia. The most common STD associated with PID is chlamydia which is caused by Chlamydia trachomatis. Next to chlamydia is gonorrhea with Neisseria gonorrhoeae as its causative agent, and other microorganisms that may cause PID may include Gardnerella vaginalis in bacterial vaginosis, H. influenzae, and agents within the Peptococcus and Bacteroides species.

Direct Ascent of Pathogens

When the patient contracts an infection, they are immediately put at risk for a PID complication as the causative agent is already in proximity to the urinary tract structures of the patient. When the condition is left untreated, particularly in a case where the patient is asymptomatic and does not realize that they have an underlying condition, the microorganisms causing the patient's current infection may directly ascend towards the upper urinary tract region of the patient. When this happens, the microorganisms will then increase in this area, causing damages later on to the structures of the urinary tract itself if left unmanaged,

Pregnancy

Pregnant women are known to be more prone to infections that involve the urinary tract, making it entirely reasonable that they are likewise more susceptible to PID when certain women are carrying a baby. However, it is essential to note that PID in pregnant women may only be contracted during the first 12 weeks of gestation or until the mucus plug solidifies and seals off the path of any bacteria in the vagina towards the urinary tract of the patient. On the one hand, it is crucial to determine whether the patient had developed ectopic pregnancy, especially when an already-pregnant woman was diagnosed to have PID, as this may result in bleeding that may be life-threatening if not addressed.

Genetics

While the specifics are still being studied, certain genetic factors, such as those that affect the development and regulation of toll-like receptors, which are essential in the body’s innate immune system, may likewise be necessary to examine in looking at the overall susceptibility of the patient to condition.

Pelvic Inflammatory Disease: Symptomatic Presentations

It is vital to understand before anything else that PID presents with non-specific symptoms during its symptomatic period – meaning that its symptoms are not necessarily distinct from other conditions, confusing those who are unaware of the exact cause of the manifestations they are experiencing.

In the case of symptomatic cases, however, the symptoms of a patient affected with PID may involve some of these common presentations:

  • Pain in the lower abdominal area
  • Pelvic pain
  • Vaginal discharge
  • Irregularity in menstrual period
  • Low-grade fever (around 38C)
  • Pain during intercourse
  • Pain during urination
  • Tenderness in the pelvic or lower abdominal region
  • Inflammation within the genital region
  • Bleeding between periods

It is vital to have yourself tested and seen by your doctor immediately if:

  • You observe these symptoms
  • You or your sexual partner was recently exposed to or diagnosed with an STD
  • You develop any genitourinary symptoms that were relatively new

Pelvic Inflammatory Disease: Diagnosis and Testing

To properly determine the condition that you are experiencing with regard to the symptoms that you were able to observe, the following diagnostic tools and processes are commonly utilized to provide a more conclusive diagnosis and outlook.

Clinical Diagnosis

This entails a clinical consultation that mainly employs a physical examination and a symptomatic assessment. It does not, in any way, provide a highly conclusive diagnosis and only provides the cue for a more detailed laboratory procedure.

Laparoscopy

Laparoscopy is a type of minor surgical procedure that involves using tiny incisions with the help of a camera to access internal regions of the body, particularly the urinary tract, in this case, to examine the structures within.

Endometrial Biopsy

Like what its name suggests, an endometrial biopsy involves the collection of a tissue sample from the lining of the uterus to determine any problems or abnormalities that might be present in the patient’s organs.

Transvaginal Ultrasound

A transvaginal ultrasound is essentially an ultrasound process that uses a machine to send soundwaves towards the lower abdominal region of the patient – producing images of the patient's internal structures and showing any abnormalities that may have formed within.

Magnetic Resonance Imaging (MRI)

An MRI is a medical imaging technique that uses a magnetic field and computer-generated radio waves to visualize the organs within the patient’s pelvic region.

Doppler Studies

A doppler study is essentially a process that estimates the blood flow through the blood vessels by sending high-frequency sound waves – showing any irregularities in the patient’s blood flow that may be caused by scarring in specific urinary tract structures.

Pelvic Inflammatory Disease: Management Approach

To resolve most PID cases, the commonly recommended approach is to administer broad-spectrum antibiotics that would be used to determine the presence of microorganisms in the upper urinary tract. As suggested by the Centers for Disease Control and Prevention, the standard medications are discussed below.

