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Inflammatory diseases of the pelvic organs
Medical expert of the article
Last reviewed: 05.07.2025
Pelvic inflammatory disease (PID) is an infection of the upper female reproductive tract: the cervix, uterus, fallopian tubes, and ovaries are involved; abscesses may occur. Common symptoms and signs of the disease include lower abdominal pain, vaginal discharge, and irregular vaginal bleeding. Long-term complications include infertility, chronic pelvic pain, and ectopic pregnancy.
Diagnosis is based on clinical manifestations and PCR data for gonorrhea and chlamydia; microscopy with saline fixation; ultrasonography or laparoscopy. Treatment is with antibiotics.
[ What causes pelvic inflammatory disease?
Inflammatory diseases of the pelvic organs are the result of the penetration of microorganisms from the vagina and cervix into the endometrium, fallopian tubes and peritoneum. Infectious lesions of the cervix (cervicitis) contribute to the appearance of mucopurulent discharge. The most common are combined inflammatory processes of the fallopian tubes (salpingitis), uterine mucosa (endometritis) and ovaries (oophoritis).
The most common causes of pelvic inflammatory disease are Neisseria gonorrhoeae and Chlamydia trachomatis, which are sexually transmitted. Pelvic inflammatory disease is also commonly caused by other aerobic and anaerobic bacteria, including the infectious agents associated with bacterial vaginosis.
Inflammatory diseases of the pelvic organs are more common in women under 35 years of age. Less often, inflammatory processes develop before menarche, after menopause and during pregnancy. Risk factors include previous diseases, the presence of bacterial vaginosis or any sexually transmitted infection.
Other risk factors, especially for PID of gonorrheal or chlamydial etiology, include young age, non-white race, low socioeconomic status, and frequent changes of sexual partners.
Symptoms of pelvic inflammatory disease
The most common manifestations of the disease are: pain in the lower abdomen, fever, vaginal discharge, abnormal uterine bleeding during or after menstruation.
Cervicitis. Hyperemia of the cervix and contact bleeding are noted. The presence of mucopurulent discharge is characteristic; usually these are yellow-green discharges, easily detectable during examination in mirrors.
Acute salpingitis. Characterized by lower abdominal pain, bilateral or unilateral, even if both tubes are involved. Pain may also occur in the upper abdominal cavity. As the pain intensifies, nausea and vomiting occur. Irregular uterine bleeding and fever occur in a third of patients. In the early stages of the disease, symptoms may be mild or absent altogether.
Later symptoms may include pain with cervical movement. Dyspareunia or dysuria may occasionally occur. Many patients have no or minimal symptoms. Pelvic inflammatory disease due to N. gonorrhoeae infection is usually more acute and has more severe symptoms than inflammatory disease due to C. trachomatis infection, which may be painless.
Complications. Acute gonococcal or chlamydial salpingitis may lead to the development of Fitz-Hugh-Curtis syndrome (perihepatitis that causes pain in the right upper quadrant of the abdomen). The infection may be chronic and characterized by frequent exacerbations and unstable remissions. Tuboovarian abscess (accumulation of pus in the appendages) develops in approximately 15% of women with salpingitis. It may be accompanied by the presence of acute or chronic infection. The development of an abscess occurs as a result of inadequate or late treatment. Severe pain, fever, and peritoneal signs may be observed. Perforation of the abscess may occur, which causes a progressive increase in symptoms of the disease and can lead to septic shock. Hydrosalpinx (accumulation of serous fluid in the fallopian tube as a result of sealing of the fimbrial area) is often asymptomatic, but can cause a feeling of pressure in the lower abdomen, chronic pelvic pain, or dyspareunia.
Tuboovarian abscess, pyosalpinx (accumulation of pus in one or both fallopian tubes) and hydrosalpinx can be detected by palpation of tumors in the area of the uterine appendages and be the cause of infertility.
Salpingitis contributes to the development of adhesions and obstruction of the fallopian tubes. Common complications of the disease are chronic pelvic pain, menstrual irregularities, infertility, and an increased risk of ectopic pregnancy.
Diagnosis of inflammatory diseases of the pelvic organs
Inflammatory diseases of the pelvic organs may be suspected in women of reproductive age, especially with risk factors. Patients report pain in the lower abdomen and unexplained vaginal discharge. PID may be suspected when patients have irregular vaginal bleeding, dyspareunia, or dysuria. PID is most likely to be suspected when patients experience pain in the lower abdomen on one or both sides, as well as increased pain with movement of the cervix. Palpation of a tumor-like formation in the area of the uterine appendages may suggest the presence of a tubo-ovarian abscess. It is necessary to carefully approach the diagnosis of the disease, because even inflammatory processes with minimal clinical manifestations can lead to severe complications.
If pelvic inflammatory disease is suspected, cervical discharge should be tested with PCR (which is nearly 100% sensitive and specific) to detect N. gonorrhoeae, C. trachomatis, and pregnancy should be ruled out. If PCR is not possible, cultures should be taken. Cervical discharge can be examined using Gram stain or saline fixation to confirm suppuration, but these tests are insensitive and nonspecific. If the patient cannot be adequately examined because of pain, ultrasonography should be performed as soon as possible. A white blood cell count can be performed, but this is of little use.
If the pregnancy test is positive, the patient must be examined for an ectopic pregnancy.
Other common causes of pelvic pain may include endometriosis, torsion of the uterine appendages, ruptured ovarian cysts, and appendicitis. In the presence of Fitz-Hugh-Curtis syndrome, it is necessary to conduct differential diagnostics between acute cholecystitis and salpingitis during examination of the pelvic organs and ultrasonography.
If tumor-like formations are palpated in the pelvic area, clinical manifestations of inflammation are observed, and there is no effect from antibacterial treatment within 48-72 hours, it is necessary to perform ultrasonography as soon as possible to exclude tubo-ovarian abscess, pyosalpinx and disorders not associated with PID (eg, ectopic pregnancy, torsion of the uterine appendages).
If the diagnosis remains in doubt after ultrasonography, laparoscopy should be performed to obtain purulent peritoneal contents, which is the diagnostic gold standard.
Treatment of inflammatory diseases of the pelvic organs
Antibiotics are initially prescribed empirically to cover N. gonorrhoeae and C. trachomatis, and then the treatment regimen is modified based on laboratory data. Patients with cervicitis and mild clinical manifestations of PID do not require hospitalization.
Bacterial vaginosis is often associated with gonorrhea and chlamydia, and therefore patients are subject to mandatory outpatient treatment. Sexual partners of patients with N. gonorrhoeae or C. trachomatis should undergo treatment.
Indications for inpatient treatment are the following pelvic inflammatory diseases: severe inflammatory processes (e.g., peritonitis, dehydration), moderate or severe vomiting, pregnancy, suspected pelvic tumors, and suspected acute surgical pathology (e.g., appendicitis). In such cases, intravenous antibiotics are prescribed immediately after receiving the culture results, treatment is continued for 24 hours after the fever has been eliminated. Tuboovarian abscess requires hospitalization and longer intravenous antibacterial therapy. Treatment is carried out by draining the pelvic abscess through the vagina or anterior abdominal wall under CT or ultrasound control. Sometimes laparoscopy or laparotomy is performed to insert the drainage. If a ruptured tuboovarian abscess is suspected, an urgent laparotomy is performed. In women of reproductive age, organ-preserving operations are performed (in order to preserve reproductive function).