PELVIS IN FLAMES
Pelvic inflammatory disease is the most common and most serious (other than HIV/AIDS) complication of sexually transmitted infections
By Miles Dumalagan
"PID, FOR ME, IS A LIFESTYLE DISEASE. GENERALLY, [IT IS] AN INFECTION OF THE PROMISCUOUS-NOT NECESSARILY THE WOMAN, BUT THE PARTNER, [AS WELL]. SO, WE CANNOT ALWAYS BLAME WOMEN FOR IT."
Dr. Ricardo M. Manalastas, vice chair for research of the obstetrics and gynecology department of the University of the Philippines-Philippine General Hospital, says this of pelvic inflammatory disease or PID, the most common and most serious (aside from HIV/AIDS) complication of sexually transmitted infections. It includes endometritis (infection of the uterus), salpingitis (infection of the fallopian tubes), tubo-ovarian abscess (TOA) and pelvic peritonitis.
Microorganisms colonizing the membranes of the uterine cervix (endocervix) ascend to the endometrium and fallopian tubes to cause PID. A complex alteration of vaginal flora through an enzymatic shifting of the cervical mucus barrier facilitates the spread of these microbes. The endogenous microorganisms found in the vagina, particularly those responsible for causing bacterial vaginosis (anaerobic bacteria such as Prevotella and peptostreptocci as well as G. vaginalis) are often isolated from the upper genital tract of women with PID.
PID is a polymicrobial infection of the upper genital tract associated with sexually transmitted organisms Neisseria gonorrhea and Chlamydia trachomatis as well as endogenous organisms, including anaerobes, H. influenza, enteric Gram negative rods, and streptococci.
Don't Let the Pain Remain
The disease is common in young, nulliparous (unable to complete pregnancy), and sexually active women with multiple partners. Patients often present with bilateral diffused, dull and constant lower abdominal pain, menstrual disturbances, abnormal vaginal discharge, pain during urination (dysuria), pain during intercourse (dyspareunia), nausea, vomiting, or fever.
The diagnosis of PID is based on a triad of signs and symptoms including pelvic pain, cervical motion tenderness and adnexal (collectively refer to the fallopian tubes and ovaries) tenderness and the presence of fever.
"Usually you have to satisfy the three major criteria," says Manalastas. "You have your diagnosis on clinical grounds, and if your patient doesn't respond to antibiotics, you think,
baka hindi ito PID. It can be endometriosis or ectopic pregnancy. Pwede rin appendicitis."
Laparoscopy is often used, and it is necessary if the diagnosis is uncertain or if the patient is unresponsive to the antibiotic treatment for 48 hours. The appendix should be visualized to rule out appendicitis. Cultures obtained at a time of laparascopy are often specific and helpful.
"Pelvic ultrasound is only supportive. A cervical culture is not always done because the commonly reported cases are gonorrheal and chlamydial infections. These organisms are not cultured routinely," adds Manalastas.
Moreover, these are very special and difficult tests that can't always be done for practical reasons. A patient with chlamydial infection may be asymptomatic or have minor symptoms, but the infection could seriously damage the reproductive organs. A delay in diagnosis can give rise to inflammatory sequelae in the upper reproductive tract. Infertility, ectopic pregnancy, or chronic pelvic pain are among the serious consequences of PID. Diagnosis is complicated by the fact that many women exhibit subtle or mild symptoms, not readily recognized as PID.
More elaborate tests like endometrial biopsy to confirm the presence of endometritis, ultrasound or radiologic tests to characterize a TOA, and laparoscopy to confirm salpingitis may be employed in women with severe symptoms to rule out incorrect diagnosis that can cause unnecessary morbidity.
Manalasatas stresses the impact of douching. "There has to be a definitive indication before you can use the highly microbicidal douches, and [only] for a limited time because this can be source of ascending infection."
Multiple Risks
Women with or who have had sexually transmitted diseases or STDs are at an increased risk because the body's defenses are damaged during the initial bout of upper genital tract infection. So are those who have multiple sexual partners and frequent sexual intercourse, or acquire a new sexual partner within three months from a previous one.
Says Manalastas: "We commonly see PID among commercial sex workers with multiple partners. They have unprotected sex and they are the ones who are very prone to PID. [It should be] part of their work to [learn] how to use barriers and to [talk] their partners [into] using condoms."
Among sexual workers in the Philippines, 30 percent develop PID. But the incidence in the general population is only three to four percent, Manalastas notes.
A ten-year-old study showed most women diagnosed with PID were not sexually promiscuous. Notes Manalastas: "Ang napapansin namin sa mga Filipino, it is the husband, [in more than half of cases] who has a history of genital infection. It is the husband who brings the infection."
Acute PID is highly unlikely when recent intercourse has not taken place or an IUD is not being used. It is not strictly classified as STD but may be caused by an ascending infection brought about by instrumentation or douching.
Need for Hospitalization and Surgery
Hospitalization is recommended when the diagnosis is uncertain, clinical disease is severe, pelvic abscess is suspected, or compliance with an outpatient regimen is in question.
Patients who have TOA, which is end-stage acute PID, may require surgical excision or transcutaneous or transvaginal aspiration of the abscess. In 70 percent of cases, antibiotics are effective; in 30 percent, there is inadequate response within 48 to 72 hours, and intervention is necessary. Hysterectomy and bilateral salpingo-phorectomy may be required for overwhelming infection or in cases of chronic disease with intractable pelvic pain.
Despite treatment, one out of every four women diagnosed with acute PID would develop long-term sequelae, including repeated episodes of infection, ectopic pregnancy, chronic pelvic pain, or infertility.
Repeated incidence of salpingitis raises the risk of infertility: 10 percent after the first episode, 25 percent after the second, and 50 percent after the third.
The Philippines follows the treatment guidelines issued by the United States Centers for Disease Control and Prevention- with some modificaions. For instance, Manalastas points out, gonorrhea resistance is high in the Philippines so "we do not recommend a fluoroquinolone-based regimen for PID." Resistance to this class of drugs is about 70 to 75 percent, he notes.
Sexual partners of women with PID should also be evaluated and treated for urethral infection with chlamydia or gonorrhea.
"We cannot tell people not to have sex. But we can tell them to do it safely, using barrier methods, and to stay in a mutually exclusive relationship with a partner who is known to be not infected," Manalastas stresses.
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