Pelvic Inflammatory Disease

A pelvic inflammatory disease (PID) is a condition that most often affects young women. Pelvic infection is usually caused by a range of pathogens that damage the fallopian tubes, which leads to such symptoms as fever and the acute abdominal pain. Although it has been noted that PID occurs in sexually active women, some of the reviewed studies show that quite a large number of adolescents (20% of 1 million cases) is annually diagnosed with PID (Goyal, Hersh, Luan, Localio, Trent, & Zaoutis, 2013). PID has unpleasant physical and physiological effects. It requires an immediate treatment because its complications are difficult and costly to treat. This paper reviews current studies related to PID and its effect on the young females health as well as summarizes treatment methods and recommendations given by the best practice studies. These researches have been carefully chosen and reviewed based on their quality and consistency.

Diagnosis and Treatment Guideline

PID is a well-researched disorder with quite distinct clinical features. It is caused by Chlamydia trachomatis and Neisseria gonorrhea, although it has been noted that other organisms such as Streptococcus, Peptococcus, and Escherichia coli can also cause PID (McKinnon, Black, Lortie, & Fleming, 2013). At this, chlamydia and gonorrhea are most closely linked to PID. In the developed countries, chlamydia has been noted to cause PID in 15-40% of patients, while gonorrhea was found in 2-5% of all cases (Ross, 2014). These infections destroy an epithelial lining of fallopian tubes, which leads to acute symptoms and signs, such as lower abdominal pain, nausea/vomiting, vaginal bleeding, vaginal discharge, and fever.

Before an initiating treatment, a clinician is required to accurately diagnose the patient. The majority of researchers agree that diagnosing PID can be rather complicated, especially basing on clinical symptoms alone. For example, Raya and Bamberger (2012) note that acute PID shows a wide variation in its clinical presentation, this is why health care providers should maintain a high index of suspicion and low threshold for its diagnosis (p. 584). Similarly, Maleckiene, Kajenas, Nadisauskiene, and Railaite (2009) report that precise diagnosis of PID based on clinical symptoms varies from 40% to 87% (p. 75). Another group of researchers also emphasizes that the clinical criteria for diagnosing PID can be imprecise. Clinicians should maintain a low threshold when initiating the treatment of patients with PID (Carr & Espey, 2013). All researchers agree that laboratory tests, such as erythrocyte sedimentation rate (ESR), white blood cell count, serum C-reactive protein (CRP), as well as gonorrhea and chlamydia tests can be helpful in diagnosing a patient with PID (Carr & Espey, 2013; McKinnon et al., 2014; Raya et al., 2012; Ross, 2010). Laparoscopy is mentioned as one of the methods that help to improve diagnostic accuracy, especially in atypical cases (Maleckiene et al., 2009; McKinnon et al., 2014). However, Maleckiene et al. (2009), McKinnon et al. (2014), and Ross (2010) disagree in the effectiveness of this method with the latter researcher claiming that laparoscopy lacks sensitivity. Its inaccurate interpretation of visual appearance may result in missing early infection.

As far as the treatment is concerned, a clinician dealing with PID has limited options. Antibiotics therapy has been mentioned as the most effective method of treating it. Raya et al. (2012) emphasize that since the underlying etiologic agents are often polymicrobal, the empirical treatment regimens should have broad coverage for STI and non-STI organisms (p. 585). The researchers mention that oral antibiotic regimen of doxycycline, azithromycin, ceftriaxone, clindamycin, and ofloxacin are the most widely antibiotics used in treating PID (Carr & Espey, 2013; McKinnon et al.; Ross, 2014). The researchers also agree as for the duration of the antibiotic therapy, which is 14 days in most of the cases. However, it is up to the clinician to decide on the type of an antibiotic, its dosage, and a route of administration. These recommendations vary depending on the severity of the disease and such individual characteristics as age (a single-dose antibiotic therapy is sometimes sufficient for adolescents), severity of the disease (for example, in case of mild or moderate PID, metronidazole can be discontinued), and special circumstances, such as allergy, pregnancy, etc. (Carr & Espey, 2013; McKinnon et al., 2013; Raya et al., 2012; Ross, 2014). It is also vital for clinicians to take into account that antibiotic regimens should be changed in response to evolving antibiotic resistance patterns. Another important issue to consider with regards to PID management is expedited partner treatment (EPT). The researchers agree that EPT is quite effective in reducing the reinfection rate this is why it should be necessarily implemented by a provider. The partner can be treated without a direct medical evaluation with a female patient simply delivering the prescription to her partner. In this way, a timely consultation, accurate diagnosis, and adequate treatment can help the patient with PID to avoid complications and undesirable outcomes of the disease, such as infertility, ectopic pregnancy, chronic pelvic pain, and PID recurrence.

