pelvic inflammatory disease
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Pelvic Inflammatory Disease
- salpingitis (Inflammation of the fallopian tubes)
- endometritis (Inflammation of the inside lining of the body of the uterus)
- tubo-ovarian abscesses (Abscesses in the tubes and ovaries)
- pelvic peritonitis (Inflammation inside of the abdominal cavity surrounding the female reproductive organs)
Causes and symptoms
- Age. The incidence of PID is very high in younger women and decreases as a woman ages.
- Race. The incidence of PID is 8-10 times higher in nonwhites than in whites.
- Socioeconomic status. The higher incidence of PID in women of lower socioeconomic status is due in part to a woman's lack of education and awareness of health and disease and her accessibility to medical care.
- Contraception. Induced abortion, use of an IUD, non-use of barrier contraceptives such as condoms, and frequent douching are all associated with a higher risk of developing PID.
- Lifestyle. High risk behaviors, such as drug and alcohol abuse, early age of first intercourse, number of sexual partners, and smoking all are associated with a higher risk of developing PID.
- Types of sexual practices. Intercourse during menses and frequent intercourse may offer more opportunities for the admission of pathogenic organisms to the inside of the uterus.
- Disease. Sixty to 75% of cases of PID are associated with STDs. A prior episode of PID increases the chances of developing subsequent infections.
Susceptibility to stds
pel·vic in·flam·ma·to·ry dis·ease (PID),
pelvic inflammatory disease
pelvic inflammatory diseasePID, salpingo-oophoritis Gynecology An imprecise term for intense pain due to direct extension of a lower genital tract infection–often sexually-transmitted along mucosae, first causing asymptomatic endometritis, then acute salpingitis, ↑ Sx as it spreads into fallopian tubes engorged with pus–pyosalpinx, pus in the peritoneum; PID is accompanied by leukostasis, fever, chills, N&V, extreme tenderness of uterine cervix and adnexae Epidemiology PID is 3–4-fold more common in IUD users and in those who douche 3+ times/month; ectopic pregnancy is 7–10-fold more common in PID; 500,000 cases of PID are reported/yr–US Etiology1⁄2 are due to N gonorrhoeae, less commonly, Chlamydia trachomatis; 15% of Pts with gonococcal cervicitis develop PID Clinical Severe pain, peritonitis, low-grade fever Complications Fallopian tube scarring, in1⁄4, infertility Epidemiology Primarily disadvantaged urban ♀, affecting ±1 million ♀–US, cost ±$4 billion Treatment Cefoxitin, doxocycline, clindamycin, ofloxacin
pel·vic in·flam·ma·to·ry dis·ease(PID) (pel'vik in-flam'ă-tōr-ē di-zēz')
pelvic inflammatory diseasePersistent infection of the internal reproductive organs of the female. This may be due to a sexually transmitted disease or may follow childbirth or an ABORTION.
Pelvic Inflammatory Disease
|Mean LOS:||5.9 days|
|Description:||SURGICAL: D&C, Conization, Laparoscopy and Tubal Interruption With CC or Major CC|
|Mean LOS:||5.4 days|
|Description:||MEDICAL: Infections, Female Reproductive System With CC|
Pelvic inflammatory disease (PID) is a polymicrobial infectious disease of the pelvic cavity and the reproductive organs. PID may be localized and confined to one area or it can be widespread and involve the whole pelvic region including the uterus (endometritis), fallopian tubes (salpingitis), ovaries (oophoritis), pelvic peritoneum, and pelvic vascular system. The infection can be acute and recurrent or chronic.
PID can be a life-threatening and life-altering condition. Complications of PID include pelvic (or generalized) peritonitis and abscess formations, with possible obstruction of the fallopian tubes. Obstructed fallopian tubes can cause infertility or an ectopic pregnancy. Other complications of PID are bacteremia with septic shock, thrombophlebitis with the possibility of an embolus, chronic abdominal pain, and pelvic adhesions.
The causes of PID vary by geographic location and population. Many types of microorganisms, such as a virus, bacteria, fungus, or parasite, can cause PID. Common organisms involved in PID include Chlamydia trachomatis, Neisseria gonorrheae, staphylococci, streptococci, coliform bacteria, mycoplasmas, and Clostridium perfringens. The means of transmission is usually by sexual intercourse, but PID can also be transmitted by childbirth or by an abortion. Organisms enter the endocervical canal and proceed into the upper uterus, tubes, and ovaries. During menses, the endocervical canal is slightly dilated, facilitating the movement of bacteria to the upper reproductive organs. Bacteria multiply rapidly in the favorable environment of the sloughing endometrium. Douching increases the risk for PID because it destroys the protective normal flora of the vagina, and it could flush bacteria up into the uterus. Risk of reoccurrence of PID is possible with the use of latex condoms. Actinomyces bacteria may lead to PID cases when linked with the use of an intrauterine device (IUD).
Heritable immune responses could be protective or increase susceptibility.
