Introduction and definition
Pelvic inflammatory disease (PID) is infection and inflammation of the female upper reproductive tract involving the endometrium, fallopian tubes, ovaries, and pelvic peritoneum.
Following breakdown of the physical mucous barrier at the cervix, infection spreads to involve some or all of these structures. The spectrum of disease ranges from asymptomatic or mild disease, through to severe infection with systemic symptoms and the presence of a tubo-ovarian abscess.Over the last decade, the incidence of pelvic infection in England has fallen by 50% (1) and in the United States it is estimated that from 2004 to 2013 the number of visits to physicians for PID decreased by 39.8% (2). The decrease, at least in part, is thought to be attributable to widespread screening for chlamydia and gonorrhoea which detects uncomplicated infection before it has progressed to PID. Despite this, the cost of PID continues to be a major burden to health economies and is estimated as an average per person lifetime medical cost of $1060-$3180, depending on whether women develop serious sequelae (3).
PID is a polymicrobial infection and the most significant complication of sexually transmitted infections (STIs) in women. Chlamydia and gonorrhoea now account for less than 30% of cases, with many cases having an unidentified microbiological aetiology. Using newer molecular detection methods, new potential pathogens have been identified including Mycoplasma genitalium, Atopobium, Leptotrichia, and other bacterial vaginosis (BV) associated bacteria (4).
Diagnosis is based on clinical assessment which is subjective and prone to variation depending on knowledge, training, and experience. The positive predictive value of clinical examination is as low as 65% and no single imaging method is sensitive or specific enough to give a definitive diagnosis.
Neither are there any highly accurate laboratory tests nor investigations which reliably confirm or exclude the diagnosis. A low threshold for diagnosis and treatment is required to minimize the adverse effects on the reproductive health of young women. Women presenting with lower abdominal pain with no other identified aetiology, and who have one or more of three minimum criteria (cervical motion tenderness, uterine tenderness, and/or adnexal tenderness), should be treated for PID. The United States Centers for Disease Control and Prevention (CDC) recommends empirical PID treatment in sexually active young women (≤25 years of age) and other women at risk for STIs (multiple sexual partners or history of STI) if they are experiencing pelvic or lower abdominal pain, when no other cause can be identified, and if these criteria are present on pelvic examination (2). Patients can be treated successfully as an outpatient. Outpatient therapy is as effective as inpatient treatment for patients with clinically mild to moderate PID (5).PID is associated with major long-term sequelae, including tubal factor infertility, ectopic pregnancy, and chronic pelvic pain, and it remains an important public health problem with far-reaching implications for women's health and high costs for healthcare systems.
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