Pelvic inflammatory disease is a generic term for the infection of the female uterus, fallopian tubes, and/or ovaries as it progresses to scar formation with adhesions to nearby tissues and organs. This may lead to tissue necrosis (with or without abscess formation). Pus can be released into the peritoneum. Two-thirds of patients with laparoscopic evidence of previous PID were not aware they had ever had PID. PID is often associated with sexually transmitted diseases, as it is a common result of such infections. PID is a vague term and can refer to viral, fungal, or parasitic infections, though it most often refers to bacterial infections. PID should be classified by affected organs, the stage of the infection, and the causative organism(s). Although an STD is often the cause, other routes are possible, including lymphatic, postpartum, post-abortal (either miscarriage or abortion) or intrauterine device (IUD)-related and hematogenous spread.

PID occurs when bacteria move upward from a woman’s vagina or cervix (opening to the uterus) into her reproductive organs. Many different organisms can cause PID, but a majority of cases are associated with gonorrhea and/or chlamydia, two very common bacterial STDs.

Pelvic inflammatory disease is more likely to occur in patients with a history of pelvic inflammatory disease, recent sexual contact, recent onset of menses, an IUD in place, or if a patient’s partner has a sexually transmitted disease. Acute pelvic inflammatory disease is highly unlikely when recent intercourse has not taken place and an IUD is not being used.

While PID itself may be cured, effects of the infection can be permanent. This makes early identification by someone who can prescribe appropriate curative treatment critical for the prevention of damage to the reproductive system. Since early gonococcal infection may be asymptomatic, regular screening of high-risk individuals (e.g., though with a history of multiple partners, history of any unprotected sex, or people with symptoms) and patients who have undergone certain procedures (e.g., post pelvic operation, postpartum, miscarriage,or abortion). Prevention is also very important in maintaining viable reproductive capabilities. If the initial infection is mostly in the lower tract, a patient will likely not have reproductive difficulties after sufficient treatment. If the infection is in the fallopian tubes or ovaries, serious complications are more likely to occur.

PID is difficult to diagnose because the symptoms are often subtle and mild. Many episodes of PID go undetected because the patient or her health care provider fails to recognize the implications of mild or non-specific symptoms. Because there are no precise tests for PID, a diagnosis is usually based on clinical findings. There may be no actual symptoms of PID for a given patient. If symptoms are present, then fever, cervical motion tenderness, lower abdominal pain, new or different discharge, painful intercourse, or irregular menstrual bleeding may be noted. It is important to note that PID can occur and cause serious harm without causing any noticeable symptoms. Other signs and symptoms include unusual vaginal discharge that may have a foul odor, painful intercourse, painful urination, and pain in the right upper abdomen (rare).

No single test has adequate sensitivity and specificity to diagnose pelvic inflammatory disease. Laboratory findings that look for signs of infection include C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and WBC count. A sensitive serum pregnancy test should be obtained to rule out ectopic pregnancy. Gram-stain/smear becomes important in identification of rare and possibly more serious organisms.

A pelvic ultrasound is a helpful procedure for diagnosing PID. An ultrasound can view the pelvic area to see whether the fallopian tubes are enlarged or whether an abscess is present. Pelvic and vaginal ultrasounds are helpful in the differential diagnosis of ectopic pregnancy of over six weeks.

Culdocentesis will differentiate hemoperitoneum (ruptured ectopic pregnancy or hemorrhagic cyst) from pelvic sepsis (salpingitis, ruptured pelvic abscess, or ruptured appendix).

Treatment depends on the cause and generally involves use of antibiotic therapy. If the patient has not improved within two to three days after beginning treatment with the antibiotics, they should return to the hospital for further treatment. Drugs should also be given orally and/or intravaneously to the patient while in the hospital to begin treatment immediately to increase the effectiveness of antibiotic treatment. Hospitalization may be necessary if there is a tubo-ovarian abscess, the patient is very ill, immunodeficiency exists, the patient is pregnant, there is cervical incompetence, or because this or something else life threatening can not be ruled out. Treating partners for STDs is a very important part of treatment and prevention. Anyone with PID and partners of patients with PID since six months prior to diagnosis should be treated to prevent reinfection. Psychotherapy is highly recommended to women diagnosed with PID as the fear of redeveloping the disease after being cured may exist. It is important for a patient to communicate any issues and/or uncertainties they may have to a doctor, especially a specialist such as a gynecologist, and in doing so, to seek follow-up care.

If symptoms continue or if an abscess does not go away, surgery may be needed. Complications of PID, which can include chronic pelvic pain and scarring, tend to be difficult to treat, though they sometimes improve with surgery.

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Although there is no documentation that when PID discovered first but, it seems to be close to first discovery of chlamydia and gonorrheal infection, as they are the leading causes of PID.

• Chlamydia trachomatis was first discovered in 1907 by Halberstaedter and von Prowazek.^[1]
• In 1879,Albert Neisser a german doctor discovered the gonococcus for the first time.

Pelvic inflammatory disease (PID) is an infection that begins in the vulva or vagina and spreads upward to involve most of the structures in the female genital system. Inflammation and the resulting scarring may lead to adhesions and infertility.

Development of PID is the result of ascension of microorganisms from the cervix or vagina to the upper genital tract including, endometrium, fallopian tubes, ovaries and contiguous pelvic structures. ^[1]

The endocervical canal functions as a barrier protecting the normally sterile upper genital tract from the organisms. Disturbance of this barrier provides vaginal bacteria access to the upper genital organs, infecting the endometrium, then endosalpinx, ovarian cortex, pelvic peritoneum, and their underlying stroma.

