CHAPTER ONE

INTRODUCTION
1.0 BACKGROUND OF THE STUDY
Pelvic inflammatory disease (PID) is a clinical syndrome that has been associated with a wide range
of potential causal pathogens. Three broad groups of organisms have been isolated from the genital
tract of people with PID: sexually transmitted organisms such as Neisseria gonorrhoeae, Chlamydia
trachomatis, Mycoplasma genitalium, and Trichomonas vaginalis; bacterial vaginosis (BV)-associated
species and genera such as Atopobium vaginae. Sneathia, and Megasphaera; and genera and species
usually associated with the gastrointestinal or respiratory tracts such as Bacteroides, Escherichia coli,
Streptococcus, or Haemophilus influenza. Although PID is often considered to be synonymous with
gonorrhea or chlamydia, these pathogens are found in only one quarter to one third of people with
PID,
suggesting that broader screening and diagnostic and treatment strategies need to be considered to
reduce the burden of PID and its associated sequelae.
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
infections, 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 STI is often the cause, other routes are possible, including
lymphatic, postpartum, post-abortal (either miscarriage or abortion) or intrauterine device (IUD)-
related and hematogenous spreadPelvic inflammatory disease (PID, is a clinical syndrome associated
with adverse reproductive health sequelae such as Pelvic inflammatory Disease (PID), ectopic
pregnancy, and chronic pelvic pain. Pelvic inflammatory disease is a clinical diagnosis, based on
symptoms of pelvic or lower abdominal pain and signs of tenderness of either the cervix, adnexa, or
uterus on examination. The diagnosis of PID is syndrome, made in sexually active people with a
uterus and cervix who have no other identifiable etiology. Pelvic inflammatory
disease is an and, as such, heterogenous in its presentation, severity, and etiology. The goal of
broadly inclusive diagnostic criteria is to ensure identification of all potential cases, so that they can
be provided antibiotic treatment to reduce the sequelae of PID. Based on self-report of PID
diagnosis, the Centers for Disease Control and Prevention estimated a lifetime prevalence of 4.4% or
2.5 million people in the United States. Although diagnostic criteria have become increasingly more
sensitive and less specific, over the past 2 decades the overall
incidence of clinically diagnosed acute PID has decreased.
Contemporary reports of the prevalence of PID sequelae range from 3% to 7% for Pelvic
inflammatory Disease (PID) and ectopic pregnancies in a military population to 36% for chronic pelvic
pain in the PID Evaluation and Clinical Health (PEACH) trial. Current diagnostic and treatment
guidelines focus on clinical presentation and symptom resolution, which is useful for clinicians but
potentially obscures subgroups of people who are at higher risk for sequelae and/or might benefft
from alternative treatments. The clinical diagnostic criteria do not grade the severity of disease, do
not require evaluation of adnexa versus
• endometrium, nor do they require identification of the causal agents), all of which
contribute
⁃ to the heterogeneity of the syndrome, It is unclear whether evaluating the presence
of upper tract disease or the etiology of infection is relevant for choosing treatment or predicting
outcomes; there are few clear predictors of who has a greater likelihood of developing long-term
complications from PID.In the PEACH trial, chronic pelvic pain occurred in approximately 32% of
participants, Pelvic inflammatory Disease (PID) in approximately 18%, and ectopic pregnancy in <1%,
which is higher than reported rates of 6-20/1000 women in epidemiologic studies. Sequelae were
more common in participants who had recurrent episodes of PID, or repeat sexuallytransmitted
infections (STIs), and in those who still had persistent symptoms 5 or 30 days after treatment.
Detection of several bacterial vaginosis (BV)-associated bacterial species orchlamydia in the cervix or
endometrium by polymerase chain reaction (PCR) was also associated with an increased risk for
Pelvic inflammatory Disease (PID), although gonorrhea was not. Trichomoniasis was associated with
an increased risk for sequelae that did not reach statistical significance. However, as mentioned
