Pelvic inflammatory disease (PID) is caused by a type of bacteria, often the same type that is responsible for several sexually transmitted diseases, such as gonorrhea and chlamydia. In some cases, PID develops from bacteria that has traveled through the vagina and the cervix by way of an intrauterine device (IUD).
PID can affect the uterus, fallopian tubes, and/or the ovaries. It can lead to pelvic adhesions and scar tissue that develops between internal organs, causing ongoing pelvic pain and the possibility of an ectopic pregnancy (the fertilized egg becomes implanted outside the uterus). Left untreated, infertility can develop. In fact, PID is currently the leading cause of female infertility. If left untreated, PID can also lead to chronic infection. In addition, if PID is not diagnosed early enough, peritonitis and inflammation of the walls of the abdominal and pelvic cavity may develop.
The following are the most common symptoms of PID. However, each individual may experience symptoms differently.
Symptoms of PID include:
- diffuse pain and tenderness in the lower abdomen
- pelvic pain
- increased foul-smelling vaginal discharge
- fever and chills
- vomiting and nausea
- pain during sexual intercourse
Symptoms may be mild enough that the condition may go undiagnosed.
The symptoms of pelvic inflammatory disease may resemble other conditions or medical problems. Always consult your physician for a diagnosis.
How is PID diagnosed?
In addition to a complete medical history and physical and pelvic examination, diagnostic procedures for PID may include the following:
- microscopic examination of samples from the vagina and cervix
- blood tests
- Pap test - test that involves microscopic examination of cells collected from the cervix, used to detect changes that may be cancer or may lead to cancer, and to show noncancerous conditions, such as infection or inflammation.
- ultrasound - a diagnostic imaging technique which uses high-frequency sound waves to create an image of the internal organs.
- laparoscopy - a minor surgical procedure in which a laparoscope, a thin tube with a lens and a light, is inserted into an incision in the abdominal wall. Using the laparoscope to see into the pelvic area, the physician can determine the locations, extent, and size of the endometrial growths.
- culdocentesis - a procedure in which a needle is inserted into the pelvic cavity through the vaginal wall to obtain a sample of pus.
Treatment for PID:
Specific treatment for cervicitis will be determined by your physician based on:
- your age, overall health, and medical history
- extent of the disease
- type and severity of the symptoms
- your tolerance for specific medications, procedures, or therapies
- expectations for the course of the disease
- your opinion or preference
Treatment for PID usually includes oral antibiotics, particularly if there is evidence of gonorrhea or chlamydia. In cases of severe infection, hospitalization may be required to administer intravenous antibiotics. Occasionally, surgery is necessary.
Specific inflammatory diseases
To specific inflammatory diseases of the female reproductive organs belong tuberculosis and sexually transmitted diseases. According to the WHO’s classification, there are 21 such diseases. Their frequency has been risen for the last years.
(the WHO’s classification)
Classic venereal diseases
1. Syphilis Treponema pallidum
2. Gonorrhea Neisseria gonorrhoeae
3. Chancroid Hemophilus ducrei
4. Lymphogranuloma venereum Chlamydia trachomatis
5. Donovanosis, or granuloma inguinale Callimmantobacterium granulomatis
3,4,5 are mostly in tropic countries
Other sexually transmitted infections
A — that affect mostly genital tract
1. Syphilis Treponema pallidum
1. Urogenital chlamydiasis Chlamydia trachomatis
2. Urogenital trichomoniasis Trichomonas vaginalis
3. Urogenital mycoplasmosis Mykoplasma hominis
4. Candidosis vulvovaginitis Candida albicans
5. Genital herpes Herpes simplex virus
6. Genital warts Papillomavirus hominis
7. Molluscum contagiosum Molluscovirus hominis
8. Bacterial vaginosis Gardnerella vaginalis та iншi збудники
9. Urogenital shigellosis of homosexualists Shigella species
10. Pediculosis pubis Phthyrus pubis
11. Scabies Sarcoptes scabiei
B — With mostly affection of other organs
1. Infection, caused by HIV Human immunodeficiency virus
2. Hepatitis B Hepatitis B virus
3. Cytomegalovirus infection Cytomegalovirus hominis
4. Amebiasis Entamoeba hystolytica
5. lambliosis Giardia lamblia
Gonorrhea is a contagious disease caused by Neisseria gonorrhoeae. Among the specific inflammatory diseases of the female genital tract gonorrhea takes the second place and is in 5-25% of cases of all STDs.
