Chronic Pelvic Inflammatory Disease

The correlation between PID and chronic pelvic pain has been known for some time and has been confirmed by a study published by Buchan et al in 1993. Such patients were 10 times more likely to develop pelvic pain or an ectopic pregnancy and were 8 times more at risk of having a hysterectomy. This was more common with moderate or severe pelvic adhesions [Eschenbach et al, 1997] but especially so if these adhesions involved the ovaries or restricted uterine or tubal motility [Beard and Dias, 2001].

Different organisms can cause pelvic inflammatory disease and most of these cases are sexually transmitted. However, in 10% of the cases infection may follow invasive diagnostic or surgical procedures. There is also an increased risk of PID during the first 3 weeks following IUCD insertion [Farley et al, 1992]. Accordingly, there is some evidence to screen for chlamydia before IUCD insertion [Prodigy Clinical Guidance, April 2003], as it is currently the most important sexually transmitted microbe. Women under the age of 25 years are at greater risk to PID in general as those with multiple partners and those not practising safe sex. In most cases it is a silent infection or may cause minimal discomfort. However, it can present with vaginal discharge, painful urination, pelvic pain and intermenstrual vaginal bleeding. The late outcome of untreated chlamydia infections will be chronic pelvic pain, infertility and increased risk of ectopic pregnancy. It is important here to stress the difference between upper and lower genital tract infections in this respect. Upper genital tract infections are 7 times more likely to cause pelvic pain than lower genital tract infections. It is also important to remember that serological tests for chlamydia do not differentiate between the two.

Recently more emphasis has been directed towards regular screening for early detection of chlamydia infection to prevent complications. As women under the age of 25 years are at greater risk, they should be targeted for annual screening [Prodigy Clinical Guidance, April 2003]. Older women may have similar screening if they had multiple partners. Retesting is advisable 3 - 4 months after finishing treatment especially in adolescents and for women with untreated partners. Opportunistic screening can be done in sexual health, family planning, gynaecology and early pregnancy clinics.  A good number of female patients accepted to be tested (80%), and reports of 6-10% positive results were confirmed in 16-25 years old women. Alarmingly 70% were asymptomatic. To reach a wider population base, postal testing kits have been used [Ostergaard et al, 2003]. Other organisms that can cause pelvic inflammatory disease include:

• Niesseria gonorrhoea
• Mycoplasma hominis
• Ureaplasma urealyticum
• Bacteroids

With PID, local tissue inflammation and thin peritubal adhesions may form after chlamydia infection. In some case, the only damage may involve the tubal mucosa. However, with repeated or severe infections including those caused by multiple organisms, thick pelvic adhesions or even an amalgamated adnexal mass can be seen. Omental adhesions are especially common to seal the infection off the rest of the peritoneal cavity. However, acute pelvic inflammatory disease does not usually show any characteristic pictures on transvaginal scan examination. Nevertheless, occasionally increased tubal wall thickness due to oedema and free fluid with floating particles in the pelvis can be detected. Furthermore, hyperaemia of the inflamed tube may lead to increased vascular markings on colour Doppler mapping. In severe cases oedematous intratubal folds on cross section scanning can show a cogwheel appearance of a thick-walled multilocular pelvic mass with echogenic fluid collection. On the other hand, patients with chronic pelvic inflammatory disease may show dilated tubes with thin or thick walls and atrophic mucosal folds. Cross sectional views of a thick wall dilated tube may show the 'beads on a string' sign. On the other hand, incomplete intratubal septae can be seen in acute as well as chronic salpingitis. Gentle movement of the probe in different directions helps to identify them as intratubal folds projecting into the lumen, but not reaching the opposite side. However, the most common ultrasonic findings in chronic salpingitis are thin wall hydrosalpinges, beads on a string appearance and incomplete septae. For clinical reasons, it is always important to differentiate a tubo ovarian complex which needs antibiotics treatment from a pelvic abscess which needs surgical drainage as well. The ovary and tube can be seen separately during scanning a tubo ovarian complex, which is not usually possible in most cases with a pelvic abscess.

• The first ultrasound image above shows a cross section and tubular parts of a dilated fallopian tube. The cross section shows thick folds which is a sign of acute inflammatory process (acute salpingitis). The x-section pattern is called Cogwheel Appearance.

• The second image above shows a dilated fallopian tube with small atrophic folds, diagnostic of chronic salpingitis. The appearance is called Pearls on the String

• The third 3D image shows a tubo-ovarian complex, made of the ovary, cross section of a fallopian tube and some peritoneal fluid with thin adhesion folds. Unlike tubo-ovarian abscesses, all structures are clearly and separately identified in this case.

Both laparoscopy and hysteroscopy may show sign of chronic pelvic infection. Micropolyps have been described as a sign of chronic endometritis by Ettore Cicinelli et al in 2005.  They present as small projections of 1 mm off the endometrium surface, either singularly, or mostly in small groups. Each one is made of a central blood vessel, covered by some thin layer of stroma tissue and outer endometrium. They are not well seen by transvaginal ultrasound and may show as focal lesions on on side or the other of the endometrium. 

The three hysteroscopic images shown below belong to three different patients who presented with pelvic pain and abnormal uterine bleeding. In all cases punches of micropolyps were seen, diagnostic of chronic endometritis. Such picture gives more bleeding than pain, unless combined with inflammatory involvement of other parts of the pelvis. In my experience gentle spiral curettage of such polyps under intravenous antibiotics, followed by at least one week of such medication, controlled the bleeding and helped with pregnancy in few cases who were infertile before.

The role of laparoscopy in the diagnosis of chlamydia infection is not as specific as DNA testing for the microbe. However, pelvic and perihepatic adhesions can be seen. 

• The first laparoscopic image shown below demonstrates pelvic adhesions following chlamydia infection. Both tubes and ovaries were involved, and the left tube is showing a hydrosalpinx. 

• The second picture shows violin string adhesions between the liver and the anterior abdominal wall caused by chlamydia perihepatitis infection [Fitz-Hugh-Curtis Syndrome]. Such perihepatic infection and adhesions can cause acute or recurrent sharp pleuritic upper right quadrant pain and may be seen in 10-20% of all pelvic infections caused by chlamydia, as reported by the British Association for Sexual Health and HIV in February 2005. A high figure of 30% has been reported by Sharma et al [2002] in patients with chronic pelvic pain compared to 16% in patients who had infertility investigations at the same time. Liver function tests and transabdominal scan examination of the liver and perihepatic area are usually unremarkable. However, CT scanning may show an enhanced hepatic capsule during the acute phase, but this usually resolves after treatment with antibiotics [Nishie et al, 2003].

The presence of pelvic adhesions as a cause of pain has been challenged over the years. This in my mind is mainly due to the fact that the background cause which lead to the formation of adhesions in the first place has never been addressed in the same equation. Accordingly, two questions still remain to be answered and these will be discussed in the chapter dealing with pelvic adhesions shown in the side menu.

1. Do adhesions cause chronic pelvic pain?
2. Is adhesiolysis effective in relieving chronic pelvic pain?