Occurence or recurrence of pelvic inflammatory disease or PID has been linked to STIs such as C. trachomatis or Neisseria gonorrhoeae. Patient education and simplified guidelines are needed to develop accurate diagnosis. In order for changes to take place, more research must be done to understand the complex nature of the disease and the most effective and cost effective method of treatment.
This paper delves into the risk factors, diagnosis processes, treatment, relevant psychological issues, public health implications, patient and family education, and appropriate referral to specialty by reviewing literature pertinent to PID. The results of the literature review show very little in the past was done in regards to researching symptoms of PID and treatment efficacy. New research shows lower abdominal pain as a main indicator of PID as well as C. trachomatis or Neisseria gonorrhoeae. The data also elaborates on the risks of infertility associated with PID.
The costs of treating infertility are high. The costs of treating of ectopic pregnancy, another risk of developing PID, is also high. Earlier detection, most importantly, preventative measures are needed to keep healthcare costs down and help women from developing the disease. Infertility is not only a costly problem, but one that affects women on a psychosocial level.
Pelvic inflammatory disease or PID, remains to this day, a mystery to the average medical professional. "PID affects around 10% of the reproductive-age female population each year." (Landers & Sweet, 2013, p. 12) The mystery lies within attaining definitive diagnostic criteria and how to tell who has it and when a PID could form. One of the reasons why PID is so hard to diagnose, let alone determine within a set group, is due to the lack of laboratory test validation available that other infectious phenomena have.
Instead, providers must rely on their own clinical judgement to prevent the worst of the disease. Normally a regimen of various antibiotics prove successful in both inpatient and outpatient treatments; but, many patients tend to have complications such as tubo-ovarian abscess/tubal occlusion and may result in ectopic pregnancy and/or infertility. Women who experience PID must not only deal with the personal costs of this disease, but also the financial. PID treatment can turn costly and lead to high medical bills for both the patient and the hospital/clinic.
"PID is the clinical syndrome associated with upper genital tract inflammation caused by the spread of micro-organisms from the lower to the upper genital tract. PID can be caused by genital mycoplasmas, endogenous vaginal flora (anaerobic and aerobic bacteria), aerobic streptococci, Mycobacterium tuberculosis, and sexually transmitted infections (STI) such as C. trachomatis or Neisseria gonorrhoeae." (Simms & Stephenson, 2000, p. xx-xx) Risk factors play an important role in determining who will most likely develop Pelvic inflammatory disease (PID). PID is most frequently caused by sexually transmitted infection (STI). "PID occurs because of migration of pathogens (most commonly chlamydia and gonorrhea) to the upper female genital tract, provoking tubal inflammation and subsequent tissue damage." (Smith, Cook, & Roberts, 2007, p. xx-xx) To detect PID, and prevent further complications, women should undergo routine STI screening in order to rule out any STI's being in the system. As Smith, Cook, & Roberts state in their paper, the Centers for Disease Control and Prevention (CDC) recommend annual screening for sexually active women aged 20-25 and adolescent women to aid in early diagnosis of PID. Although some recommend adolescent women and women under 25 go as much as every six months for STI screening especially routine gonorrhea screenings. The U.S. Preventive Services Task Force adds that previously infected women should get tested every 6- to 12-months due to high rates of reinfection
Liu et al. wrote about the very little research performed in improving practitioner and patient adherence to PID diagnosis and management guidelines. Of the three studies they identified, the need for further studies, particularly in primary care settings, should be performed. It is here where they found diagnosis and management of PID to be suboptimal, and where further research should be conducted. They advised that in order for diagnosis and treatment to improve, patient and practitioner must follow certain guidelines such as: "abbreviated practitioner clinical management guidelines, provision of the full course of antibiotic treatment to the patient at presentation, simplified antibiotic regimens, and written instructions for patients." (Liu et al., 2012, p. xx-xx)
Blake, Fletcher, Joshi, & Emans wrote in their paper, that "most patients given a clinical diagnosis of PID in an adolescent medical setting reported lower abdominal pain in the medical history and that all patients diagnosed with PID reported either lower abdominal pain or dyspareunia." These two symptoms may be seen as indicators of PID. When there is no presence of these symptoms, a low risk of PID may be noted. Of the many studies evaluating diagnostic indicators, only a few were performed in primary care settings, where most were done in hospital settings. "Many have used the symptom "lower abdominal pain" as a required inclusion criterion, preventing an analysis of the sensitivity and specificity of its presence." (Blake, Fletcher, Joshi, & Emans, 2003, p. xx-xx) Blake et al. noted, most studies identified in their review used abdominal pain as a required inclusion criterion. Labeling it as a required inclusion criterion kept analysis of its sensitivity low and from being a diagnostic indicator.
