List of Abbreviations
AUB - abnormal uterine bleeding
HIV - human immunodeficiency virus
WHO – World Health Organization
STI - sexually transmitted infection
MRI - magnetic resonance imaging
LMWH – low-molecular-weight heparins (according to the Anatomical Therapeutic Chemical (ATC) classification – Heparin group)
НПВС – non-steroidal anti-inflammatory and antirheumatic drugs
PCR – polymerase chain reaction
CRP - C-reactive protein
ESR – erythrocyte sedimentation rate
VTE - venous thromboembolic events
US – ultrasound examination
hCG - human chorionic gonadotropin
Terms and Definitions
Pelvic inflammatory disease (PID) refers to a spectrum of inflammatory disorders of the upper female genital tract, comprising endometritis, parametritis, salpingitis, oophoritis, tubo-ovarian abscess, pelvic peritonitis, or any combination thereof [1-3].
Tubo-ovarian abscess – a purulent inflammatory mass involving the ovary and fallopian tube [6].
Endometritis – inflammation of the endometrium [4-6].
Parametritis – inflammation of the parametrium (parametrial connective tissue) [4].
Pelvic peritonitis – inflammation of the visceral and parietal peritoneum of the pelvis [5].
Salpingitis – inflammation of the fallopian tubes [4-6].
Oophoritis – inflammation of the ovaries [4-6].
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Pelvic inflammatory disease (PID) refers to a spectrum of inflammatory disorders of the upper female genital tract, comprising endometritis, parametritis, salpingitis, oophoritis, tubo-ovarian abscess, pelvic peritonitis, or any combination thereof [1-3].
Salpingitis – inflammation of the fallopian tubes [4-6].
Oophoritis – inflammation of the ovaries [4-6].
Tubo-ovarian abscess – a purulent inflammatory mass involving the ovary and fallopian tube [6].
Endometritis – inflammation of the endometrium [4-6].
Parametritis – inflammation of the parametrium (parametrial connective tissue) [4].
Pelvic peritonitis – inflammation of the visceral and parietal peritoneum of the pelvis [5].
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
PID represents inflammatory diseases of the upper female genital tract, including endometritis, parametritis, salpingitis, oophoritis, tubo-ovarian abscess, and pelvic peritonitis, which develop predominantly as a result of ascending infection [2, 7]. Absolute pathogens involved in the development of PID include Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, Mycoplasma genitalium. In immunocompromised states, the causative agents are opportunistic microorganisms—obligate and facultative anaerobes and their polymicrobial associations—which may be present in low titers as part of the normal vaginal and perianal microflora: Bacteroides spp., Peptostreptococcus spp., Prevotella spp., Escherichia coli, Gardnerella vaginalis, Streptococcus spp., etc. [7]. The predominance of polymicrobial associations in the presence of compromised barrier defense mechanisms and local anti-infective immunity can contribute to disease chronicity and the activation of autoimmune processes, as well as atypical clinical manifestations depending on the interactions between various pathogen species [4]. Currently, the role of Mycoplasma hominis and Ureaplasma urealyticum in the etiology of PID remains controversial; in combination with other microorganisms, they are considered potential etiologic factors of PID [1, 8, 9]. The relative importance of various pathogens varies across countries and regions [2]. The mixed nature of the infection and the high frequency of uncontrolled repeated use of antibacterial drugs contribute to the development of antimicrobial resistance [4]. Several multicenter studies have demonstrated that increasingly prevalent drug resistance poses the greatest challenge in the management of patients with various infectious processes of mixed etiology [10]. PID increases the risks of infertility, miscarriage, pelvic adhesions, chronic pelvic pain, and ectopic pregnancy, which significantly impairs women's quality of life [1].
Risk factors for PID [1,2,11,12]:
young age (under 25 years) [2, 11];
sexual behavior-related factors [2, 11];
multiple sexual partners [2, 11];
change of sexual partner (within the last three months) [11];
history of sexually transmitted infections (STIs) in the patient or her partner [1, 2];
obstetric and gynecological surgeries and intrauterine diagnostic procedures [1,2];
insertion of an intrauterine device within the past 3 weeks [12].
