Pelvic Inflammatory Disease in Africa: Diagnosis and Treatment

Overview of Screening, Diagnosis and Treatment

• Offer routine screening, diagnosis, and empirical treatment of infected persons and their sex partners so as to reduce the incidence and prevalence of STI in the community.
•  Also offer routine screening for chlamydial infection in line with best practice guidelines to:
  • all sexually active non-pregnant women up to age 25 years,
  • non-pregnant women 25 years and older who are at increased risk of infection,
  • pregnant women up to age 25 years, and
  • pregnant women 25 years and older who are at increased risk of infection.
• Women with PID should be counseled to abstain from sexual activities or use appropriate barrier protection strictly until their symptoms and those of their partner have fully cleared and treatment is complete.

- US Centers for Disease Control and Prevention.

How is PID diagnosed?

Because many women with PID are asymptomatic, they may never get diagnosed.

There is no single test that is highly specific and sensitive for PID. A combination of laboratory tests, imaging studies and procedures may help in increasing the specificity of diagnosis of the disorder. Some of these include:

• Complete blood count.
• Erythrocyte sedimentation rate (ESR).
• C-reactive protein (CRP) level.
• Chlamydial and gonococcal DNA probes and cultures.
• Endometrial biopsy.
• Imaging studies may be helpful in unclear cases.

e.g., ultrasonography, computed tomography [CT], and magnetic resonance imaging [MRI] may be helpful in unclear cases where these resources are available and affordable.

In most African clinical settings, reliance is often placed more on the history, clinical examination findings and few basic laboratory and ultrasound workout in making a diagnosis of PID.

In resource rich countries, the gold standard for diagnosing PID is a laparoscopy examination. Even then, this is still infrequently used, given its cost, invasiveness, and unavailability to uninsured or underinsured populations.

A delay in diagnosis or treatment of PID can result in long-term consequences, such as chronic pelvic pain and tubal infertility.

All female patients of childbearing age with lower abdominal pain should get a pregnancy test done as PID is the most common incorrect diagnosis in missed ectopic pregnancy

How do I get treated for PID?

From the individual perspective, the goals of treatment of PID are to:

• Relieve acute symptoms like pain;
• Eradicate current infections; and
• Minimise risk of long term complications like
  • chronic pelvic pain
  • ectopic pregnancy and
  • tubal factor infertility

Medical treatment

Most patients with PID can be effectively treated on outpatient basis or from the doctor’s office. This is cost effective for African patients. Hospital treatment should only be considered if a patient has any of the following conditions:

• Uncertain diagnosis.
• Confirmed pelvic abscess.
• Pregnancy.
• Inability to tolerate outpatient oral antibiotic regimen.
• Severe illness.
• Immunodeficiency or immunocompromise.
• Failure to improve clinically after 72 hours of outpatient therapy.

Regardless of the location of care and in addition to pain and other supportive care, prompt and aggressive broad spectrum antibiotic treatment that covers common organisms should be initiated in at-risk women who have lower abdominal pain, adnexal tenderness, and cervical motion tenderness.

The antibiotic regimes must be effective against C trachomatis and N gonorrhoeae, as well as against gram-negative facultative organisms, anaerobes, and streptococci.

Depending on the circumstances of the patient, antibiotic treatment may be initiated per oral, intramuscularly or intravenously.

Intravenous or intramuscular antibiotics should be replaced with oral treatment once the patient shows good improvement after 24-48 hours on i.v. / i.m. treatment. Oral antibiotics treatment may then be continued for 10 – 14 days.

Professionals needing more information on recommended antibiotics regimes in the treatment of PID should click here for more details.

Most medically treated patients will show good clinical response within 48-72 hours after initiation of medical therapy.

If a patient continues to have fever, chills, uterine or adnexal tenderness, and cervical motion tenderness, other possible causes need to be considered and diagnostic laparoscopy is recommended to be performed.  

The removal of intrauterine devices (IUDs) in women diagnosed with acute PID is not advised. But antibiotics and close clinical follow-up is required if the IUD is left in place.

Surgical treatment

If surgery is indicated in the treatment of PID, the focus of care should be to conserve reproductive potential with –

• Simple drainage.
• Break up of adhesions, and
• Copious irrigation.

From a public health perspective, the goal of treatment is the prompt eradication of infection in order to reduce the risk of transmission to new sexual partners. In addition, identification and treatment of current and recent partners are indicated for further reduction of community-based sexually transmitted infections (STIs).

How can PID be prevented?

The patient-centered and public health goals of PID prevention dovetail significantly and include the following:

Education

• Patient-centered and public health education should be focused on advocacy strategies to:
  • Prevent PID and STIs.
  • Reduce the number of sexual partners.
  • Avoid unsafe sexual and self-medication practices.
  • Increase the routine use of appropriate barrier protection.
  • Motivate adolescents to delay engagement in sexual intercourse until age 16 or older.
  • Improve medical literacy generally towards embrace of screening, HIV testing, medication compliance, follow up and partner notification.

Community-level Screening, Diagnosis and Care

• Offer routine screening, diagnosis, and empirical treatment of infected persons so as to reduce the incidence and prevalence of STI in the community.
•  Also offer routine screening for chlamydial infection in line with best practice guidelines to:
  • All sexually active non-pregnant women up to age 25 years,
  • Non-pregnant women 25 years and older who are at increased risk of infection,
  • Pregnant women up to age 25 years, and
  • Pregnant women 25 years and older who are at increased risk of infection.
• Women with PID should be counseled to abstain from sexual activities or use appropriate barrier protection strictly until their symptoms and those of their partner have fully cleared and treatment is complete.

Takeaway

This article has provided a clear outlook on the burden, clinical features, diagnosis, treatment and prevention of PID in the African setting. More research is needed to characterize and better understand the drivers of trends in PID in Africa and help to inform future prevention opportunities for the disorder in different countries on the continent.

Resources:

1. Elie Nkwabong and Madye A.N. Dingom (2015): Acute Pelvic Inflammatory Disease in Cameroon: A Cross Sectional Descriptive Study African Journal of Reproductive Health December 2015; 19(4):90.

2. Oseni, T.I.A.: Occurrence of pelvic inflammatory disease and associated factors among undergraduates attending Irrua Specialist Teaching Hospital, Irrua, Edo state, Nigeria. A dissertation submitted to the National Postgraduate Medical College of Nigeria. May 2016. Retrieved Online as a PDF download, March 9, 2023.

3. Lindsey K. Jennings; Diann M. Krywko. Pelvic Inflammatory Disease. National Library of Medicine. NIH.  June 5, 2022.

4. Tough DeSapri, K. A. Pelvic Inflammatory Disease. Medscape. Updated August 2021. (Subscription and log in is required to access material).

5. CDC: Pelvic Inflammatory Disease: Treatment Guidelines. 2021. Retrieved March 10, 2023.

Related:

Endometriosis: What you need to know                Pelvic examination: What is it and why you may need one?            What you need to know when you do not have a period?

Published: February 21, 2023

Updated: March 10, 2023.

© 2023. Datelinehealth Africa Inc. All rights reserved.                                                     

Permission is given to copy, use and share content freely without alteration or modification and subject to attribution as to source.