Pelvic Infection (Pelvic Inflammatory Disease)

PELVIC INFECTION (PELVIC INFLAMMATORY DISEASE)

Pelvic inflammatory disease (PID) is an inflammatory condi-tion of the pelvic cavity that may begin with cervicitis and may involve the uterus (endometritis), fallopian tubes (salpingitis), ovaries (oophoritis), pelvic peritoneum, or pelvic vascular system. Infection, which may be acute, subacute, recurrent, or chronic and localized or widespread, is usually caused by bacteria but may be attributed to a virus, fungus, or parasite. Gonorrheal and chlamydial organisms are the most likely causes. Cytomegalovirus (CMV) has also been implicated. This condition can result in the fallopian tubes becoming narrowed and scarred, which increases the risk for ectopic pregnancy (fertilized eggs become trapped in the tube), infertility, recurrent pelvic pain, tubo-ovarian abscess, and recurrent disease. Rupture of a tubo-ovarian abscess has a 5% to 10% mortality rate and usually necessitates a complete hys-terectomy. About 1 million women are diagnosed with PID each year in the United States; most are younger than 25 years of age, and one fourth of them have serious sequelae (ie, infertility, ec-topic pregnancy, or chronic pelvic pain) (Rein, Kasler, Irwin & Rabiee, 2000). PID is the most common gynecologic cause of hos-pital admissions in the United States. The true incidence of PID is unknown because most cases are asymptomatic (Ross, 2001).

Pathophysiology

The exact pathogenesis of PID has not been determined, but it is presumed that organisms usually enter the body through the vagina, pass through the cervical canal, colonize the endocervix, and move upward into the uterus. Under various conditions, the organisms may proceed to one or both fallopian tubes and ovaries and into the pelvis. In bacterial infections that occur after child-birth or abortion, pathogens are disseminated directly through the tissues that support the uterus by way of the lymphatics and blood vessels (Fig. 47-1). In pregnancy, the increased blood sup-ply required by the placenta provides more pathways for infec-tion. These postpartum and postabortion infections tend to be unilateral. Infections can cause perihepatic inflammation when the organism invades the peritoneum.

In gonorrheal infections, the gonococci pass through the cer-vical canal and into the uterus, where the environment, especially during menstruation, allows them to multiply rapidly and spread to the fallopian tubes and into the pelvis (see Fig. 47-1). The in-fection is usually bilateral. In rare instances, organisms (eg, tu-berculosis) gain access to the reproductive organs by way of the bloodstream from the lungs (see Fig. 47-1). One of the most common causes of salpingitis (inflammation of the fallopian tube) is chlamydia, possibly accompanied by gonorrhea.

Pelvic infection is most commonly caused by sexual transmis-sion but can also occur with invasive procedures such as endome-trial biopsy, surgical abortion, hysteroscopy, or IUD insertion. Bacterial vaginosis, a vaginal infection, may predispose women to pelvic infection. Risk factors include early age at first intercourse, multiple sexual partners, frequent intercourse, intercourse with-out condoms, sex with a partner with an STD, and a history of STDs or previous pelvic infection.

Clinical Manifestations

Symptoms of pelvic infection usually begin with vaginal dis-charge, dyspareunia, lower abdominal pelvic pain, and tenderness that occurs after menses. Pain may increase while voiding or with defecation. Other symptoms include fever, general malaise, anorexia, nausea, headache, and possibly vomiting. On pelvic ex-amination, intense tenderness may be noted on palpation of the uterus or movement of the cervix (cervical motion tenderness). Symptoms may be acute and severe or low-grade and subtle.

Complications

Pelvic or generalized peritonitis, abscesses, strictures, and fallopian tube obstruction may develop. Obstruction may cause an ectopic pregnancy in the future if a fertilized egg cannot pass a tubal stric-ture, or scar tissue may occlude the tubes, resulting in sterility. Ad-hesions are common and often result in chronic pelvic pain; they eventually may require removal of the uterus, fallopian tubes, and ovaries. Other complications include bacteremia with septic shock and thrombophlebitis with possible embolization.

Medical Management

Broad-spectrum antibiotic therapy is prescribed. Women with mild infections may be treated as outpatients (Ness, Soper, Holley et al., 2002c), but hospitalization may be necessary. Intensive therapy includes bed rest, intravenous fluids, and intravenous antibiotic therapy.

If the patient has abdominal distention or ileus, naso-gastric intubation and suction are initiated. Carefully monitor-ing vital signs and symptoms assists in evaluating the status of the infection. Treating sexual partners is necessary to prevent re-infection.

Nursing Management

Infection takes a toll, both physically and emotionally. The pa-tient may feel well one day and experience vague symptoms and discomfort the next. She may also suffer from constipation and menstrual difficulties.

The hospitalized patient is maintained on bed rest and is usu-ally placed in the semi-Fowler’s position to facilitate dependent drainage. Accurate recording of vital signs and the characteristics and amount of vaginal discharge is necessary as a guide to therapy.

The nurse administers analgesic agents as prescribed for pain relief. Heat applied safely to the abdomen may also provide some pain relief and comfort.

The nurse minimizes the transmission of infection to others by carefully handling perineal pads with gloves, discarding the soiled pad according to hospital guidelines for disposal of biohazardous material, and performing meticulous hand hygiene.

PROMOTING HOME AND COMMUNITY-BASED CARE

Teaching Patients Self-Care. 

The patient must be informed ofthe need for precautions and must be encouraged to take part in procedures to prevent infecting others and protecting herself from reinfection. If a partner is not well known or has had other sexual partners recently, use of condoms may prevent life-threat-ening infection and its sequelae. If reinfection occurs or if the in-fection spreads, symptoms may include abdominal pain, nausea and vomiting, fever, malaise, malodorous purulent vaginal dis-charge, and leukocytosis. Patient teaching consists of explaining how pelvic infections occur, how they can be controlled and avoided, and their signs and symptoms. Guidelines and instruc-tions provided to the patient are summarized in the accompany-ing Home Care Checklist (Chart 47-3).

All patients who have had PID need to be informed of the signs and symptoms of ectopic pregnancy (pain, abnormal bleed-ing, delayed menses, faintness, dizziness, and shoulder pain) be-cause they are prone to this complication.