Pelvic Inflammatory Disease (CAUSE OF INFERTILITY)

Pelvic Inflammatory Disease

Introduction

In this article, I will be discussing a very common gynecologic disease called Pelvic Inflammatory Disease.  It is so common that if not adequately treated can cause infertility and ectopic pregnancy and is a disease of reproductive age especially a menstruating woman younger than age 25 years, who has a multiple sex partner and doesn’t use contraception in an area with a high prevalence of Sexually Transmitted Infection.

Presenting Complaint;   Lower abdominal pain

                                      Abnormal vaginal discharge

                                      Painful Sexual intercourse

Pelvic Inflammatory Disease

        

DEFINITION 

Pelvic Inflammatory Disease, defined as an upper female genital tracts infection characterized by inflammation and infection arising from the endocervix leading to endometritis (inflammation of the uterus lining), salpingitis (inflammation of the Fallopian tube), oophoritis (inflammation of the ovary) and pelvic peritonitis. 

What Happen in  Pelvic Inflammatory Disease

Or in a simple way, define as an infection and inflammatory disorder of upper female genital tracts including uterus, Fallopian tubes, and adjacent pelvic structures.

Women Genital Tracts refer to your reproductive organs or structures located at the lower part of your abdomen (tummy) and this includes the vagina, cervix, uterus (the so called womb), Fallopian tube and the ovaries. All these are all connect directly with each other starting from outside as vagina and open into the abdominal cavity via the Fallopian tubes. This explain why infection can ascend (travel) from the vagina to the uterus and enter the abdominal cavity.

Genital Tracts are divided into upper and lower tracts. Both are susceptible to infection and infection from lower to upper tracts is more common than upper to lower tracts. The lower tracts are the vaginal and the cervix/endocervix while the upper tracts include the uterus, fallopian tubes and the ovaries.

Organisms which are implicated include Chlamydia trachomatis and are the predominant sexually transmitted organism associated with pelvic inflammatory disease; others include Neisseria gonorrhea, Haemophilus influenza EST. These have made pelvic inflammatory disease a polymicrobial infection.

Risk Factors for Pelvic Inflammatory Disease

Multiple sexual partners and young age at first intercourse is also at risk, however, PID is very low in women who are not sexually active and those with total abdominal hysterectomy.

Infected sperm from Partner who has Sexually Transmitted Infection

History of previous sexually transmitted infection in either partner

History of sexual abuse

Frequent vaginal douching

Uterine curettage from abortion/miscarriage

Contraception such as intra-uterine device in family planning

Excessive usage of antibiotics

NOTE

Bilateral tubal ligation doesn’t protect against pelvic inflammatory disease

Mechanism of Pelvic inflammatory Disease

The major process is by ascending of infection through the vagina to the uterus and Fallopian tubes.

First stage, acquisition of vaginal and cervical infections that are often sexually transmitted and the Second stage, is by direct ascent of microorganism from the vagina or the cervix to the upper genital tract with infection and inflammation of the structures.

Opening of the cervix during menstruation and retrograde menstrual flow facilitate ascending of microbe.

Excessive usage of antibiotics for sexually transmitted infection, this disrupts the balance of endogenous flora (i.e. protective bacteria that resides within the vagina) in the lower genital tract causing normally non pathogenic organism to overgrow and ascend

Intercourse may contribute to the ascent of the infection through rhythmic uterine contraction occurring during orgasm while bacteria may also be carried along with sperm into the uterus and Fallopian tubes

Clinical Presentation/Manifestation

 The diagnosis of pelvic inflammatory disease is predominantly historical i.e. Patient complaint and clinical i.e. doctors finding on examination, therefore, I will advise you pay attention to the signs and symptoms.

Lower abdominal pain, the most common present complaint, dull aching or cramps, bilateral and constant

In a severe case, fever with temperature >38, nausea and vomiting with severe pelvic and abdominal pain

Begins a few days after the onset of last menstruation worsen by cervical motion, exercise and coitus

Signs And Symptoms

Abnormal vaginal discharge in 75% of case

Dyspareunia, pain during sex

Vaginal bleeding after sex (post coital) in 40% of cases

Rebound lower abdominal tenderness and involuntary guarding. These are signs elicited my doctor

Diagnosis

Scan: a pelvic/ trans-vaginal scan is most appropriate form of scan to do and shows a fluid fill pouch of Douglas’

Full blood count/Complete blood count shows elevated white cells that signify infection

High Vaginal Swab (HVS)

Complications of Pelvic Inflammatory Disease

Chronic pelvic pain

Ectopic pregnancy

Complication of Pelvic Inflammatory Disease

Fallopian tube blockage causing infertility

Tube Blockage  by Pelvic Inflammatory Disease

Implantation failure leading to infertility

Management of Pelvic Inflammatory Disease

The management depends on the severity, complications and other associated genital infections including the unexpected fungi infections which most of the time is seen on HVS.

The treatment will also go along way if culture can be done to detect the likely culprit organisms.

From my little experience inadequate treatment and exclusion of the partner causes recurrent of this infection in most time

For proper management of mild to moderate infection following culture and sensitivity with pelvic scan, use the following combination

Tab DOXYCYCLINE 100mg twice daily plus tab METRONIDAZOLE 400mg twice daily for 7 – 14 days

Tab OFLOXACIN 400mg daily plus METRONIDAZOLE 400mg,

I will not give more than this combination, because microscopic, culture and sensitivity from HVS/ECS outline the most appropriate medication to tackle the infection.

These investigations when done usually reveal most appropriate and sensitive injections and tablets that can be used.

Even changing the own pattern if tests shows resistance to drugs may be warranted, meaning after first trial and no improvement see your physician to prevent resistance.

Your partner must be treated for you to gain full control of the disease.

In addition to the above combination, I prefer to add an anti-fungal agent to patient treatment either oral or per vaginal (insertion).

They are TAB FLUCONAZOLE 50mg twice daily for 3-5 days

NYSATIN insertion I daily or KLOVINAL insertion 1 daily for 5-6 days

Bear in mind that different doctor treat patient differently and medications differ in individual handlers.

Lastly for those who prefer supplements,  a combination of the following do help a lot, most especially after completing the antibiotics with all taking under appropriate prescription.

GYNAEPHARM

RESSIHI

EVES’ COMFORT

Need help contact me

Thanks for reading and don't forget to share