Epi, enfermedad pelvica inflamatoria

Clinical Expert Series

Pelvic Inflammatory Disease
David E. Soper,
MD

Pelvic inflammatory disease (PID) is an infection-caused inflammatory continuum from the cervix to the peritoneal cavity. Most importantly, it is associated with fallopian tube inflammation, which can lead to infertility, ectopic pregnancy, and chronic pelvic pain. The microbial etiology is linked to sexuallytransmitted microorganisms, including Chlamydia trachomatis, Neisseria gonorrheae, Mycoplasma genitalium, and bacterial vaginosis-associated microorganisms, predominantly anaerobes. Pelvic pain and fever are commonly absent in women with confirmed PID. Clinicians should consider milder symptoms such as abnormal vaginal discharge, metrorrhagia, postcoital bleeding, and urinary frequency as potential symptomsassociated with the disease, particularly in women at risk of sexually transmitted infection. The diagnosis of PID is based on the findings of lower genital tract inflammation associated with pelvic organ tenderness. The outpatient treatment of mild-to-moderate PID should include tolerated antibiotic regimens with activity against the commonly isolated microorganisms associated with PID andusually consists of an extended spectrum cephalosporin in conjunction with either doxycycline or azithromycin. Clinically severe PID should prompt hospitalization and imaging to rule out a tuboovarian abscess. Parenteral broad-spectrum antibiotic therapy with activity against a polymicrobial flora, particularly gram-negative aerobes and anaerobes, should be implemented. Screening for and treatment ofChlamydia infection can prevent PID.
(Obstet Gynecol 2010;116:419–28)

P

elvic inflammatory disease (PID) is characterized by an infection-caused inflammatory continuum from the cervix to the peritoneal cavity (endocervicitis, endometritis, salpingitis, peritonitis) (Fig. 1).1 This is an important disease for women because it can be associated with significant sequelae, including tubal factorinfertility, ectopic pregnancy, and chronic pelvic pain. Women developing PID are also at increased risk of recurrent infection. Finally, acute PID may lead to tuboovarian abscess formation, which can be life threatening if rupture occurs.

Pelvic inflammatory disease is diagnosed in more than 800,000 women annually in the United States. Ninety percent of women with PID are treated asoutpatients. Most of these women are less than 25 years old with sexually active adolescents being at the highest risk.2 The annual cost of this condition now approaches US $2 billion, with 70% of these costs attributed to the care of women with acute PID rather than diagnosis and treatment of sequelae.3 Unfortunately, these estimates fail to take into consideration the number of women with “silentsalpingitis,” an entity that remains asymptomatic or is associated with atypical symptoms eluding diagnosis.4

From the Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, South Carolina. Continuing medical education for this article is available at http://links.lww.com/ AOG/A190. Corresponding author: David E. Soper, MD, Medical University of South Carolina,Department of Obstetrics and Gynecology, 96 Jonathan Lucas Street, Suite 634, P.O. Box 250619, Charleston, SC 29425; e-mail: soperde@musc.edu. Financial Disclosure The author did not report any potential conflicts of interest. © 2010 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/10

PATHOPHYSIOLOGY
The mucosal innate immunesystem of the female reproductive tract is uniquely adapted to facilitate the specialized physiologic functions that include menstruation and fertilization while eliminating threatening sexually transmitted and environmental pathogens. The vagina and cervix harbor a variety of commensal bacteria in their normal state as well as potential pathogens when bacterial vaginosis is present. Despite this...