Etiology and pathogenesis. Gonorrhea is caused by Neisseria gonorrhea (fig. 92). The causative agent was found in 1879 by A. Neisser. Gram-negative N. gonorrhea is not stable in the outer surrounding and dies quickly at the influence of antiseptic solutions, boiling, drying, but it is rather stabile in human organism. In uncomfortable conditions they transform into L-forms, which can transform into the usual form in the favourable conditions. In case of chronic gonorrhea, N. gonorrhoeae are situated mostly in leukocytes and out of the cells, in case of the acutening of the process they are found in the leukocytes.
N. gonorrhea affects mostly those parts of urogenital tract, that are covered with cylindric epithelium: mucosa of urethra, cervical canal, Bartholin’s glands ducts, mucosa of uterine cavity, uterine tubes, ovarian epithelium, peritoneum. During the pregnancy, childhood and menopausal period there can be gonorrheal vaginitis.
The source of infection is a person with gonorrhea.
Ways of infecting:
l the disease is sexually transmitted
l homosexual contacts, orogenital contacts
l very rarely through sponges, towels, underwear
l during labour from mother (infected eyes, vagina in girls)
Incubational period lasts for 3-7 days, sometimes for 2-3 weeks.
According to the stage of spreading the process the gonorrhea of lower part of genital organs (gonorrheal urethritis, endocervicitis, Bartholinitis, vulvovaginitis) and gonorrhea of upper parts — gonorrhea ascendens (endometritis, salpingitis, pelvioperitonitis) is classified.
According to duration there are such forms of gonorrhea:
l fresh gonorrheal infection with acute, subacute, torpid passing, which lasts less than two months
l chronic gonorrheal infection, lasting more than two months
l latent gonorrheal infection
In women the clinic of gonorrhea depends on the localization of the process, virulency of causative agent, age of woman, organism’s reactivity, stage of the disease (chronic, acute).
Fresh gonorrhea in acute forms has expressed clinical manifestations. Subacute form is characterized by subfebrile condition, sometimes by expressed clinical symptoms, which appeared two weeks before. Torpid gonorrhea in acute form has mild clinical manifestations or is asymptomatic, but N. gonorrhoeae are found in the patient. Latent form is diagnosed when there is no bacteriologic and bacterioscopic confirment, no symptoms, but person is a source of infection. Chronic gonorrhea lasts for more than 2 months, or without establishing of the beginning.
Gonococcal urethritis. Clinical manifestation appears within 3-5 days after infection and is characterized by dysuria. Variable degrees of edema and erythema of the urethral meatus, purulent or mucopurulent discharge are present.
Gonococcal Bartholinitis. It may occur when N. gonorrhea with vaginal discharge infects the Bartholin’s gland. It is manifested by edema, erythema around the duct’s os. When the occlusion occurs, pseudoabscess or Bartholin’s abscess which are accompanied by purulent process symptoms can develop.
Gonococcal endocervicitis. Inflammatory process develops in mucosal layer of the cervical canal. Examination reveals edema and erythema of vagina and part of the cervix. There is a red crown around the cervical os and a mucopurulent cervical discharge.
Gonococcal proctitis occurs very rarely. Rectum is involved into the process in the result of contamination with the infected genital discharge. Clinic includes tenesmus and rectal pain.
Gonococcal endometritis is the first stage of the ascendant gonorrhea with infection of basal and functional layer of endometrium. It is manifested by lower abdominal pain, high body temperature, sometimes nausea, vomiting. Pain often has spasmatic character. Discharge is sanguine-purulent or mucopurulent. Uterus is painful at palpation. Chronic endometritis is characterized by menstrual disorders.
Gonococcal salpingitis is the infection of the fallopian tubes, mostly bilateral. In acute stage the pain in lower part of abdomen is common. It becomes stronger, motion, nausea, vomiting. Menstrual disorders can occur.
Gonococcal pelvioperitonitis — a specific inflammation of pelvic peritoneum and is a sequel of salpongoophoritis. The onset is acute. Severe lower abdominal pain, peritoneal irritation symptoms, vomiting, meteorism, constipation, high body temperature can be found. Gonococcal inflammation is characterized by the tendency to adhesion process, that leads to localization of inflammation in pelvis.