1.3 Epidemiology of the Disease or Condition
PID represents a major public health problem with a substantial impact on the health of women of reproductive age [4,7]. This group of disorders holds a leading position in the structure of gynecological morbidity and is the most frequent cause of hospital admission among women [4]. According to the World Health Organization (WHO), 448 million new cases of PID are registered worldwide annually (up to 60% of the total number of gynecological diseases). The peak incidence (4-12%) occurs in women aged 17–28 years, which is associated with sexual activity and low utilization rates of barrier contraception methods [4].
1.4 Features of Coding the Disease or Condition
N70.0 Acute salpingitis and oophoritis
N70.9 Salpingitis and oophoritis, unspecified
N71.0 Acute inflammatory disease of uterus
N71.1 Chronic inflammatory disease of uterus
N71.9 Inflammatory disease of uterus, unspecified
N73.0 Acute parametritis and pelvic cellulitis
N73.1 Chronic parametritis and pelvic cellulitis
N73.2 Parametritis and pelvic phlegmon, unspecified
N73.3 Acute pelvic peritonitis in female
N73.4 Chronic pelvic peritonitis in female
N73.5 Pelvic peritonitis in female, unspecified
N73.8 Other specified inflammatory diseases of female pelvic organs
N73.9 Inflammatory disease of female pelvic organs, unspecified
1.5 Classification of the disease or condition
The Geneva International Classification of Diseases, Injuries, and Causes of Death (WHO, 1980) identifies the following nosological forms of PID [4]:
614.0 Acute salpingitis and oophoritis:
abscess: fallopian tube, ovary, tubo-ovarian,
oophoritis,
pyosalpinx,
salpingitis,
inflammation of the uterine adnexa,
614.3 Acute parametritis and pelvic phlegmon
614.4 Chronic or unspecified parametritis and pelvic phlegmon.
614.5 Acute or unspecified peritonitis
Classification proposed by V.I. Krasnopolsky et al., which allows for the identification of clinical forms of PID [5]:
1. Uncomplicated: acute salpingitis; endometritis; metroendometritis.
2. Complicated: pyosalpinx; pyovarium; parametritis; tubo-ovarian abscess; abscess of the rectouterine pouch; pelvioperitonitis; peritonitis; sepsis.
By localization [4]:
unilateral
bilateral.
By clinical course [14]:
acute – with pronounced clinical symptoms (less than 30 days)
chronic – with undetermined disease duration or duration exceeding 30 days.
1.6 Clinical presentation of the disease or condition
The main symptoms include lower abdominal pain, dyspareunia, dysmenorrhea, mucopurulent discharge from the cervical canal or vagina when combined with acute cervicitis, bacterial vaginosis, or endometritis, and abnormal uterine bleeding (AUB) in the form of intermenstrual spotting, heavy menses, or postcoital bleeding, most commonly associated with cervicitis and endometritis [2,3,16]. PID symptoms are non-specific. In some cases, fever, chills, dysuria, or vomiting may occur [15-17]. Less commonly, women may be completely asymptomatic or present with atypical symptoms such as right upper quadrant pain, which can be a result of perihepatitis (Fitz-Hugh-Curtis syndrome) [2,3], frequently caused by chlamydial infection (pathogen Chlamydia trachomatis).
To improve PID diagnosis, the following objective and subjective symptoms have been grouped into presumptive, supportive, and definitive criteria [7] (see Appendix G, Table 1).
2. Diagnostics, medical indications and contraindications for diagnostic methods
The diagnosis is established based on patient complaints, anamnesis, physical examination, laboratory, and instrumental findings [1,2,5,7,17].
2.1 Complaints and Anamnesis
See sections 1.2 and 1.6.
2.2 Physical Examination
It is recommended that all patients with suspected PID undergo visual inspection of the external genitalia, physical examination (assessment of skin and mucous membranes, body temperature, heart rate, respiratory rate, abdominal palpation, speculum examination of the cervix, and bimanual pelvic examination) [2,4,7,18].
GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).
Comment: PID symptoms are outlined in section 1.6. Deterioration of general condition, elevated body temperature, pallor of the skin, lower abdominal pain, and a positive peritoneal irritation sign may indicate the development of pelvioperitonitis [4]. During bimanual pelvic examination, special attention should be paid to cervical motion tenderness, the presence of a palpable mass with clear contours in the adnexal region, and tenderness upon palpation of the vaginal fornices [4,7]. However, these signs are non-specific and can also occur in other pelvic and intestinal disorders [2,4,7].
2.3 Laboratory Diagnostics
It is recommended that all patients with suspected PID undergo a complete blood count (CBC) with differential to assess the infectious-inflammatory process and monitor treatment efficacy [1-4,7].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comments: A patient with PID may exhibit leukocytosis with a left shift (increase in band neutrophils) and an elevated ESR [2, 4]. However, normal CBC findings do not rule out an infectious process and are frequently observed in mild to moderate forms of PID [1-4, 7].
It is recommended that all patients with suspected PID undergo a serum C-reactive protein (CRP) test to assess the infectious and inflammatory process and monitor the effectiveness of ongoing treatment [1-4, 7, 19, 20].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comments: CRP is an informative laboratory marker of systemic inflammation. The CRP level reflects the severity of the inflammatory process, although its reference values do not rule out PID. Changes in its concentration over time can be used to assess the effectiveness of ongoing therapy [1-4, 7]. An elevated procalcitonin level above 0.33 ng/mL can be used as a marker of a tubo-ovarian abscess (sensitivity is 62%, specificity is 75%) [20].
It is recommended that all patients with suspected PID undergo testing for human immunodeficiency virus HIV-1/2 antibodies (IgM, IgG) and p24 antigen (Human immunodeficiency virus HIV 1/2 + Agp24) in the blood, non-treponemal tests (RPR, VDRL) for antibodies to Treponema pallidum (qualitative and semi-quantitative test) in blood serum, hepatitis B virus IgM and IgG or HBs antigen, and hepatitis C virus IgM and IgG or HCV antigen [1-3].
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
Comments: The course of PID in HIV-infected patients may be more severe, with an increased risk of tubo-ovarian abscess formation [1-3, 6].
It is recommended that all patients with suspected PID undergo molecular biological testing of female genital mucous membrane discharge for sexually transmitted pathogens (Neisseria gonorrhoeae, Trichomonas vaginalis, Chlamydia trachomatis, Mycoplasma genitalium) to detect sexually transmitted infections [1-3, 6, 7, 21-26, 28].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comment: The absence of STIs does not rule out the diagnosis of PID [1-3, 6, 7]. The preferred diagnostic method is the detection of DNA of sexually transmitted pathogens (Neisseria gonorrhoeae, Trichomonas vaginalis, Chlamydia trachomatis, Mycoplasma genitalium) in female genital mucous membrane discharge using PCR (biological material should be taken from the cervical canal using a cytobrush into a sterile laboratory container). The sexual partner should also be advised to undergo STI screening [3, 19].
It is recommended that patients with suspected PID undergo microscopic examination of vaginal smears to assess the state of the vaginal microbiocenosis [1-3, 7, 19].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comments: An increased leukocyte count in the smear may be detected, but it is nonspecific, as normal leukocyte levels can be observed in mild and chronic infections [1-3, 7]. Microscopy helps clarify the nature of the vaginal microflora to identify concomitant vaginal infections (bacterial vaginosis, trichomoniasis, aerobic vaginitis, vulvovaginal candidiasis). Gram staining is preferred due to higher diagnostic value [19].
It is recommended that all patients with suspected PID undergo microbiological (culture) examination of female genital discharge for aerobic and facultatively anaerobic microorganisms to verify the causative agent [1, 9, 15, 20].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comments: When collecting biological material for microbiological (culture) examination, the following rules must be observed: biological material should be taken from the cervical canal (using a dacron swab into a sterile tube with transport medium); material obtained during surgery (peritoneal fluid, abscess contents, fallopian tube contents, endometrium, etc.) should be collected using a dacron swab into a sterile tube with transport medium or a syringe into a sterile laboratory container (for tissues and fluids).
