Pelvic Inflammatory disease (PID): the treatment, the drugs

Pelvic inflammatory disease (PID) is an infection of the upper genital tract (the uterus, fallopian tubes, ovaries, and the pelvic peritoneum). The infection usually spreads from the lower genital tract (vagina and cervix).

It is an infection of the reproductive organs of women. Several types of bacteria can cause PID, including the same bacteria that cause sexually transmitted infections-gonorrhea, mycoplasma and chlamydia. The bacteria first enters the vagina and cause an infection. With time, this infection can move into the pelvic organs- uterus, fallopian tubes, and ovaries. In rare cases, the infection can be blood borne.

Pelvic inflammatory disease is a cause of infertility in 1 in 8 women.

Risk factors of pelvic inflammatory disease.

The following factors increases your risk of developing PID:

• having an STI or a previously poorly treated STI from gonorrhoea, chlamydia, and mycoplasma.
• douching
• multiple sexual partners
• unprotected sex
• unsafe abortion (D and C)
• using an intrauterine contraceptive device (IUCD) to prevent pregnancy
• gynaecological procedures such as hysterosapingogram (HSG)
• Wearing of dirty underpants

Microorganisms that causes PID

The common infecting agents that causes pelvic inflammatory diseases are:

• Neisseiria gonorrhoea
• Chlamydia trachomatis
• Mycoplasma hominis

Other infecting organisms include:

• staphylococci
• E. coli
• Streptococci
• Haemophilus influenza
• Bacteriodes
• Mycobacterium tuberculosis- causes chronic PID

Symptoms of PID

Some women with pelvic inflammatory disease are without symptoms. Other women who have symptoms usually complains of:

• lower abdominal pain
• painful menstruation (dysmenorrhoea)
• painful sex (dyspareunia)
• pain on urination
• irregular vaginal bleeding
• irregular menstrual bleeding
• smelly vaginal discharge
• heavy bleeding during periods
• fever and chills
• vomiting

In Nigeria, the chronic variety with chronic pelvic pain and infertility is particularly common. These women see the doctor after several consultations with traditional ‘doctors’ and chemists.

tests for pelvic inflammatory disease

• Blood test: A full blood count will be done to check your white cell count and also check for anemia. In acute PID, your white cell count will be elevated. Your blood sample is also used for pregnancy test.
• Urine test: a midstream urine specimen will be collected for microscopy, culture and sensitivity to rule out urinary tract infection.
• Culture: swabs will be obtained from your urethra, endocervix and rectum for culture and sensitivity. High vaginal swab is of little diagnostic value in PID.
• Ultrasound: imaging test that uses sound waves to create pictures of your internal organs. It is useful in diagnosis of adnexal masses in chronic PID and in distinguishing adnexal abscess or other cystic pelvic collections.
• laparoscopy: It is the most accurate method of diagnosing pelvic inflammatory disease. During the procedure, a doctor inserts a flexible instrument through an incision in your abdomen and takes pictures of your pelvic organs.

treatment of pelvic inflammatory disease/ drugs for PID

The treatment of pelvic inflammatory disease is aimed at the relief of symptoms and the preservation of the functions of the Fallopian tubes. Early diagnosis and treatment will reduce the the complications of PID. Antibiotic therapy is the mainstay of treatment and this should be commenced as soon as the swabs for culture are taken and diagnosis is suspected.

Antibiotic treatment is aimed at covering all the infecting agents that causes PID- Neisseria gonorrhoea, chlamydia, mycoplasma and anerobes.

The choices of antibiotics should be dictated by local sensitivities of these organisms. In Nigeria, the abuse of antibiotics , a consequence of poor control of access to prescription drugs makes resistance to antibiotics very high.

The antibiotics in general use in treatment of PID include:

• penicillins
• cephalosporins
• metronidazole(flagyl)
• clindamycin
• tetracyclines
• chloramphenicol
• aminoglycoside

Patients with pelvic inflammatory disease can either be treated as outpatients or inpatients. The tetracyclines and metronidazole are used for outpatient treatment.

The tetracyclines continue to enjoy wide usage in the treatment of PID. Their main advantages include oral absorption, good coverage of aerobes, anerobes, chlamydia and mycoplasma.

Doxycycline, a second generation tetracycline has higher compliance rate because it given as 100mg twice daily dosage.

Metronidazole provides wider coverage over anerobes and enjoys wide usage in treatment of PID. The tablet is taken as 400mg three times daily.

Cephalosporins provide antibacterial activity for many strains of gram positive cocci and E.coli. Cefixime, a third generation cephalosporin is effective against pelvic inflammatory disease. It is taken as 400mg daily. Cefixime cost about N3,000 naira in Nigeria.

Clindamycin is a member of the macrolide family and has good antibacterial activity. It is an effective drug for PID.. Tablets is taken as 300mg four times daily. Azithromycin(Zithromax) is another member of the macrolide family. It is taken as 1g daily. Azithromycin costs N4,000 naira in Nigeria.

Aminoglycosides such as gentamycin is a commonly used drug for treatment of severe pelvic inflammatory disease. It is used in combination with other antibiotics. Because of its common side effects of renal toxicity and hearing loss, its use should be carefully monitored.

READ ALSO: TREATMENT OF MENSTRUAL PAINS

Quinolones as exemplified by ofloxacin and ciprofloxacin are good antibacterial activity against a wide range of infecting agents especially chlamydia. They are used in combination with other antibiotics. Ciprofloxacin tablets are taken as 500mg twice-daily. Ofloxacin is taken as 400mg daily.

In summary, it is the usual practice to treat outpatients with doxycycline 100mg twice daily for 14 days in combination with metronidazole 400mg orally three times daily also for 14 days. Ofloxacin 400mg orally twice daily can be combined with clindamycin 450mg orally or metronidazole for 14 days.

If your were admitted, you will be given intravenous antibiotics for the first 48 hours of admission. Cefoxitin is given at a dose of 2g intravenously every 6 hours for 48 hours. As an alternative, clindamycin 900mg intravenously is combined with gentamycin 80mg intramuscularly or intravenously every 8 hours for 48 hours. Thereafter, doxycycline 100mg daily or clindamycin 450mg four times daily can be given orally for 14 days.

Avoid sexual intercourse until you have been effectively treated.

In Nigeria, the cost of antibiotics can be a constraint in the treatment of PID. Fortunately, doxycyline and metronidazole, which are in common, are affordable to most of these patients.

complications of PID

Complications may result from inappropriate or delayed treatment of pelvic inflammatory disease. Chronic pelvic pain, ectopic pregnancy (pregnancy outside the womb) and infertility from tubal blockage are the common complications of PID.

prevention of pelvic inflammatory disease

• practice safe sex
• avoid douching
• personal hygiene
• get tested for STIs

Sources

Textbook on Obstetrics and Gynaecology by Akin Agboola

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