Gonorrhea during pregnancy is often asymptomatic. It can lead to complication of pregnancy, labor and is a risk factor both for the fetus and for the newborn. Possible complications for mother (chorioamnionitis, subevolution of uterus, endometritis) and fetus (premature delivery, unophthalmia, intrauterine sepsis, death) can occur. Artificial abortion is dangerous because of possibility of the uterus, ovaries, tubes infection and other complications.
Gonorrhea in children. Mechanism of infection: during delivery when a child passes through infected birth canal, or intrauterine through amnionic fluid, and from ill mother to child while looking after it. Elder children may be infected while using common toilet, sponge, bath.
Gonorrhea in girls is acute with the expressed edema and erythema of mucosal membrane, mucopurulent discharge, frequent and painful urination, itching. There can be high body temperature. In girls gonorrhea causes the same complications as in women.
Peculiarities of the gonococcal infection:
l increasing of quantity of capsular and l-forms of n. gonorrhea
l decreasing of sensitivity to penicillin antibiotics
l large percentage of asymptomatic and torpid forms
l frequent relapsing as a sequele of inadequate treatment
l urogenital infection is often mixed (gonococci, chlamidias, trichomonades, mycoplasmas, candides)
This should be taken into account during treatment.
Diagnosis of the process is based on the data of complex examination. The disease is characterized by urethritis, bartholinitis, endocervicitis, bilateral salpingitis, proctitis, pelvioperitonitis. But diagnosis of gonorrhea can’t be confirmed without laboratory tests.
Diagnosis of gonorrhea is confirmed by positive results of bacterioscopic and bacteriologic tests of cervical, vaginal, urethral discharge. To acuten the chronic process the so-called “provocation” is conducted:
1) 0,25% solution of argentum nitrici on mucosal membrane of the cervix, vagina and urethra is applied
2) introducing of gonovaccine, pyrogenal, prodigiozan
Smears must be taken on the 2-4th day of the menstrual cycle and after provocation in 24, 48, 72 hours, that allows to reveal N. gonorrhea.
Treatment is provided in special clinic. Sometimes the patient is treated by the venerologist in ambulatory.
To reveal another sexually transmitted diseases clinical and laboratory examination must be performed. While prescribing medicines the clinical form, complications and severity of the process should be taken into consideration.
The main medicines in gonorrhea treatment are antibiotics. Gonococcal infection very often is accompanied with trichomoniasis, chlamidiasis, candidiasis, mycoplasmosis.
Antibiotics that have influence on the following agents such as: ciprofloxacin, doxycyclin, trobicyn, sumamed, cephtriaxon, afloxacin in combination with metronidazol, tiberal, naxogyn should be prescribed. The dose of antibiotics is taken according to the methodical instructions of the Ukraine MHP and annotation of medicines.
Gonovaccine is used after ineffective antibiotic treatment and relapse in the latent fresh torpid and chronic form of the disease (200-300 mln. of microbe bodies, in 2-3 days intramuscularly). During pregnancy immunotherapy and antibiotics with negative influence on a fetus are not used.
For toilet of external genital organs 0,002% solution of chlorhexidine, recutan, baliz-2 are prescribed. Local treatment of chronic gonorrhea is conducted after disappearing of the signs of acute inflammation. In chronic and subacute stages physiotherapeutic methods are used: laser radiation, paraffinotherapy, mud-cure, diathermy, inductothermy, U.H.F-therapy.
The control of the results of treatment: disappearing of subjective signs and microbe agents in all the infected organs and discharge. On the 7-10th day after medical therapy the bacterioscopic and bacteriologic methods are used to confirm the results of treatment. If there is no N. gonorrhea in the material, then the combined provocation is conducted: injection of gonovaccine (500 mln. of microbe bodies), instillation of 1% Lugol’s solution in urethra, 0,5% solution of argentum nitrate into cervical canal. Discharge from this organ should be examined during 3 days. Smears are taken during menstruation and then after provocation in 24, 48, 72 hours. Such examinations are provided during 2-3 menstrual cycles. Women which have contacts or work with children are not allowed to work.