The factors determining the rate of infection ascending to the upper genital tract include:^[2]

• Untreated chlamydial infections
• untreated gonoccoal infections
• Sexual intercourse
• Retrograde menstruation

Infection results in fibrinous or suppurative inflammatory damage along the epithelial surface of the fallopian tubes and the peritoneal surface which leads to scarring, adhesions, and possibly partial or total obstruction of the fallopian tubes.

Pelvic inflammatory disease causes a selective loss of ciliated epithelial cells, which interferes with intratubal ovum transport, resulting in infertility or ectopic pregnancy.^[3]

• T-cell neutrophils and plasma cells accumulation are the immune system response to the infective pathogen.^[4][5]

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Common causes of pelvic inflammatory disease include Neisseria gonorrhoeae and Chlamydia trachomatis. Other causes of pelvic inflammatory disease include Bacteroides, Enterococci, Staphylococci, Streptococci, Ureaplasma urealyticum, gram negative rods, and anaerobes.

• Chlamydia trachomatis ^[1][2][3]
• Neisseria gonorrhoeae^[4][1][2]
• Mycoplasma genitalium^[5][6]

• Anaerobes such as peptostreptococcus spp and prevotella spp
• Pathogens associated with BV including: atopobium vaginae and leptotrichia spp^[7]
• Mixed infection: Sometimes, it is caused by mixed flora including, Bacteroides, Enterococci, Staphylococci, Streptococci, Ureaplasma urealyticum, E.coli, Klebsiella spp, Proteus mirabilis, Haemophilus spp and gram negative rods

Pelvic inflammatory disease must be differentiated from ectopic pregnancy, ovarian torsion, ovarian cyst hemorrhage, ruptured ovarian cysts, appendicitis, endometriosis, diverticulitis and urinary tract infection.

It is difficult to have an accurate estimate of PID incidence and prevalence because most of this patients are sub-clinical.^[1] PID is the most common reason for hospitalization among women. It is more common among young sexually active woman aged 15-29.

• It is estimated that between 750,000 and 1.2 million women are affected by PID each year in the United States.^[2][3]
• Incidence and prevalence are decreasing since 1985 because of widespread chlamydia screening and treatment.^[4]
• PID is the most common gynecologic reason for hospital admission in the United States, accounting for 18 per 10,000 recorded hospital discharges.^[5][6]
• Approximately 50,000 women become infertile in the US each year as a consequence of PID.
• N. gonorrhoea is isolated in only 40-60% of women with acute salpingitis.^[7] C. trachomatis was estimated to be the cause in about 60% of cases of salpingitis, which may lead to PID.

• 
  Pelvic Inflammatory Disease—Hospitalizations of Women Aged 15–44 Years, United States, 2001–2010
• 
  Pelvic Inflammatory Disease—Initial Visits to Physicians’ Offices by Women Aged 15–44 Years, United States, 2002–2011

Graphs adapted from https://www.cdc.gov/

PID is a common disease that tends to affect young women between the ages of 15 and 29 years.^[2]

In the United States, African-American or Black-Caribbean ethnicity has been associated with a higher risk of PID.^[8]

Common risk factors in the development of pelvic inflammatory disease include prior history of pelvic inflammatory disease, recent sexual contact, multiple sexual partners and IUD.

Important risk factors in PID development include:

• Multiple partners:

Having multiple sexual partners within last six months increase the risk of PID.^[1]

• Previous PID:

Recurrent PID is more common among women who have a history of PID.^[2]

• IUD:

It will increase the risk of PID in first 3 weeks after implementation.^[3][4]

The overall prognosis of PID is good. Timely, appropriate treatment often prevents serious complications such as ectopic pregnancy, infertility, hydrosalpinx, and chronic pelvic pain.

If left untreated, PID may lead to infertility in approximately 16% of affected women.^[1] It may progress to adjacent organ involvement or even peritonitis.

The overall prognosis of PID is good if patients are treated within 3 days of the onset of symptoms onset, though clinical improvement cannot guarantee protection against infertility.^[2]

Factors that predict poor prognosis include:^[3]

• Advanced age
• History of previous open gynecological surgery
• Any cystic lesion identified by ultrasonography
• High CRP levels

• Chronic pelvic pain is defined as lower abdominal pain that lasts for at least 6 months and causes functional disability. Approximately 1 in 3 of women affected by PID will experience chronic pelvic pain.^[4]
• Recurrent PID is the strongest predictor for the development of chronic pelvic pain due to the scars and adhesions that result from repeated inflammation.^[5]

• PID may cause permanent damages to the fallopian tubes, this damages include loss of ciliary action, fibrosis, and occlusion that may result in infertility.^[6]
• Risk factors for infertility include:
  1. Chlamydial infection^[7]
  2. Delayed PID treatment^[8]
  3. Frequent PIDs^[9]
  4. Severity of infection^[10]

• Tubal damage due to PID may result in anatomical distortion, which can predispose the patient to ectopic pregnancy.^[1]

• Tubal damage may lead to tubal blockade, sterile fluid accumulation, and/or fallopian tube enlargement, which may cause pain or infertility.^[11]

• Inflammation and adhesion formation in the liver capsule (perihepatitis) may cause right upper quadrant abdominal pain and tenderness.^[12]