Blake et al. further note that two studies used abdominal pain as a diagnostic indicator of PID. "In one study, 112 women undergoing diagnostic laparoscopy for infertility were interviewed prior to the laparoscopic procedure. Eighty percent of the women noted to have laparoscopic findings consistent with a previous episode of PID reported a past history of lower abdominal pain compared with 42% of those with no findings consistent with previous PID. In the other study 72 of 90 patients (82%) diagnosed with a lower genital tract infection due to chlamydia or gonorrhea and who had an endometrial biopsy consistent with endometritis reported abdominal pain as compared with 36 of 60 patients ( 60%) with lower genital tract infection but no endometritis." (Blake, Fletcher, Joshi, & Emans, 2003, p. xx-xx)
Mirblook, Asgharnia, Forghanparast, & Soltani performed a study with an aim to compare two oral treatments: Ofloxacin and Metronidazole, with Azithromycin and Metronidazole in outpatients with PID. The study was administered through Randomized Clinical Trial in Al-zahra Women's Hospital of Rasht. The number of women selected and who participated in the study were two hundred. Eligibility was based on the following criteria. Women with the three of the five following symptoms were considered: lower abdominal pain, vaginal discharge, adnexal tenderness, cervical motion tenderness and cervicitis. "Group A was treated with Ofloxacin (400 mg) with Metronidazole (500 mg) and Group B. was treated with a single dose of oral Azithromycin (1gr) with Metronidazole (500 mg) for 10 days." (Mirblook, Asgharnia, Forghanparast, & Soltani, 2011, p. xx-xx) The regimens were compared with regards to efficacy and side effects. Patient check up began after two weeks passed from initial treatment.
The study lasted for six months with only 4 patients taken off treatment due to adverse reactions. After the six months, the study found that post-treatment cure rates for groups A and B. were 90.3% for group A and 93.75% for group B. Although there was a small difference in cure rate between the groups, there was no statistical difference in the outcome of both treatments. Both medications were proven to have high efficacy and cure rate. The difference with patient satisfaction between medications is Azithromycin was the preferred treatment for Pelvic Inflammatory Disease "due to the simplicity and shorter duration of its use." (Mirblook, Asgharnia, Forghanparast, & Soltani, 2011, p. xx-xx) Successful treatment has been shown with Azithromycin but it has also proven resistant to M. genitalium which is often the leading cause of PID. "M. genitalium has demonstrated susceptibility to macrolides, azithromycin resistance has recently been reported." (Sweet, 2011, p. xx-xx)
Relevant Psychosocial Issues
Infertility is a major concern is Pelvic inflammatory disease (PID). Because PID is an upper genital tract infection, the uterus and fallopian tubes may get damaged from complications of PID . Long-term implications of PID include "higher rates of infertility, ectopic pregnancy, and chronic pelvic pain." (Songer, Lave, Kamlet, Frederick, & Ness, 2004, p. xx-xx) Fertility is often the most important in preserving when it comes to treatment of PID and often becomes a major goal in generating optimal treatment strategies. "About 10% of the population of childbearing age is affected by infertility." (Songer, Lave, Kamlet, Frederick, & Ness, 2004, p. xx-xx) Although fertility plays a vital role in a woman's emotional well being, limited research on the role infertility plays in quality of life is severely limited. Of the few reports that exists, some suggest infertility causes social isolation, depression/anxiety, and decreased or impaired job performance. In general, little is known on how infertility impacts women overall.