Optimal Treatment

Parenteral Administration

  • Ceftriaxone 1g IV every 4 hours + Doxycycline 100 mg orally or IV every 12 hours + Metronidazole 500 mg orally IV every 12 hours
  • Cefotetan 2g IV every 12 hours + Doxycycline 100 mg orally or IV every 12 hours
  • Cefoxitin 2g IV every 6 hours + Doxycycline 100 mg orally or IV every 12 hours

Intramuscular or Oral Administration

  • Ceftriaxone 500 mg IM single dose + Doxycycline 100 mg orally twice daily for 14 days WITH Metronidazole 500 mg orally twice daily for 14 days
  • Cefoxitin 2g IM single dose and Probenecid 1g orally administered concurrently in a single dose + Doxycycline 100 mg orally twice daily for 14 days WITH Metronidazole 500 mg orally twice daily for 14 days
  • Parenteral 3rd generation cephalosporin + Doxycycline 100 mg orally twice daily for 14 days WITH Metronidazole 500 mg orally twice daily for 14 days

Follow-Up

It is important to remember that most women would experience improvement in symptoms within 3 days after therapy initiation. However, retesting is still necessary after 3 months of treatment to ensure that the underlying infection has been resolved.

Frequently Asked Questions (FAQs)

Is it possible to have sex when a patient has PID?

It is not recommended as the patient may transmit the infection that caused the PID case, and most PID cases may likewise cause pain during sexual intercourse.

How long does it usually take for an infected person to develop PID?

It would depend on the circumstances, but as a rule of thumb, it may take a few days to a few weeks for someone to develop PID.

How long would antibiotic courses usually last when treating PID?

For oral medications, the treatment course would often last for 14 days following a single dose antibiotic injection.

Is it possible for men to be affected with PID?

No, since PID mainly affects the fallopian tubes and ovaries – structures men do not have.

Is it still possible for someone who had PID to get pregnant?

Due to the scarring in the fallopian tubes and ovaries, it might be hard for someone to get pregnant after a PID case, but it is still possible with sufficient professional help and monitoring.

Additional Resources

Centers for Disease Control and Prevention

Office on Women’s Health

American Family Physician

References

  • Centers for Disease Control and Prevention. (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. https://www.cdc.gov/std/treatment-guidelines/pid.htm
  • Centers for Disease Control and Prevention. (n.d.). Pelvic Inflammatory Disease (PID) – CDC Fact Sheet. https://www.cdc.gov/std/pid/stdfact-pid.htm
  • Cleveland Clinic. (n.d.). Pelvic Inflammatory Disease (PID). https://my.clevelandclinic.org/health/diseases/9129-pelvic-inflammatory-disease-pid
  • DeSapri, K. (2019). What are the risk factors for pelvic inflammatory disease (PID)? https://www.medscape.com/answers/256448-25895/what-are-the-risk-factors-for-pelvic-inflammatory-disease-pid
  • DeSapri, K. (2019). What is the role of endometrial biopsy in the workup of pelvic inflammatory disease (PID)? https://www.medscape.com/answers/256448-25878/what-is-the-role-of-laparoscopy-in-the-diagnosis-of-pelvic-inflammatory-disease-pid
  • DeSapri, K. (2019). What is the role of laparoscopy in the diagnosis of pelvic inflammatory disease (PID)? https://www.medscape.com/answers/256448-25878/what-is-the-role-of-laparoscopy-in-the-diagnosis-of-pelvic-inflammatory-disease-pid
  • DeSapri, K. (2021). Pelvic Inflammatory Disease. https://emedicine.medscape.com/article/256448-overview
  • Mayo Clinic. (n.d.). Pelvic Inflammatory Disease (PID). https://www.mayoclinic.org/diseases-conditions/pelvic-inflammatory-disease/symptoms-causes/syc-20352594
  • NHS. (n.d.). Complications – Pelvic Inflammatory Disease. https://www.nhs.uk/conditions/pelvic-inflammatory-disease-pid/complications/
  • Sheps, S. (n.d.). Doppler ultrasound: What is it used for? https://www.mayoclinic.org/doppler-ultrasound/expert-answers/faq-20058452
  • The American College of Obstetricians and Gynecologists. (n.d.). Pelvic Inflammatory Disease (PID). https://www.acog.org/womens-health/faqs/pelvic-inflammatory-disease
  • Tinkanen, H., & Kujansuu, E. (1992). Doppler ultrasound studies in pelvic inflammatory disease. Gynecologic and obstetric investigation, 34(4), 240–242. https://doi.org/10.1159/000292770
Mark Riegel, MD

Quick Snapshot

Can it be cured?

Yes and No. Gonorrhea is easily treated with a course of antibiotics.

Type of Infection

Bacterial. Gonorrhea is caused by the Neisseria gonorrhoeae bacterium.

How is it treated?

Antibiotics. A single Cefixime, Ceftriaxone, or Cephalosporin.

Recovery Time

Upto 1 week. One to two weeks can be needed for symptoms to fully disappear.

Can I have sex?

No. Sexual activity should be avoided until treatment is successful.

Can I get re-infected?

Yes. Re-infection is possible from sexual activity with an infected person.

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