**7. Acute Pelvic Inflammatory Disease**

Pelvic inflammatory disease (PID) is a spectrum of inflammatory disorders of the upper female genital tract, including any combination of endometritis, salpingitis, oophoritis or tuboovarian abscess and pelvic peritonitis/cellulitis. Sexually transmitted organisms, particularly Neisseria gonorrhoeae and Chlamydia trachomatis, are implicated in many cases. Organisms of the vaginal flora however also cause PID, which is often polymicrobial.

There is a worldwide increase in the incidence of PID, and it is the most common infectious disease that affects young women and accounts for a significant percentage of the morbidity that is associated with sexually transmitted diseases (STDs). Although it does not usually constitute an emergency in the sense that immediate treatment is life-saving, urgent treatment is required to minimize the effect of the disease on subsequent fertility and reduces the risk of sequelae such as ectopic pregnancy and chronic pelvic pain. This applies to both mild and severe disease.

The diagnosis of PID is usually based on clinical features although clinical diagnosis is usually imprecise, and many cases of PID go unrecognized or are subclinical. These patients are usually young, sexually active, and complain of abdominal pain, with or without fever

and vaginal discharge. Bimanual pelvic examination usually elicits extreme tenderness on movement of the cervix, uterus and parametria. On laboratory investigations, saline microscopy of vaginal discharge may show abundant leucocytic infiltration, complete blood count may reveal leucocytosis, and C-reactive protein and erythrocyte sedimentation rate may be raised.

Endocervical swab may be positive for infection with N. gonorrhoeae and C. trachomatis. The true significance of this is questionable and the results lack consistency. However all women who have acute PID should be tested for these organisms, and screened for other STDs [33].

Endometrial biopsy, though not often done in practice, is more specific and usually shows histopathologic evidence of endometritis. Imaging, most especially transvaginal ultrasonog‐ raphy, showing thickened fluid-filled tubes with or without free fluid in the pouch of Douglas or tubo-ovarian mass are quite specific for PID. In less complicated cases imaging may be normal.

Laparoscopy is the gold standard for diagnosis of PID. However limited access and attendant surgical risks preclude its universal use for this purpose. The criteria for diagnosis of PID using laparoscopy include visualizing an overt hyperaemia of the tubal surface, oedema of the tubal wall, and sticky exudates on the tubal surface and/or fimbrial ends. All 3 are required for diagnosis.

The treatment of PID is essentially empirical, with use of antibiotics (parenteral and oral) for 10-14 days. Based on the severity and response to treatment this can either be done on outpatient or inpatient basis. Goals of treatment are to alleviate the acute symptoms of inflammation, and prevent the long term sequelae associated with PID. There may be need for contact tracing and treatment of sexual partners. Follow up and education are necessary to prevent re-infection and complications.

For those complicated by tubo-ovarian abscess unresponsive to extended antibiotic therapy, surgical management involving exploratory laparotomy by an experienced gynaecologic surgeon may be required. The extent of the surgery depends on the extent of the disease, the patient's age and desire for future fertility. There is risk of injury to contiguous structures as a result of the inflammatory process, which may cause adhesions and a frozen pelvis.