Prophylaxis. Using of condom is the most effective prevention method. If the sexual intercourse has happened without it, then the external genital organs should be washed with water and soap, and after urination syringing with 0,05% chlorhexidin solution should be performed.
Urogenital trichomoniasis is caused by Trichomonas vaginalis and is a result of their invasion into the lower part of genital tract and urethra.
Ethiology. Trichomonas vaginalis is a flagellate protozoan and it is transmitted by sexual intercourse. It is not stable in outer environment, dies in few seconds under the influence of antiseptic solutions, in water it dies during 15-45 minutes, and also when they wash hands with soap, it is sensitive to drying. In human organism Trichomonas vaginalis can exist in 3 forms: common one (pear-shape form), amebiform with the expressed phagocytosis action (it can phagocytise mycoplasmas, N. gonorrhea and other bacteria that caused the recurrence of mycoplasmas or gonorrhea. this is the most spread disease among all the sexually transmitted ones. Its frequency rate reaches 50-70% of sexually active women. According to the WHO statistics, 10% of world population suffer from trichomoniasis. Non-sexual transmission is very seldom: when they use sponges, underwear, towels.
Incubation period lasts for 5-15 days. the main places of trichomonas parasitizing are mucose membranes of vagina, cervical canal, uterus cavity, uterine tubes, Bartholin gland’s duct, urethra, urinary bladder.
Inflammatory process develops in the infected mucous membrane: edema, hyperemia, exudation, desquamation affects epithelial cells.
Clinical manifestations. Vaginitis, urethritis, endocervicitis, proctitis are the most common manifestations, ascendant infection meets rarely.
Forms of genital trichomoniasis:
l fresh (acute, subacute and torpid forms)
l chronic trichomoniasis (with torpid form and duration of more than 2 months)
l trichomonas carriage (is characterized by the absence of symptoms, while Trichomonas vaginalis are present)
At acute and subacute forms women complain of foamy vaginal discharge with foul odor, vulvar itching, dysuria.
Objective data: erythema, maceration, vulva, perineum scratching, cervical erosion, erythema and edema of vaginal mucosa, foamy purulent discharge. At torpid forms clinical manifestations are mild or absent.
Chronic trichomoniasis is characterized by vaginal discharge, itching, but there are no inflammatory manifestations, there can be frequent relapsing.
Diagnosis. Diagnosis is confirmed by anamnestic data, objective examination, vaginal smears.
Peculiarity of the mixed trichomoniasis-gonococcal infection is the longer incubation period. At first trichomoniasis and after gonorrhea is treated.
Treatment. The main principles are:
l treatment of the woman and her sexual partner
l avoiding of intercourse until the patient and her partners are cured
l using of antitrichomonades treatment with local treatment, and hygienic procedures: shaving hair on pubis, everyday changing of underwear
l treatment of accompanying diseases of genital organs
Antitrichomonade remedies are metronidazole (trichopol, clion, metragil, flagil), fasigyn (tinidazol), atrican, naxogyn, tiberal, solkotrichovak, tergynan.
Recently for treatment of trichomoniasis metronidazole should be prescribed. on the first day they use 0,25g 4 times a day, on the next days — 0,25g 3 times a day. All dosage on treatment course is 5-6 g. Tinidazole is used in such regimen after meals:
l once 2 g (4 tablets each 0,5 g)
l 0,5g every 15 minutes 4 times
l 0,15g twice a day during 7 days
Naxogyn is used in dose of 500 mg twice a day 6 days. During pregnancy and breast-feeding all these medicines are contraindicated.
Clion-D is used in the form of vaginal tablets 1 tabl. for night during 10 days. Locally antiseptic solution can be used: baliz-2, 0,002% solution of chlorhexidin, trichomonacid.
Control of the treatment is fulfilled during 2-3 menstrual cycles.
Prophylaxy. To prevent trichomoniasis condom using is recommended. If the sexual intercourse has happened without the condom, then the external genital organs should be washed with water ans soap, and after urination syringing with 0,05% chlorhexidin solution should be performed.