Microbiological (culture) examination of female genital discharge for aerobic, facultatively anaerobic, and obligately anaerobic microorganisms can identify opportunistic pathogens (Enterobacteriaceae, Streptococcus groups A and B, Enterococcus spp., Gardnerella vaginalis, Bacteroides spp., and others, as well as rarer PID pathogens such as Actinomyces) [1, 9, 15, 19, 26, 28].
It is recommended that all patients with suspected tubo-ovarian abscess (based on ultrasound data) undergo a serum human chorionic gonadotropin (free beta-subunit) test to rule out pregnancy [2, 7].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comments: Testing serum human chorionic gonadotropin (free beta-subunit) levels should be performed to rule out ectopic pregnancy in patients with suspected PID who present with menstrual irregularities [7]. If emergency serum beta-hCG testing is unavailable, a urine pregnancy test may be used.
2.4 Instrumental Diagnostics
It is recommended that all patients with suspected PID undergo comprehensive pelvic ultrasound (transvaginal and transabdominal) to verify the diagnosis and detect concomitant gynecological pathology [2, 4, 6, 7].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comment: Comprehensive pelvic ultrasound (transvaginal and transabdominal) has higher diagnostic value for tubo-ovarian abscess [6, 7]. Ultrasound can be used for differential diagnosis with other conditions [4, 29]. Normal ultrasound findings do not rule out PID [2, 4].
It is recommended that pelvic magnetic resonance imaging (MRI) be performed in patients with widespread forms and severe courses of PID, or with extensive adhesions following previous surgeries, for differential diagnosis with other pelvic (gynecological and extragenital) conditions and to determine management tactics [2, 6].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comments: The evaluation of patients with widespread and severe forms of PID should be carried out in healthcare facilities of the appropriate level, involving multidisciplinary specialists.
It is recommended that patients with suspected PID and non-response to conservative treatment and/or for differential diagnosis with other pelvic disorders undergo diagnostic laparoscopy [1-3, 7].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comment: Diagnostic laparoscopy is valuable in the diagnosis and management of PID, but performing it routinely in all patients with suspected PID is not advisable [2]. In some cases, the clinical presentation of PID resembles other conditions. Diagnostic laparoscopy is used to differentiate PID from ectopic pregnancy, acute appendicitis, diverticulitis, fallopian tube carcinoma, ovarian cancer, infiltrative endometriosis, etc. [3, 30].
It is recommended that female patients with suspected chronic endometritis and intrauterine synechiae (based on ultrasound), infertility, 2 or more failed embryo transfer attempts, pregnancy loss, abnormal uterine bleeding, etc., undergo uterine tissue (endometrial) biopsy with pathomorphological examination of the biopsy material, preferably under hysteroscopic guidance [1, 2, 7].
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
2.5 Other Procedures
In complicated, widespread forms of PID and septic conditions, it is recommended to perform targeted chest radiography and/or chest computed tomography (if radiographic changes are present) to rule out pneumonia [31].
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
Comment: Patients at risk for urogenital tuberculosis must be evaluated by a phthisiatrician (those with close contact with tuberculosis infection, history or active tuberculosis of any localization, chronic urogenital infections prone to recurrence, resistance to standard therapy, persistent dysuria, progressive decrease in bladder capacity, sterile pyuria, pyuria, hematuria) [32].
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
3.1 Conservative Treatment
Treatment of PID includes antimicrobial, anti-inflammatory, infusion-transfusion, anticoagulant, desensitizing therapy, etc. [4].
