DEFINITION-

Pelvic inflammatory disease (PID) is a sexually transmitted inflammatory condition of the

pelvic cavity characterized by upper genital tract infection in females .It is often initiated by the
presence of Neisseria gonorrhoea and/or Chlamydia trachomatis in the lower genital tract that
ascend to infect the uterus (endometritis), fallopian tubes (salpingitis), and ovaries (oophoritis),
pelvic peritoneum, or pelvic vascular system.

EPIDEMIOLOGY
- About 85% are spontaneous infection in sexually active females of reproductive age.
- Two-thirds are restricted to young woman of less than 25 years and remaining one third
limited among to 30 years and older.
- The annual incidence of PID in in woman 15 to 39 years of age seems to be 10 to 13 per
1000 woman with a peak incidence of about 20 per 1000woman in the age group of 20-
24 years.
RISK FACTOR
Research has identified a number of risk factors in PID development that include
Young age -15 to 24 years of age who initiate their coital experience early in
adolescence
Immature cervix that contains columnar epithelium transitional zone that can be a
positive milieu for N. gonorrhoeae and C. trachomatis.
Multiple coital partners,
Past PID
Vaginal douching – it is the process of washing or cleaning out the inside of vagina with
liquid solution( mixture of water, vinegar, baking soda or iodine) which changes vaginal
flora in harmful ways by propelling microorganisms from the vagina through the
cervical os into the uterus, fallopian tubes, and pelvic cavity.
Coitus during menstruation
IUD insertion
Contaminated hands or instruments during gynaecologic surgery, childbirth, abortion,
and pelvic examinations.
Low immunity and compromised resistance to infection
women who are poorly nourished

CAUSATIVE ORGANISM- Infection, which may be acute, subacute, recurrent, or chronic and
localized or widespread, is usually caused by
 Neisseria gonorrhoeae
 Chlamydia trachomatis
 Gardnerella vaginalis
 Mycoplasma hominis
 Ureaplasma urealyticum
 Trichomonas vaginalis
 Herpes simplex virus-2
 Cytomegalovirus(CMV)
  Haemophilus influenzae
 Strepotococcus agalactiae
 Enteric gram-negative rods
 Anaerobes

PATHOPHYSIOLOGY-

Due to etiological factors

Entry of the microbes through vagina, pass through cervical canal

Colonisation of organism in endocervix

Upward movement of organism,facilitated by mensturation or intercourse

Rapid multiplication and growth

spreading to one or both fallopian tube, ovaries, into pelvis

Pelvic inflammatory disease

CLINICAL MANIFESTATION
PID may be a silent infection with no symptoms. As a result, it may remain untreated while
causing damage to pelvic structures. Symptoms of pelvic infection usually begin with-

 Foul smelling Purulent cervical or vaginal discharge

 Dyspareunia
 Dysuria
 Irregular bleeding- between periods or after sex
 Lower abdominal pelvic pain, and tenderness that occurs after menses. Pain may increase
while voiding or with defecation. Mild to severe. Movement such as walking, coughing
can increase the pain.
 Pain associated with intercourse
 fever, chills
 General malaise
 diarrhoea
 Anorexia
 Nausea, and possibly vomiting.
 Headache
On pelvic examination,
 Intense tenderness may be noted on palpation of the uterus or movement of the cervix
(cervical motion tenderness)
 Adnexal tenderness

In many instances, evidence of PID is first discovered during surgery for ectopic pregnancy,
blocked fallopian tubes, ovarian abscess, or other pelvic disorders
Gonorrheal PID is the most severe form whereas chlamydial PID is more likely to be
subclinical with little or no symptoms, but with potentially adverse long-term consequences.