Gender, ethnic/racial, and life span considerations
PID is the most common cause for hospitalization of reproductive-age women. It predominantly affects women who are sexually active, particularly those who have multiple partners or who change partners frequently. Associated risk factors for PID include 16 to 24 years of age, unmarried, nulliparous, history of sexually transmitted infections, and use of an IUD with multiple sex partners. Ethnicity and race have no known effects on the risk for PID. In the future, men may be screened for chlamydia to decrease PID in females.
Global health considerations
PID is a serious problem internationally. The causative organism is highly dependent on geographical region.
A thorough history of past infections, a sexual history, and a history of contraceptive use are essential to evaluate a woman with PID. The patient may describe a vaginal discharge, but the characteristics of the discharge (e.g., color, presence of an odor, consistency, amount) depend on the causative organism. For example, a gonorrhea or staphylococcus infection causes a heavy, purulent discharge. With a streptococcus infection, however, the discharge is thinner with a mucoid consistency. The woman may also experience pain or tenderness, described as aching, cramping, and stabbing, particularly in the lower abdomen, pelvic region, or both. Low back pain may also be present. Other symptoms include dyspareunia (painful sexual intercourse); fever greater than 101°F; general malaise; anorexia; headache; nausea, possibly with vomiting; urinary problems such as dysuria, frequency, urgency, and burning; menstrual irregularity; and constipation or diarrhea.
Observe closely for vaginal discharge and the characteristics of this discharge. Common symptoms include pain or tenderness, described as aching, cramping, and stabbing, particularly in the lower abdomen or pelvic region. Inspect the vulva for signs of maceration. Note if the woman has experienced pruritus that has led to irritated, red skin from scratching. If vomiting is reported, inspect the skin for signs of fluid deficit, such as dryness or poor skin turgor. Rebound tenderness may be noted. When the cervix is manipulated, the woman may complain of pain in this area. Uterine adnexal tenderness is usually present. Auscultate the bowel; at first, the bowel sounds are normal, but as the disease progresses, if it is not treated, the bowel sounds are diminished or even absent if a paralytic ileus is present.
Because PID may be a life-threatening and life-altering disease, assess the patient’s emotional ability to cope with the disease process. In particular, explore the woman’s and her partner’s concerns about fertility. Because sexual partners need to be treated to prevent reinfection, the patient may have concerns about discussing her illness with her partner or partners. Studies show that many teens with PID are reinfected within 48 months.
General Comments: A variety of tests, along with clinical symptoms and sexual history, support the diagnosis of PID. All females of childbearing age should have a pregnancy test.
|Test||Normal Result||Abnormality With Condition||Explanation|
|White blood cell (WBC) count||5,000–10,000/mm3||> 10,500/mm3||Infection and inflammation elicit an increase in WBCs|
|Erythrocyte sedimentation rate||Up to 20/hr||> 20 mm/hr||Inflammation increases the protein content of plasma, thus increasing the weight of red blood cells and causing them to descend faster|
|C-reactive protein||Negative to trace||Elevated||Indicates inflammation|
|Laparoscopy (the gold standard)||Normal-appearing reproductive organs||Pelvic structures are red and inflamed; possible adhesions and scarring||Direct visualization of the pelvic cavity|
|Falloposcopy||Normal-appearing fallopian tubes||Tubes are red and inflamed; possible adhesions and scarring||Visual inspection of the tubes to detect damage|
Other Tests: Transvaginal sonography or magnetic resonance imaging; endometrial biopsy with histopathological evidence of infection
Primary nursing diagnosis
DiagnosisPain related to infectious process
OutcomesPain control; Pain level; Comfort level
InterventionsMedication administration; Pain management; Heat/cold application; Analgesic administration
Planning and implementation
Without treatment, this disease process can be lethal for women. The goal is to rid the patient of infection and preserve fertility if possible. Because no single antibiotic is active against all possible pathogens, the Centers for Disease Control and Prevention (CDC) recommends combination regimens. These regimens vary if the patient is hospitalized or treated on an outpatient basis. Usually, the treatment is with broad-spectrum antibiotics. Both the affected woman and her sexual partner(s) should be treated with antibiotics. Women with PID are usually treated as outpatients, but if they become acutely ill, they may require hospitalization. Women should be followed up in an outpatient setting within 72 hours to check on the effectiveness of treatment. The hospitalized patient with PID usually is placed on bedrest in a semi-Fowler's position to promote vaginal drainage. Priority should be given to timely administration of intravenous (IV) antibiotics to maintain therapeutic blood levels. IV fluids may be initiated to prevent or correct dehydration and acidosis. If an ileus or abdominal distention is present, a nasogastric tube is usually inserted to decompress the gastrointestinal tract. Urinary catheterization is contraindicated to avoid the spread of the disease process; tampons are also contraindicated.
