Introduction:
Pelvic inflammatory disease (PID) is a common medical problem,
affecting nearly 1 million women each year,
being one of the main due to medical visits on emergency room in worldwide.
PID is serious medical problem described as cause of urgent pathology in female pelvic; the diagnosis is based on clinical and analytical parameters and the treatment with ambulatory antibiotics is effective in 90 % of women.
The other 10 % of women with PID will have a serious PID,
needing hospital admission for the risk of complications.
In the latter group of patients the diagnosis by images is very important,
to delimit the origin and extension of the disease,
complications,
and as method of guide for the drainage of possible abscesses.
The radiological findings of the PID were changing according to the severity of the disease,
from endometritis,
salpingitis up to the presence of tubo-ovarian abscess.
We are described also all the possible abdominal PID complications and the main differential diagnosis in the context of the pelvic feminine urgent pathology.
Definition
PID is an infectious and inflammatory disorder of the upper female genital tract; including the uterus,
fallopian tubes and ovaries as well as in some cases,
the infection may spread to adjacent pelvic structures.
Epidemiology
PID is a common medical problem,
affecting nearly 1 million women each year distributed worldwide.
The annual rate of PID in high-income countries has been reported to be as high as 10-20 per 1000 women of reproductive age and approximately represent 24% of office visits owing to pelvic pain,
representing for over 275,000 hospitalizations each year.
The direct and indirect costs of PID to society have been estimated at $10 billion annually,
it due to the need of medical attention added to the serious sequels that it can produce (infertility,
ectopic pregnancy,
chronic pelvic pain,
recurrent infections and life-threatening emergency by rupture of tubo-ovarian abscess).
The risk factors include:
- Young age
- Multiple sex partners
- High coital frequency
- Low socioeconomic status
- Douching and use of an intrauterine device (particularly during the first few months after insertion)
Etiology:
PID usually results from ascending infection by Neisseria gonorrhoeae or Chlamydia trachomatis,
although 30% of cases are polymicrobial.
In addition,
aerobic and anaerobic,
gram positive and negative organism,
normal vaginal flora,
viruses,
tuberculosis,
mycoplasma,
and other atypical organism have been implicated as causative agents (Fig. 2).
Dissemination routes:
PID may disseminate to neighboring organs or even affect abdominal organs across three primary routes:
1.
- Extension to parametrials structures
2.
- Direct ascent of microorganisms to upper genital tract: Pyosalpinx,
salpingitis,
endometritis
3.
– Primary vaginal or cervical infection: endocervical inflammation.
4.
– Less frequent:
Direct spread from a nearby infection such as appendicitis or diverticulitis
Hematogenous,
peritoneal or lymphatic spread: Salpingitis secondary to tuberculosis.
Clinical and laboratory features:
Unfortunately,
patients usually present with a nonspecific symptoms,
including fever,
abdominal or pelvic pain,
vaginal discharge,
uterine bleeding,
dyspareunia,
dysuria,
adnexal or cervical tenderness,
nausea,
vomiting,
and other vague constitutional symptoms.
On the other hand,
it is believed that 35% of patients with PID are asymptomatic.
Because of the severity of these long-term consequences,
it is important that PID be diagnosed accurately and treated promptly; following The Centers for Disease Control and Prevention (CDC) criteria for the diagnosis of PID are as follows:
Minimum criteria (1 or more) are as follows:
- Lower abdominal tenderness
- Adnexal tenderness
- Tenderness with cervical motion
Additional criteria (patients with PID should have 1 or more) are as follows:
- Signs of lower genital tract inflammation
- Oral temperature higher than 101ºF
- Abnormal cervical and vaginal discharge
- Greatly increased numbers of white blood cells on saline microscopy of vaginal secretions
- Elevated erythrocyte sedimentation rate
- Elevated C-reactive protein level
- Laboratory documentation of cervical infection with C trachomatis or N.
gonorrhoeae
Elaborate criteria (additional findings) are as follows:
- Histopathologic evidence of endometritis at endometrial biopsy
- Thickened fluid-filled tubes with or without free pelvic fluid or a tubo-ovarian complex on transvaginal sonograms or images from other modalities
- Laparoscopic abnormalities those are consistent with PID
Workup:
The diagnosis of PID is primarily based on historical and clinical findings.
It is believed that 90% of patients with PID are classified as mild to moderate disease,
these patients can safely be treated as outpatients with antibiotics; on the other hand,
10% of patients have clinically severe or complicated PID and should be considered for hospitalization and inpatient parenteral therapy,
being necessary imaging studies to realize a precise diagnosis.
Imaging is required:
- If symptoms are nonspecific,
- If the patient is not responding as expected to treatment,
and to evaluate for complications such as abscess
- To determine the origin and the extent of the process
- To decide if a known abscess is amenable to percutaneous drainage.