Summary and Recommendations

Five best practice studies have been chosen for this review. They all present the problem of PID from different perspectives. Some of them present only the disease-oriented evidence while others are diagnostic case-control studies. However, irrespectively of the type of evidence presented, these sources offer valuable recommendations as for a diagnosis, treatment, and prevention of the researched medical conditions. Each of them is a unique and valuable study able to make an enormous contribution into the research of a health care professional exploring PID. Moreover, despite viewing the problem from different angles, their findings are, for the most part, consistent; and their conclusions are coherent and similar with each other. A thorough analysis of these studies allows grouping their recommendations into two main sets.

The first group of researchers recommends using specific methods of diagnosing a patient with PID. It especially concerns the studies performed by Maleckiene et al. (2009) and McKinnon et al. (2014). The study performed by Maleckeine et al. is a meta-analysis of good-quality cohort studies. Its aim is to evaluate risk factors of PID and emphasize the importance of laparoscopy in diagnosing women with PID. In this study, 28.8% of patients could have been misdiagnosed if laparoscopy has not been used. Laparoscopy, according to the researchers, proves the efficiency of this method of diagnosing PID (Maleckiene et al., 2009). Similarly, McKinnon et al. (2014) presents a case in which laparoscopy played a decisive role in diagnosing a patient. This is a high-quality individual RTC with good-quality patient-oriented evidence. It presents a case of PID caused by an atypical organism, F. nucleatum. These two groups of researchers strongly recommend using laparoscopy when diagnosing patients with PID. At this, McKinnon et al. (2014) also mentions that it may be more effective that CT, MRI, and ultrasound when diagnosing patients with abdominal pain, because it gives more information than can be obtained from mere imaging.

Another set of recommendations is focused on the prevention of PID. Some researchers are convinced that the regular screening, EPT, and repeat testing of women who had PID can help to reduce the number of PID cases. These ideas are forwarded by Carr and Espey (2013) whose study deals with PID among adolescents as well as the use of intrauterine device (IUD) by adolescents and young adults as an effective means of contraception. It is a SR of good-quality cohort studies with strong recommendations as for PID prevention. Together with Ross (2014) and Raya et al. (2012), Carr and Espey (2013) posit that the public education campaign and patient-directed counselling tools can not only dispel the myth that adolescents should not use IUD because of infectious risks. It also counsels sexually active adolescents about high-risk behavior associated with PID. Although the study presented by Ross (2014) is only a case series for studies of diagnosis, it is a valuable contribution into this research. It gives the exhaustive information about PID, its etiology, clinical presentation, treatment, and prevention. Similarly, Raya et al. (2012) also presents disease-oriented evidence discussing risk factors and diagnostic criteria for PID among adolescents and young adults. A great advantage of these two studies is that they give strong recommendations as for prevention and future trends of PID. Thus, they support an idea of health education and its ability to reduce risk-taking sexual behavior. Together with this, they emphasize the necessity of primary prevention of PID stating that the use of barrier contraception and contact tracing, as well as abstinence in case with adolescents, can help to control and reduce PID spread among the population.

In conclusion, this paper has reviewed a number of studies evaluating their quality and consistency. All these studies research PID as a medical condition that occurs frequently among young females and adolescents. The researchers agree that it is improper to diagnose PID basing on the clinical symptoms only. Although some of them disagree that laparoscopy can increase the accuracy of PID diagnosis, the fact that laboratory investigations should be performed is incontestable. With regards to this, the recommendations of one group of researchers concern diagnosing PID accurately, which presupposes laparoscopy, while another group is more concerned with the prevention of PID.

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