DIAGNOSTIC EVALUATION
 History Taking and Physical and Gynaecologic exam
 Cervical and vaginal swab culture
 Transvaginal ultrasound: Insertion of a camera into the vaginal opening to identify
areas of inflammation or abscess.
 Laparoscopy: Gold standard Invasive diagnostic examination in which camera is
surgically inserted to identify structural changes, such as inflammation or scarring inside
the reproductive tract, abdominal cavity. Violin string like adhesion in the pelvis and
around the liover suggests chlamydial infection.
 Pelvic exam -check for tenderness and swelling. Use of cotton swabs to take fluid
samples from your vagina and cervix. The samples will be tested at a lab for signs of
infection and organisms such as gonorrhoea and chlamydia.
 Pap smear test- examined under a microscope to identify growth of bacterial infection.
 Blood and urine tests-  to test for ectopic pregnancy, HIV or other sexually transmitted
infections, or to measure white blood cell counts or other markers of infection or
inflammation.
 Endometrial biopsy- inserting a thin tube into the uterus to remove a small sample of
endometrial tissue to test for signs of infection and inflammation.
 Culdocentesis- Procedure that checks for abnormal fluid in the space behind vagina from
pouch of Douglas through a needle. If WBC exceeds 30000 per mL shows significant
PID.
COMPLICATION-
Immediate complications of PID include
 Fitz-Hugh-Curtis syndrome, which occurs when PID spreads to the liver and causes
acute peri-hepatitis. The patient has symptoms of right upper quadrant pain, right pleural
effusion and/or right shoulder pain but liver function tests are normal.
 Tubo-ovarian abscesses may “leak” or rupture, resulting in pelvic or generalized
peritonitis. As the general circulation is flooded with bacterial endotoxins from the
infected areas, septic shock may result.
 septic shock
 Embolisms -as the result of thrombophlebitis of the pelvic veins.
 Adhesions and strictures in the fallopian tubes.
 Ectopic pregnancy may result when a tube is partially obstructed because the sperm can
pass through the stricture, but the fertilized ovum cannot reach the uterus. After one
episode of PID, fallopian tubes becoming narrowed and scarred
 Infertility

MEDICAL MANAGEMENT-

The principle of the therapy are-

1. To control the infection energetically
2. To prevent infertility and late sequale
3. To prevent re-infection

PID is usually treated on an outpatient basis with a combination of antibiotics

The patient must have no intercourse for 3 weeks. Her partner(s) must be examined and
treated.
An important part of care is physical rest and oral fluids.

AMBULATORY MANAGEMENT OF ACUTE PID( CDC-2006)

Patient should have oral therapy for 14 days.
Regimen A - Levofloxacin 500mg (or, ofloxacin 400mg )PO once daily with or
without
- Metronidazole 500 PO bid
Regimen B - Ceftriaxone 250mg IM single dose PLUS
- Doxycycline 100mg PO bid with or without
- Metronidazole 500mg PO bid for 14 days
Broad spectrum antibiotic coverage (cefotaxime/ cefoxitin) is indicated as most PIDs are
polymicrobial (gram negative and positive aerobes as well as anaerobic rods and cocci)

Hospitalization is required if
 Unresponsive to Outpatient therapy for more than 48 hour.
 Severe illness, vomiting
  Intolerance to oral antibiotic
 Co-existing pregnancy
 Has a tubo-ovarian abscess
 Patient known to have HIV infection

INPATIENT ANTIBIOTIC THERAPY- CDC 2006

Regimen A - Cefoxitin 2gm IV every 6 hours for 2-4days PLUS
- Doxycycline 100mg PO for 14 days
Regimen B - Clindamycin 900mg IV every 8 hour PLUS
- Genatmycin 2mg/kg IV loading dose followed by 1.5mg/kg IV
maintance dose every 8 hour
Alternative - Levofloxacin 500mg IV once daily with or without
Regimen - Metronidazole 500mg IV every 8 hours
Regimen B is preferred for cases with pelvic abscess as it has anaerobic coverage.
Alternative regimen is dosed once a day.

Corticosteroids may be added to the antibiotic regimen to reduce inflammation, allowing

for faster recovery and optimizing the chances for subsequent fertility.
Application of heat to the lower abdomen or sitz baths may improve circulation and
decrease pain.
Bed rest in a semi-Fowler’s position promotes drainage of the pelvic cavity by gravity
and may prevent the development of abscesses high in the abdomen.
Analgesics to relieve pain
IV fluids to prevent dehydration and acidosis.

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

SURGICAL MANAGEMENT-

Surgery is indicated for abscesses that fail to resolve with IV antibiotics.

