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16 Articles in Volume 20, Issue #5
20/20 with Drs. Carmen R. Green and Johnathan Goree: Racial Disparities in Pain Care
A Kratom Primer: Miracle Medicine or Herb of Abuse?
A Pilot Study: Incidence and Prediction of Diversion among Opioid Therapy Patients
Analgesics of the Future: G-Protein Biased Mu-Opioid Receptor Ligands
Application Note: Decellularized Human Placenta in the Treatment of Infracalcaneal Heel Pain
Are Clinicians Effectively Counseling Patients on Safe Opioid Storage and Disposal? Survey Results
Ask the PharmD: How to Manage Pain Meds During Pregnancy?
Behavioral Medicine: Managing Anxiety and Maladaptive Behaviors
Case Report: Spinal Cord Stimulation for the Treatment of Pain Associated with Chronic Pancreatitis
Differential Diagnoses: Inflammatory or Non-inflammatory Chronic Back Pain?
Pelvic Inflammatory Disease: Diagnosis, Education, and Treatment Options
Product Review: Non-Invasive Neuromodulation for the Treatment of the Most Difficult Pain Conditions
Provider Perspective: Carpal Tunnel's Association with Hypothyroidism
Research Insights: Opioid Use During the Peripartum Period – What to Expect
Special Report: Race, Pain Management, and the System
When Patients Become Pregnant: How to Maintain Chronic Pain Management

Pelvic Inflammatory Disease: Diagnosis, Education, and Treatment Options

Along with screening for and early treatment of sexually transmitted infections, evidence-based sex education is crucial to prevent this painful, debilitating disease that affects young women in particular.

PID Causes and Prevalence

Pelvic inflammatory disease (PID) is a clinical syndrome of the female reproductive tract characterized by inflammation of the endometrium, fallopian tubes, and/or the peritoneum. PID occurs when micro-organisms ascend from the vagina or cervix to the fallopian tubes and other genital tract structures. PID can result from untreated bacterial infections, most commonly chlamydia and gonorrhea.1

More than 85% of PID cases are thought to be caused by microorganisms acquired during sexual transmission.2 Although several different sexually transmitted pathogens have been implicated, Chlamydia trachomatis (CT)and Neisseria gonorrhoeae (GC) in particular are the most prevalent causes.

Up to 30% of women with PID are estimated to present with CT infections and up to 26% of women with GC infections associated with subclinical PID.3,4

Untreated, PID can lead to infertility, ectopic pregnancy, chronic pelvic pain, and permanent damage of a woman’s reproductive organs.1,5

Pelvic inflammatory disease continues to be the most common gynecologic cause of emergency department visits in the United States.6 In stratified analyses by Kreisel et al,7 the prevalence of self-reported lifetime PID among women reporting a previous STI diagnosis was similar in Whites and Blacks (10.0% [95% CI = 4.4–15.6] versus 10.3% [95% CI = 1.3–19.4], P = 0.97). However, they noted, “among women with no previous STI diagnosis, the prevalence of self-reported lifetime PID in black women was 2.2 times the prevalence in White women (Black: 6.0% [95% CI: 3.4–8.6] versus White: 2.7% [95% CI: 1.1–4.4], P = 0.01).”7

Young age is a significant risk factor for developing PID as well. Adolescents are the most vulnerable population with more than 70,000 annual emergency department visits and a 10-fold increased risk as related to a 24-year-old woman. This increased risk is secondary to biologic and behavioral vulnerabilities, including an immature cervix with a larger surface area of columnar epithelium, as well as higher rates of unprotected sex and multiple sex partners.8,9 In addition, adolescents with PID are more likely to receive suboptimal treatment, have poor adherence to outpatient treatment regimens, and are at a high risk of PID recurrence.10,11

Early diagnosis and treatment of PID by patient’s primary care provider or gynecologist is of utmost importance to prevent long-term reproductive sequelae while screening for and early treatment of sexually transmitted diseases such as chlamydia and gonorrhea is crucial to prevent PID.12,13