If antibiotic therapy is not successful and the patient has an abscess, hydrosalpinx (distention of the fallopian tube by fluid), or some type of obstruction, a hysterectomy with bilateral salpingo-oophorectomy (removal of ovaries and fallopian tubes) may be done. A laparotomy may be done to incise adhesions and to drain an abscess. Signs of peritonitis, such as abdominal rigidity, distention, and guarding, need to be reported immediately so that medical or surgical intervention can be initiated. If the patient is poorly nourished, a dietary consultation is indicated.
Analgesics are prescribed to manage the pain that accompanies PID. Comfort measures can include the use of heat applied to the abdomen or, if they are approved by the physician, warm douches to improve circulation to the area. (See other interventions for pain in the following section.)
Two outpatient oral/oral-parenteral antibiotic regimens are also newly recommended by the CDC: (1) ofloxacin 400 mg by mouth (PO) twice a day for 14 days or levofloxacin 500 mg PO daily for 14 days with or without metronidazole 500 mg PO twice a day for 14 days or (2) ceftriaxone 250 mg intramuscular (IM) single dose or cefoxitin 2 g IM single dose and probenecid 1 g PO plus doxycycline 100 mg PO twice a day for 14 days with or without metronidazole 500 mg PO twice a day for 14 days.
|Medication or Drug Class||Dosage||Description||Rationale|
|Cefoxitin or cefotetan and doxycycline||2 g IV q 6 hr, 2 g IV q 12 hr, 100 mg q 12 hr PO × 10–14 days||Cephalosporin, second-generation cephalosporin, second-generation tetracycline antibiotic||Inpatient treatment recommended by the CDC|
|Clindamycin and gentamycin||900 mg IV q 8 hr, 2 mg/kg IV or IM loading dose, then 1.5 mg/kg q 8 hr||Antibiotic, aminoglycoside||Inpatient treatment recommended by the CDC|
Monitor vital signs and the patient’s symptoms to evaluate the course of the infection and its response to treatment. Always follow universal precautions; ensure that any item used by the patient is carefully disinfected. Provide perineal care every 2 to 4 hours with warm, soapy water to keep the area clean. Teach the patient that she needs to do these procedures as well. Allow the patient time to express her concerns. If appropriate, include the woman’s partner in a question-and-answer session about the couple’s potential to have children. Note that the inability to bear children is a severe loss for most couples, and they may need a referral for counseling.
Interventions that can help relieve pain include having the patient lie on her side with the knees flexed toward the abdomen. Massaging the lower back also increases her comfort. Use diversions such as music, television, and reading to take the patient’s mind off the discomfort.
Teach the patient interventions to prevent the recurrence of PID: to use condoms, to have all current sexual partners examined, to wash hands before changing pads or tampons, and to wipe the perineum from front to back. Encourage her to obtain immediate medical attention if fever, increased vaginal discharge, or pain occurs. Discuss with the patient when sexual intercourse or douching may be resumed (usually at least 7 days after hospital discharge).
Evidence-Based Practice and Health Policy
Trent, M., Haggerty, CL., Jennings, J.M., Lee, S., Bass, D.C., & Ness, R. (2011). Adverse adolescent reproductive health outcomes after pelvic inflammatory disease. Archives of Pediatric and Adolescent Medicine, 165(1), 49–54.
- PID has significant implications for sexual and reproductive health, especially among adolescents. In one study among 831 female participants between ages 14 to 38, 21.3% had recurrent PID over an 84-month follow-up period.
- Investigators found that the adolescent women (ages 14 to 19) were 1.54 times more likely than the adult women (ages 20 to 38) to experience recurrent PID (95% CI, 1.03 to 2.3; p = 0.03). In this sample, 25.1% were adolescents.
- Although the adolescent women were more likely than the adult women to report consistent condom use as well as recent condom use within the previous 30 days (p < 0.001 and p = 0.006, respectively), a larger proportion of the adolescent women tested positive for Neisseria gonorrhoeae/Chlamydia trachomatis infection at baseline (63.2% versus 40.8%; p < 0.001) and at 30 days posttreatment (20% versus 5.2%; p < 0.001).
- Additionally, a larger proportion of adolescent women compared to adult women had evidence of endometritis at baseline (56.1% versus 44.7%; p = 0.01) and had become pregnant during the follow-up period (72% versus 52.6%; p < 0.001).
- Physical findings: Vital signs, abdominal assessment, condition of integument
- Occurrence of pain: Location, intensity, duration, triggers, response to pain interventions
- Presence of vaginal discharge: Characteristics, amount of discharge
Discharge and home healthcare guidelines
prevention.To prevent a recurrence of PID, teach the patient the following:
- Take showers instead of baths
- Wear clean, cotton, nonconstrictive underwear
- Avoid using tampons if they were the problem
- Do not douche
- Change sanitary pads or tampons at a minimum of every 4 hours
- If using a diaphragm, remove it after 6 hours
- If any unusual vaginal discharge or odor occurs, contact a healthcare provider immediately
- Maintain a proper diet, with exercise and weight control
- Maintain proper relaxation and sleep
- Have a gynecological examination at least annually
- Use a condom if there is any chance of infection in the sexual partner
- Use a condom if the sexual partner is not well known or has had another partner recently