- Laparoscopy or laparotomy- to drain out the abscess
- Hysterectomy- In extreme cases of infection or severe chronic pelvic pain

NURSING MANAGMENT
Subjective Data
Important Health Information regarding Use of IUD; previous PID, gonorrhea, or chlamydial
infection; multiple sexual partners; exposure to partner with urethritis; infertility
Medications: Use of and allergy to any antibiotics
Surgery or other treatments: Recent abortion or pelvic surgery
Functional Health Patterns on nutritional, elimination, Cognitive-perceptual, Sexuality-
reproductive pattern.
Objective Data
Reproductive evaluation-Mucopurulent cervicitis, vulvar maceration, vaginal discharge (heavy
and purulent to thin and mucoid), tenderness on motion of cervix and uterus; presence of
inflammatory masses on palpation
Possible Diagnostic Findings

Nursing diagnosis-1-Acute pain related to inflammation of the pelvic structures caused by

invasion of pathogens as evidence by guarding behaviour, facial grimace.
Goal- To reduce pain.
Intervention- Assess pain intensity, duration, frequency, quality, radiation of the pain.
- Application of heating pad to the lower abdomen.
- Place patient in semi fowler position to facilitate drainage which will help in relieve of
pain.
- Encourage for non-pharmacological technique for pain management such as relaxation,
massage, guided imagery or distraction.
- Administer antibiotic as indicated.
Evaluation-client will report satisfactory pain control.

Nursing diagnosis-2-Hyperthermia related to physiological response to the inflammatory and

infectious process as evidence by flushed skin, body temperature recorded above normal range.
Goal-To reduce body temperature.
Intervention-Monitor vital signs.
- Identify triggering factors.
- Provide tepid sponge bath.
- Loosen or remove excess clothing and covers.
- Provide well ventilated cool environment.
- Encourage adequate fluid intake to prevent possible dehydration.
- Administer antipyretics as prescribed.
Evaluation-Client will maintain core temperature within normal range.

Nursing diagnosis-3-Situational low self-esteem related to fear of societal acceptance.

Goal-To enhance self-esteem.
Intervention-Help client to identify current behaviours resulting from low self-esteem.
- Invite patient to record past and current achievements- emotional, social, intellectual,
vocational and physical.
- Encourage to verbalize thoughts and feelings about current situation by providing
favourable environment.
- Encourage client to create a sense of competence through short term goal setting and goal
achievement.
- Provide resources and social support network available to them.
- Encourage to find a self-help therapy group that focuses on self-esteem enhancement.
- Teach systematic problem solving process and educate about harmful effects of negative
self-talk.
Evaluation-Patient identifies strengths and healthy coping skills
Nursing diagnosis 4- Inadequate knowledge regarding therapeutic regimen as evidence by
inability to answer properly.
Goal- To improve knowledge level of patient.
Intervention- Asses the patient level of understanding and his perception.
- Encourage to ventilate feelings. Provide opportunity to ask, make necessary changes.
- Clarify doubts, if any.
- Review disease process, medication, purpose, side effects. Involve him in treatment
process.
- Identify community resources and support groups.
Evaluation- patient will perform newly learned tasks safely and correctly.

PREVENTION-

 Practice safe sex. Use condoms every time you have sex, limit your number of partners
and ask about a potential partner's sexual history.
 Talk to your health care provider about contraception. Many forms of contraception do
not protect against the development of PID. Using barrier methods, such as a condom,
helps to reduce your risk. Even if you take birth control pills, use a condom every time you
have sex with a new partner to protect against STIs.
 Get tested. If you're at risk of an STI, make an appointment with your provider for testing.
Set up a regular screening schedule with your provider if needed. Early treatment of
an STI gives you the best chance of avoiding PID.
 Request that your partner be tested. If you have pelvic inflammatory disease or an STI,
advise your partner to be tested and treated. This can prevent the spread of STIs and
possible recurrence of PID.
 Don't douche. Douching upsets the balance of bacteria in your vagina.
 Health education- Abstinence during treatment, compliance with treatment, regular
follow-up.

CONCLUSION-

Pelvic inflammatory disease is a major health problem in developed or developing countries of

the world. PID is not a notifiable disease, as accurate statistics on disease prevalence are rarely
available. PID can be said to be a very serious complication of sexually transmitted disease
which should be critically and promptly handled by healthcare providers. The right type sample
should be aseptically collected and be appropriately handled for laboratory investigation.
Treatment of PID should be initiated as soon as the presumptive diagnosis has been made.
Immediate administration of antibiotics has been effective in the long-term sequelae associated
with PID.