Adolescents are the most vulnerable population for pelvic inflammatory disease with more than 70,000 annual emergency department visits and a 10-fold increased risk as related to a 24-year-old woman. This increased risk is secondary to biologic and behavioral vulnerabilities, including higher rates of unprotected sex and multiple sex partners. (Image: iStock)

Diagnosing Pelvic Inflammatory Disease

Although signs and symptoms of PID are often very subtle, the hallmark for diagnosis is uterine, adnexal, or cervical tenderness and lower genital tract inflammation.2,3,14 The onset of PID ranges from the abrupt onset of severe lower abdominal pain to subclinical manifestations that are often much milder.2 Due to the potentially serious sequelae associated with PID as well as the fact that PID is the most common gynecological reason for visits to the emergency departments in the US,6,14 recognition and accurate diagnosis is of utmost importance.

The acute onset of signs and symptoms of PID most commonly include unusual vaginal discharge, post-coital bleeding, spotting in between menstrual cycles, dyspareunia, dysuria, cervical friability (easily induced bleeding of the cervix), and lower abdominal and pelvic pain.2,14 Other associated symptoms that may occur include fever and right upper quadrant pain.2,14,15 The “chandelier sign,” a colloquial term, is the classic description of exquisite cervical motion tenderness on bimanual exam, and adnexal and uterine tenderness are shown to be highly specific (> 95%) for the diagnosis of PID.2,14 Signs of lower genital tract inflammation have been shown to increase the specificity of the diagnosis, and include cervical friability, green or yellow cervical mucous, and increased white cells seen on wet mount.3

Additional diagnostic findings may include fever and elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR).2,3,15 Endometrial biopsy showing endometritis, MRI or transvaginal ultrasound (TVUS) revealing thickened and fluid-filled fallopian tubes, and findings consistent with PID seen during laparoscopy are all specific findings for the diagnosis of PID.14,15

At a minimum, clinical criteria for the diagnosis of PID must include one of the following on bimanual examination: cervical motion tenderness, uterine tenderness, or adnexal tenderness.14,15 If a woman is suspected to have PID, she should undergo testing for GC and CT via nucleic acid amplification tests.2

Treatment Options for Pelvic Inflammatory Disease

While many pathogens can lead to PID, the most important causes to identify and treat, as noted, are Chlamydia trachomatis (CT)and Neisseria gonorrhoeae (GC). While PID can be treated, without prompt care, the scarring that can take place secondary to a PID infection is irreversible and may lead to issues with fertility, ectopic pregnancies, and tubal damage.3,14

The most recent CDC guidelines (2015) on sexually transmitted infections provide diagnostic criteria algorithm and treatment recommendations.14,15 Empiric treatment aimed at GC and CT should be initiated if the clinical picture includes a sexually active patient with unexplained lower abdominal or pelvic pain, with cervical, uterine, or adnexal tenderness noted on bimanual exam.13 Regardless of the results of testing performed, due to the high morbidity associated with PID, empiric treatment covering the most common pathogens should be immediately initiated if the clinical picture points to PID.2

While most patients can be treated in an outpatient setting, inpatient management may be required for those who have complicated PID secondary to pregnancy, tubo-ovarian abscess (TOA), intolerance to oral medications, or severe illnesses.14

According to the CDC, the treatment recommendation for mild to moderate PID should include:

  • doxycycline (100 mg PO twice daily for 2 weeks) with or without the addition of metronidazole for anaerobic coverage (500 mg PO twice daily for 2 weeks)

plusa single dose of one of the following:

  • ceftriaxone (250 mg IM)
  • cefoxitin (2 g IM) with addition of probenecid
  • or another third-generation cephalosporin2,14,16

Most patients in the PEACH trial with mild to moderate PID were successfully treated with a combination of the above treatment regimens.16

Patients in the outpatient setting should be closely monitored and reassessed 24 to 48 hours after treatment initiation. If the patient’s symptoms lack apparent improvement or are worsening, then consideration of inpatient management along with further diagnostic workup may need to be initiated and alternative diagnoses considered.3