Urogenital chlamidiasis (chlamidiosis urogenitalis) is a rather spread infectional disease, which is transmitted mostly sexually. In women it can be manifested as urethritis, vaginitis, bartholinitis, endocervicitis, cervical erosion, endometritis, salpingitis, pelvioperitonitis, proctitis etc. It can occur even in the newborns (infected during labor). Chlamidial infection occurs in 50% of cases among women with the inflammatory processes, besides these chlamidias are often accompanied by gonorrhea (40%) and trichomoniasis (40%). According to the WHO statistics nearly 90 millions of the new infected are registered annually. The reason of its wide spreading is mild duration, complicated diagnostics and treatment. More often the women of 20-30 years age become ill.
Ethiology and pathogenesis: Infective agent of urogenital chlamidiasis is gram-negative bacteria, Chlamydia trachomatis, preferentially it infects columnar epithelium and reproducts itself intracelluarly. There are two main forms of chlamidia — elementary body and reticular body.
Elementary bodies are the infective form of the agent, which transmit the infection, can exist outcellularly. The cell can be penetrated with few elementary bodies, that have tendency to conflowing, making one particle. During 48-72 hours infected cells are destroyed. Elementary bodies come out from cells and infect the new ones. Reticulative bodies are vegetative forms of chlamidia and are the result of reproduction in the infected cells, a new generation of elementary bodies. practically they don’t cause the infection. Microscopy allows to identify both kinds of bodies. Chlamidia has a complicated antigenic structure. It is very sensitive to disinfectant substances. At 35-37°C during 24-26 hours outcellular chlamidia become nonvirulent, at temperature 95-1000C they die during 5-10 minutes. In cotton material they can survive up to 2 days at temperature 19-20°C.
The source of infection is the ill person.
Ways of transmission:
l intrapartum (passing through the infected birth canal)
l nonsexual way (polluted hands, instruments, underwear, toilet, etc.)
Besides infection of urogenital organs, Chlamidia trachomatis can cause pharyngitis, conjunctivitis, perihepatitis, otitis, pneumonia, other diseases (Reiter’s syndrome).
Clinical manifestations. Incubational period lasts from 5 to 30 days. The main primary form of chlamidial infection is endocervicitis with mild symptoms or without any. In acute stage purulent or mucopurulent discharge from the cervix, edema and erythema of the vaginal part of the cervix are observed. In chronic stage there is the mucopurulent discharge and pseudoerosion of the cervix.
Chlamidial urethritis can be asymptomatic or it manifests itself by dysuria. There are no specific symptoms for clinical diagnostics of chlamidiasis.
Salpingitis, caused by Chlamidia trachomatis, is characterized by the same symptoms like the process caused by other bacteria.
The sequale of chlamidial salpingitis is infertility.
Diagnosis is based on the history (both partners are ill, there is the infertility). Residual diagnosis is established after revealing chlamidias in the scrap from the cervix and vagina. The most exact are immuno-enzyme and immunofluorescent methods.
Treatment. It is necessary to cure the woman and her sexual partner. The woman should avoid sexual intercourses, alcohol, psychical and physical overload.
Medicines from the tetracyclin group are prescribed (doxycyclin, rondomicyn, morphocyclin), sumamed, tarivid, macrolids (clacid, erythromycin).
To prevent candidosis diflucanum in dose 150 mg is used, nistatin or levorin (2.000.000 IU per day during treatment) are prescribed. Fromilid (clarythromycin), an acid-resistant antibiotic from macrolid group is recommended. An important property of this drug is its possibility to cell penetration, that’s why fromilid is 8 times more active, than erythromycin. It doesn’t suppress immune system, activates phagocyto-macrophagal system and some enzymes, that take part in destroying of pathogenic bacterias. The dose of fromilid is 500 mg twice a day during 7-14 days in case of fresh incomplicated chlamidiosis. In chronic forms the treatment course must be elongated till 3-4 weeks.
At urogenital chlamidial infection medicines from ftorchinolon group, ciprofloxacin (ciprinol) are used. Ciprinol is prescribed in the dose of 0,5g orally or 0,2g intravenously each 12 hours during 10-14 days. During treatment the ultraviolet irradiation including sun radiation are contraindicated.
Treatment of chlamidiasis demands from the doctor and patient accurate fulfilling of all the indications (dose and duration of the therapy), especially at chronic, long-lasting forms of disease. At the same time accompanying urogenital diseases should be treated. To reduce side effects of antibiotics hepatoprotectors, antioxydants, polivitamins are used.
Ethiology. Microbal agents are Mycoplasma hominis, Mycoplasma genitaloum, Ureaplasma urealiticum.
