Content Reviewers:Antonella Melani, MD, Lisa Miklush, PhD, RNC, CNS, Jodi Berndt, PhD, RN, CCRN-K, PCCN-K, CNE, CHSE, Gabrielle Proper, RN, BScN, MN
Margarita Salvador is a 25-year-old female client who presents to her gynecologist’s office with a report of lower abdominal pain, a fever of 101°F or 38.3°C, chills and thick, yellow foul smelling vaginal discharge.
She states her symptoms began three days ago. A pelvic examination is positive for cervical motion tenderness and right-sided adnexal tenderness. A transvaginal ultrasound visualizes a 4 cm right-sided tubo-ovarian abscess.
A vaginal swab was sent for laboratory analysis to check for chlamydia and gonorrhea. Ms. Salvador is diagnosed with pelvic inflammatory disease, or PID, and will be admitted to the medical surgical unit for treatment.
Most often, PID develops from a bacterial infection that begins in the vagina or cervix, such as sexually transmitted infections, or STIs, like chlamydia, caused by Chlamydia trachomatis, and gonorrhea, caused by Neisseria gonorrhoeae.
Another cause of PID can be bacterial vaginosis, which refers to the infection of the vagina due to overgrowth of bacteria like Gardnerella vaginalis, which are normally present in low numbers in the vaginal flora.
Occasionally, PID can be caused by other forms of bacteria introduced in the reproductive tract during surgery, abortion, or even childbirth. Now, PID is typically caused by only one type of bacteria, but in some clients, the infection can become polymicrobial, meaning the original infection makes it easier for other bacteria to settle into the reproductive tract.
Risk factors associated with pelvic inflammatory disease can be subdivided into two main groups. Modifiable risk factors include having unprotected sexual contact, as well as new or multiple sexual partners.
On the other hand, non-modifiable risk factors include being under the age of 35, since they’re more likely to have new or multiple sexual partners, as well as having a history of prior pelvic inflammatory disease, STIs, or bacterial vaginosis.
Some clients with PID will have no or mild symptoms. On the other hand, symptomatic clients may present with fever, pelvic pain, and tenderness around the ovaries and fallopian tubes, as well as dyspareunia, which is pain during sexual intercourse.
Additionally, some may complain of mucopurulent vaginal discharge or irregular uterine bleeding. Pelvic inflammatory disease can cause some serious complications, such as adhesions and strictures of the fallopian tubes, subsequently increasing the risk of ectopic pregnancy and infertility.
Finally, if the inflammation affects the peritoneum and Glisson’s capsule surrounding the liver, it can result in strings of scar tissue that attach the liver to the peritoneum.
These “violin string” adhesions are also known as Fitz-Hugh-Curtis syndrome, which is also called perihepatitis. Diagnosis of PID is usually based on history and clinical findings, such as pelvic pain and cervical motion tenderness, which refers to the pain and discomfort that occurs during mobilization of the cervix.
In some clients, the cervix can also be inflamed, erythematous, and bleed easily when touched. In addition, it’s important to check blood levels of beta human chorionic gonadotropin, or beta hCG for short, and perform an ultrasound to rule out pregnancy.
Ultrasound can also help visualize complications like a tubo-ovarian abscess. Next, a swab sample from the inside of the vagina or cervix can be tested for chlamydia and gonorrhea, using the nucleic acid amplification test or NAAP for short.
Finally, urinalysis can be performed to rule out urinary tract infections that might present with similar clinical findings. Clients with pelvic inflammatory disease are typically treated with a mix of antibiotics, including ceftriaxone or cefotetan, doxycycline, and metronidazole.
Now, let’s get back to Ms. Salvador and begin her assessment. As you enter her room you note Ms. Salvador appears uncomfortable and is guarding her lower abdomen.
While reviewing her history, she tells you she has had several male sexual partners in the past and no female sexual partners. She does not routinely use protection and last had intercourse two days ago, which she recalls as being painful.