Those requiring inpatient management for PID should receive:

  • cefotetan (2 g IV q12 hrs) plus doxycycline (100 mg PO or IV q12 hrs)
  • orcefoxitin (2 g IV q6 hrs) plus doxycycline (100 mg PO or IV q12 hrs)
  • orclindamycin (900 mg IV q8 hrs) plus gentamicin (3 to 5 mg/kg IV qd) especially if PID complicated by TOA.2

Women with intrauterine devices (IUD) should not have these devices removed, as there is currently insufficient evidence to recommend removal as part of treatment.3,14It is, however, advised that those with PID and an IUD in place be closely monitored and if on the initiation of treatment, they lack improvement, then the removal of the device should be considered.3

Additionally, it is important to consider that part of complete treatment includes testing and treating the patient’s partner or partners for infections.3,14 This is of utmost importance, as the prevention of STIs and future spread of infections is one of the most important interventions that can be made.

By the time a pelvic inflammatory diagnosis has been made, the patient has likely suffered significant morbidity and may already be at risk of long-term sequela including infertility. (Image: iStock)

 

Preventing Pelvic Inflammatory Disease: Education, Education, Education

By the time a PID diagnosis has been made, the patient has likely suffered significant morbidity and may already be at risk of long-term sequela including infertility. Ideally, PID can therefore be prevented through patient education, including safe sex education. Educating young patients at a time when they are most vulnerable constitutes may make clinical management of related disease unnecessary.

Prevention efforts are best stratified between the patient, the clinician, and schools. Education should focus not only on the prevention of sexually transmitted infections and diseases (STDs) by practicing abstinence or safe sex but also, on the signs and symptoms of such diseases so that seeking prompt healthcare becomes a priority.17,8

At highest risk and most in need of sex and health education are middle school, high school, and college-aged students. As described, the high-risk sexual activities that younger adults and teens participate in increase their risk of acquiring a sexually transmitted infection and potentially developing an STD.

In many cases, parental and/or healthcare provider education and access may be limited, making public education systems the best choice for disseminating information. However, only 24 of the 50 states currently mandate sex education classes in public schools.19 The implementation of sex education in the US also varies district by district and continues to change as various administrators take office.19

In 2014, the CDC outlined 16 critical health topics that should be discussed in sexual education courses.20 While a good effort to standardize and ensure more inclusive education, studies and surveys have revealed that the time spent in schools on those 16 critical topics laid out were as few as 6.2 hours on average per year and of the 16 topics those covered in full were only implemented by one-fifth of middle schools.19The CDC reports that less than 43% of high schools and 18% of middle schools currently teach sexual education topics.21

In 2018, the agency further released evidence-based guidelines for quality sexual health education (SHE), in which they outlined what works in schools along with action plans that can be taken to help in the prevention of unintended pregnancies, HIV, and sexually transmitted infections.21 Clinicians and educators can visit the CDC site for further education and resources on proper sexual education. While more information can be found on the CDC website, in brief, the curriculum provided aims to provide age-appropriate sexual health education that focuses on providing diverse education for students with different backgrounds and identities.21

Sexual education in the schools can go a long way, but clinicians must be vigilant about educating individuals from an early, yet appropriate age –  and their parents/families –  about the risks and symptoms of both sexually transmitted infections and pelvic inflammatory disease. If not made a priority, high rates of transmission and PID may continue to rise and morbidity from these diseases will continue to constitute a preventable, yet clinically difficult, lifelong condition.

 

Practical Takeaways

  • Pelvic inflammatory disease is characterized by uterine, adnexal, or cervical tenderness and lower genital tract inflammation. Recognition of these signs early on is imperative for proper diagnosis and treatment.
  • Early diagnosis and treatment from primary care along with gynecology providers can aid in decreasing morbidity and long term sequelae from sexually transmitted infections.
  • With inclusive age-appropriate sexual health education using curriculum designed by sources such as the CDC, sexually transmitted infections can be prevented.
Continue Reading:
When Patients Become Pregnant: How to Maintain Chronic Pain Management
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