earlier, many infertile people who have intra-abdominal adhesions and tubal occlusion do not report
any history of PID, suggesting thatsubclinical disease may be a significant source of adverse
outcomes.In studies among people presenting with clinical PID, endometritis (25 neutrophils/400x
field # ≥1 plasma cell/120x field) is confirmed by endometrial biopsy in as few as 54% and as many as
70%, and salpingitis evaluated by diagnostic laparoscopy is confirmed in 20%-89%. If endometritis is
used as the gold standard, one study estimates the sensitivity of clinical criteria in symptomatic
people at only 36%. However, tubal scarring and other evidence of upper genital tract (UGT)
infection and inflammation is also present in people
⁃ who do not report a clinical history of PID, suggesting that symptomatic cases are
only one
⁃ - part of the total burden of disease. Subclinical PID is defined as the presence of
endometritis in the absence of clinical signs and symptoms of PID. People with subclinical PID have
similar demographic characteristics as those with acute PID, the diagnosis is also associated with
detection of Chlamydia trachomatis, Neisseria gonorrhoeae, or BV, and is linked to adverse outcomes
such as Pelvic inflammatory Disease (PID). These data suggest that even the broad, nonspecific
clinical criteria for the diagnosis of PID do not capture all people at risk for sequelae.
⁃ Thus, there is a gap between people identified by the clinical diagnostic algorithm
and the entire population at risk for adverse outcomes from PID. Examining the etiology of PID may
allow better screening, testing, and evaluation algorithms to bridge that gap between clinically
diagnosed, symptomatic cases and the full spectrum of disease. There are 3 general groups of
pathogens associated with PID, which are not mutually exclusive: sexually transmitted organisms
(Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma
⁃ genitalium, Trichomonas vaginalis), BV-associated bacteria (eg, BVAB3, Prevotella
bivia, Atopobium vaginae, Leptotrichia/Sneathia spp), and gastrointestinal (GI) or respiratory bacteria
(eg, anaerobes, facultative and aerobic bacteria such as Haemophilus influenzae, Escherichia coli,
Bacteroides). The proportion of participants with each of these types of pathogens detected differs
depending on the era in which studies were performed, how PID was defined in each study, and the
sensitivity and type of testing performed. However, detection of an organism does not necessarily
mean that it is the causal agent of PID. In addition, co-occurrence of organisms from multiple groups
may create a synergy that worsens the clinical course. For example, aerobic bacteria can act to create
tissue necrosis
⁃ and anaerobic conditions leading to the growth of anaerobes and development of a
tubo-ovarian abscess. A more nuanced understanding of how different pathogens and communities
of pathogens contribute to PID, the severity of disease, and the risk for sequelae will help guide
treatment recommendations, population-level prevention strategies, and future studies to improve
care for people with PID.
⁃ Objective Of the Study
1. To know more about Pelvic Inflammatory Disease
2. To identify patient with PID
3. To be able to give proper management to client with Pelvic Inflammatory Disease
4. To be able to counsel patient with PID

⁃ 1.2. Definition of Terms

 ⁃ Pathogens: A pathogen is defined as an organism causing disease to its host, with the
severity of the disease symptoms referred to as virulence. Pathogens are taxonomically widely
diverse and comprise viruses and bacteria as well as unicellular and multicellular
⁃ eukaryotes.
⁃ Respiratory bacteria: Bacteria. Bacterial causes of respiratory illnesses include
Bordetella pertussis, Burkholderia pseudomalilei, Chlamydophila pneumoniae, Corynebacterium
diphtheriae, Haemophilus influenzae, Mycoplasma pneumoniae, and Streptococcus
⁃ pneumoniae.
⁃ * Heterogenous: of different origin; not from the same source, individual, or species.
Tubo-ovarian abscess: A tubo-ovarian abscess is a pocket of pus that forms because of an infection in
a fallopian tube and ovary. A tubo-ovarian abscess is most often caused by pelvic inflammatory
disease (PID).
⁃ Tissue Necrosis: Necrosis is the death of body tissue. It occurs when too little blood
flows to the tissue. This can be from injury, radiation, or chemicals.