PELVIC INFLAMMATORY DISEASE (PID)
Pelvic inflammatory disease (PID) is an infectious and inflammatory disorder of the upper female genital tract, including the uterus, fallopian tubes, and adjacent pelvic structures. Infection and inflammation may spread to the abdomen, including perihepatic structures. The classic high-risk patient is a menstruating woman younger than 25 years who has multiple sex partners, does not use contraception, and lives in an area with a high prevalence of sexually transmitted disease (STD).
Other organisms implicated in the pathogenesis of PID include, Gardnerella vaginalis (which causes bacterial vaginosis (BV), Haemophilus influenzae, and anaerobes such as Peptococcus and Bacteroides species. Laparoscopic studies have shown that in 30-40% of cases, PID is polymicrobial.
CAUSES
In the United States, N gonorrhoeae is no longer the primary organism associated with PID, but gonorrhea remains the second most frequently reported sexually transmitted disease, after chlamydial infection. In addition to N gonorrhoeae and C trachomatis, organisms involved in PID include the following:
➡️ Gardnerella vaginalis
➡️ Mycoplasma hominis
➡️ Mycoplasma genitalium
➡️ Ureaplasma urealyticum
➡️ Herpes simplex virus 2 (HSV-2)
➡️ Trichomonas vaginalis
➡️ Cytomegalovirus (CMV)
➡️ Haemophilus influenzae
➡️ Streptococcus agalactiae
➡️ Enteric gram-negative rods (eg, Escherichia col
➡️ Anaerobes
PATHOPHYSIOLOGY
Pelvic inflammatory disease (PID) is a polymicrobial infection of the upper reproductive tract (uterus, fallopian tubes, or ovaries) associated with the sexually transmitted organisms and with endogenous organisms.
Most cases of PID are presumed to occur in 2 stages. The first stage is acquisition of a vaginal or cervical infection. This infection is often sexually transmitted and may be asymptomatic. The second stage is direct ascent of microorganisms from the vagina or cervix to the upper genital tract, with infection and inflammation of these structures.
The mechanism (or mechanisms) by which microorganisms ascend from the lower genital tract is unclear. Studies suggest that multiple factors may be involved. Although cervical mucus provides a functional barrier against upward spread, the efficacy of this barrier may be decreased by vaginal inflammation and by hormonal changes that occur during ovulation and menstruation.
The organisms ascend through the endocervical canal to the endometrial cavity, and then to the fallopian tubes and ovaries. The endocervical canal is slightly dilated during menstruation, allowing bacteria to gain entrance to the uterus and other pelvic structures. After entering the upper reproductive tract, the organisms multiply rapidly in the favorable environment of the sloughing endometrium and ascend to the fallopian tube.
SYMPTOMS
Symptoms of pelvic infection usually begin with vaginal discharge, dyspareunia, lower abdominal pelvic pain, and tenderness that occurs after menses. Pain may increase while voiding or with defecation. Other symptoms include
➡️ fever,
➡️ general malaise,
➡️ anorexia,
➡️ nausea,
➡️ headache,
➡️ possibly vomiting.
On pelvic examination, intense tenderness may be noted on palpation of the uterus or movement of the cervix (cervical motion tenderness). Symptoms may be acute and severe or low-grade and subtle.
RISK FACTORS
A number of factors might increase your risk of pelvic inflammatory disease, including:
• Being a sexually active woman younger than 25 years old
• Having multiple sexual partners
• Being in a sexual relationship with a person who has more than one sex partner
• Having sex without a condom
• Douching regularly, which upsets the balance of good versus harmful bacteria in the vagina and might mask symptoms
• Having a history of pelvic inflammatory disease or a sexually transmitted infection
There is a small increased risk of PID after the insertion of an intrauterine device (IUD). This risk is generally confined to the first three weeks after insertion.
DIAGNOSIS
➡️ medical history. This includes history of sexual habits, history sexually transmitted infections and method of birth control.
➡️ A pelvic exam. During the exam, the pelvic region is examined for tenderness and swelling. Vaginal swab will be taken from the vagina and cervix. The samples will be tested at a lab for signs of infection and organisms such as gonorrhea and chlamydia.
➡️ Blood and urine tests. These tests may be used to test for pregnancy, HIV or other sexually transmitted infections, or to measure white blood cell counts or other markers of infection or inflammation.
➡️ Ultrasound. This test uses sound waves to create images of the reproductive organs.
If the diagnosis is still unclear, the following may additional tests may be recommended , such as:
➡️ Laparoscopy. During this procedure, a thin lighted instrument is inserted through a small incision in the abdomen to view the pelvic organs.