In the etiology of the inflammatory diseases of female genital organs the associaton of mycoplasmosis with trichomoniasis, N. gonorrhea, chlamidia trachomatis, anaerobes is of great importance.
Mycoplasmas are transmitted sexually and they are highly spread among the population.
Clinic. Mycoplasmas infection can occur in acute and chronic form, and has no symptoms, which are specific for this agent. It is often found in healthy women. Mycoplasmosis is characterized by torpid course, sometimes the latent forms of the reproductive system inflammation are observed. The agents may be activated under the influence of menstruation, oral contraceptives, pregnancy, delivery. Ureaplasma is identified in the patients with vaginitis, cervicitis, urethritis, in association with other bacteria the symptoms are typically and described in the part “Nonspecific inflammatory diseases of the female genital organs”.
Diagnosis. To reveal ureaplasmas the bacteriological method is used. Material is taken from the purulent discharge of Bartholin’s glands, from uterine tubes at salpingitis, tuboovatian tumors at pelvic inflammatory disease. Test on the urease is done (colour index). It is based on the property of ureaplasms to product urease, that changes the pH and the colour of indicator. Serological diagnosis is also used. Immunogram in diagnosis of mycoplasmosis and other infection (chlamidia, gonorrhea, trochomoniases, herpes simplex virus) is indicated.
Treatment. Using of antimicrobal medicines from macrolid group (erythromycin, sumamed, roxitromycin), Tetracyclin group (tetracyclin, doxycyclin), fluorochinolones (ciprofloxacin) is etiotropic treatment. They are prescribed for not less than 10-14 days with the following laboratory control. Another course of treatment is immunity stimulation (immunoglobulin, levamizol, T-activin, ginseng tincture).
Prophylaxis. examination of the risk group (prostitutes, women with infertility, inflammatory processes of genital organs), and keeping to the same measures for preventing sexually transmitted diseases are used.
Candidiasis is a polyorganic disease, caused by yeast fungi (Candida albicans, C. glabrata, C. tropicalis). It can be transmitted sexually. The most frequent localization is in vagina, vulva, but there can be candidiasis endocervicitis, endometritis, salpingitis.
l endogenous long lasting diseases, such as diabetes mellitus, avitaminosis
l exogenous factors, that predispose fungal colonization and decrease the general reactivity of the organism (long treatment with antibiotics) and local immunity in vaginal mucosa
l high virulency of candidas
There are such kinds of candididas vulvovaginitis:
l antibiotics-induced (as a result of antibiotic treatment)
l as a sequale of changes in different systems of the organism (diabetes, pregnancy, using of estrogens)
On the suppressed immunity of the organism fungi, that were previously saprophites, become pathogenic. They adher to vaginal epithelial cells, causing superficial inflammation and desquamation of vaginal cells. Genital candidiasis mostly doesn’t cause a deep damage of mucosa and spreading of the process, but if the agent has high virulence, it can penetrate into intra- and subepithelium parts. in some cases there can be dissemination of candidiasis.
Clinical manifestations: Candidiasis vulvovaginitis is characterized by vulvar itching, pruritus, cottage-cheese-like discharge.
Examination reveals edema and erythema of genital mucos with whitish adherent discharge, that include pseudomicelium of fungi, exfoliated epithelial cells and leukocytes.
Diagnosis. Diagnosis is based on the clinical manifestations, vaginal examination, colposcopy, bacterioscopic and bacteriological methods.
Treatment. Acute form is treated by orungal 200 mg twice a day during 3 days; at chronic form they use 100 mg twice a day during 6-7 days, then during 3-6 menstrual cycles 1 capsule on the first day of menstrual cycle is taken. High effectiveness is observed while using diflucan in dose 150 mg per 1 reception, and gyno-pevaril — one suppository (150 mg) during 3 days. In case of relapse one suppository (50 mg) twice a day for 7 days and application of gyno-pevaril creme on glans penis during 10 days is recommended. The next step of treatment is normalization of vaginal ecosystem.
Prophylaxis: rational antibiotic treatment with keeping to optional doses and duration of the therapy course, in-time using of antimycotic medicines with the preventive aim. Avoiding of premarriage and extramarital relationships, condom using for preventing fungal colonization of the female genital tract.