➡️ Endometrial biopsy. During this procedure, a thin tube is inserted into the uterus to remove a small sample of endometrial tissue. The tissue is tested for signs of infection and inflammation.
One or more of the following additional criteria can be used to enhance the specificity of the minimum clinical criteria and support a diagnosis of PID:
➡️ oral temperature >101°F (>38.3°C);
➡️ abnormal cervical mucopurulent discharge or cervical friability;
➡️ presence of abundant numbers of WBC on saline microscopy of vaginal fluid;
➡️ elevated erythrocyte sedimentation rate;
➡️ elevated C-reactive protein; and
laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis.
The most specific criteria for diagnosing PID include:
➡️ endometrial biopsy with histopathologic evidence of endometritis;
➡️ transvaginal sonography or magnetic resonance imaging techniques showing thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex, or Doppler studies suggesting pelvic infection (e.g., tubal hyperemia); or
➡️ laparoscopic findings consistent with PID.
NURSING DIAGNOSIS
➡️ Acute pain related to inflammation of the upper reproductive organs evidenced by patient verbalization, restlessness and facial expressions.
➡️Anxiety related to the unknown outcome of the diagnosis evidence by patients asking too many questions.
➡️ Deficient knowledge about the disease and its management.
COMPLICATIONS
Untreated pelvic inflammatory disease might cause scar tissue and pockets of infected fluid (abscesses) to develop in the reproductive tract. These can cause permanent damage to the reproductive organs.
Complications from this damage might include:
• ECTOPIC PREGNANCY: PID is a major cause of tubal (ectopic) pregnancy. An ectopic pregnancy can occur when untreated PID has caused scar tissue to develop in the fallopian tubes. The scar tissue prevents the fertilized egg from making its way through the fallopian tube to implant in the uterus. Instead, the egg implants in the fallopian tube. Ectopic pregnancies can cause massive, life-threatening bleeding and require emergency medical attention.
• INFERTILITY: Damage to the reproductive organs may cause infertility, the inability to become pregnant. The more times you've had PID, the greater your risk of infertility. Delaying treatment for PID also dramatically increases your risk of infertility.
• CHRONIC PELVIC PAIN: Pelvic inflammatory disease can cause pelvic pain that might last for months or years. Scarring in your fallopian tubes and other pelvic organs can cause pain during intercourse and ovulation.
• TUBO-OVARIAN ABSCESS: PID might cause an abscess — a collection of pus — to form in your reproductive tract. Most commonly, abscesses affect the fallopian tubes and ovaries, but they can also develop in the uterus or in other pelvic organs. If an abscess is left untreated, you could develop a life-threatening infection.
TREATMENT
Treatment may involve hospitalization with intravenous administration of antibiotics. If the condition is diagnosed early, outpatient antibiotic therapy may be sufficient. Treatment is aimed at preventing complications, which can include pelvic adhesions, infertility, ectopic pregnancy, chronic abdominal pain, and tuboovarian abscesses. Accurate diagnosis and appropriate antibiotic therapy may decrease the severity and frequency of PID sequelae.
If the patient has abdominal distention or ileus, nasogastric intubation and suction are initiated. Carefully monitoring vital signs and symptoms assists in evaluating the status of the infection. Treating sexual partners is necessary to prevent reinfection.
NURSING MANAGEMENT
Infection takes a toll, both physically and emotionally. The patient may feel well one day and experience vague symptoms and discomfort the next. She may also suffer from constipation and menstrual difficulties.
➡️ The hospitalized patient is maintained on bed rest and is usually placed in the semi-Fowler’s position to facilitate dependent drainage. Accurate recording of vital signs and the characteristics and amount of vaginal discharge is necessary as a guide to therapy.
➡️ The nurse administers analgesic agents as prescribed for pain relief. Heat applied safely to the abdomen may also provide some pain relief and comfort.
➡️ The nurse minimizes the transmission of infection to others by carefully handling perineal pads with gloves, discarding the soiled pad according to hospital guidelines for disposal of biohazardous material, and performing meticulous hand hygiene.
PREVENTION
To reduce risk of pelvic inflammatory disease:
• PRACTICE SAFE SEX: Use condoms every time you have sex, limit your number of partners and ask about a potential partner's sexual history.
• GET TESTED: If you're at risk of an STI, make an appointment with your doctor for testing. Set up a regular screening schedule with your doctor if needed. Early treatment of an STI gives you the best chance of avoiding PID.
• REQUEST THAT YOUR PARTNER BE TESTED: It is advisable that partners are tested as this can prevent the spread of STIs and possible recurrence of PID.
• AVOID DOUCHING: Douching upsets and alters the PH of the vagina thereby creating a favourable environment for the growth of bacterias.
REFERENCES
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