An important component in the treatment of pelvic inflammatory disease (PID) is the prescription of antibacterial drugs. Antibacterial regimens are diverse; however, it should be noted that there is a scarcity of adequate controlled clinical trials regarding their efficacy. Recommendations for PID antibacterial regimens vary across different countries, but the core treatment principles are generally accepted [2]. Elimination of the full spectrum of potential pathogens (gonococci, chlamydia, genital Mycoplasma, gram-negative intestinal microflora, gram-positive aerobes, anaerobes, etc.) must be ensured [1, 7]. Throughout treatment, careful monitoring of efficacy and timely decision-making regarding changing the antibacterial drug are necessary if there is no effect within 48-72 hours and/or if the female patient develops undesirable adverse drug reactions [3, 9, 14, 16, 33-36].
The dosage regimen and route of administration of antibacterial drugs are determined based on the extent of the inflammatory process, the severity of the patient's condition, the pharmacokinetic and pharmacodynamic profiles of the drug, and taking into account the identified pathogen [34, 37]. The duration of PID therapy is 10-14 days [1, 2]. This duration is necessary to achieve complete eradication of pathogens in order to prevent chronicity of the inflammatory process, as well as relapses and complications. There is practically a lack of statistically significant data on the long-term efficacy of various treatment regimens. In case of ineffectiveness of conservative PID therapy, patient management tactics are determined by a medical board decision [30, 33-34].
Recommended antibacterial treatment regimens are presented in Appendix A3.
It is recommended to prescribe empirical systemic antibacterial therapy to female patients with PID, covering the entire spectrum of likely pathogens, with preliminary microbiological (culture) testing for subsequent treatment adjustment, followed by a transition to alternative regimens (in case of treatment failure) (Appendix A3) [4, 19, 20, 38].
GCR CLOE 5Grade of Recommendation C, Level of Evidence – 5.
It is recommended to prescribe oral antibacterial therapy at the outpatient or inpatient stage of treatment for female patients with mild and moderate forms of PID (Appendix A3) [1, 2].
LeR CLoE 5Level of Evidence C, Level of Confidence of Data – 5).
It is recommended that all female patients with severe (disseminated) forms of PID begin treatment in a hospital setting with parenteral administration of systemic antibacterial drugs and continue therapy for 24 hours after clinical improvement, followed by a switch to the oral form (Appendix A3) [1, 2, 7, 16, 39].
GCR CLOE 5Grade of Recommendation C, Level of Evidence – 5.
Comments: Adjustment of antibacterial therapy should be performed based on the results of microbiological (culture) testing 48-72 hours after the start of treatment in the absence of improvement in clinical and laboratory parameters indicating positive disease dynamics and/or pathogen resistance to the ongoing therapy [34-35].
It is recommended to prescribe systemic antifungal drugs (according to the Anatomical Therapeutic Chemical (ATC) classification – J02 Antimycotics for systemic use) to female patients with PID for the treatment of fungal infection confirmed by microbiological (culture) data [2, 37, 40].
GCR CLOE 5Grade of Recommendation C, Level of Evidence – 5
Comments: The risk of invasive mycosis during the use of antibacterial drugs in patients without specific risk factors (neutropenia secondary to cytostatics – according to ATC: antineoplastic agents, hematopoietic stem cell transplantation, liver transplantation, etc.) is low; therefore, prophylaxis with antifungal drugs (according to ATC: Antimycotics for systemic use) is not recommended [34].
It is recommended to prescribe nonsteroidal anti-inflammatory drugs (ATC: Anti-inflammatory and antirheumatic products, non-steroids) (NSAIDs) to female patients with PID, taking into account contraindications, for pain relief, reduction of fever, and anti-inflammatory action [41-42].
GCR CLOE 2Grade of Recommendation C, Level of Evidence – 2.
It is recommended to administer complex therapy (infusion (according to ATC: Solutions affecting the electrolyte balance), transfusion (according to ATC: Blood and blood products), anticoagulant (according to ATC: Antithrombotic agents), antihistamine (according to ATC: Antihistamines for systemic use), etc.) to female patients with widespread forms and severe PID, taking into account the severity of the patient's condition [4].
GCR CLOE 5Grade of Recommendation C, Level of Evidence – 5.
Comments: Infusion therapy (crystalloids (according to ATC: Solutions affecting the electrolyte balance), electrolyte balance correctors, plasma substitutes, and protein fractions (according to ATC: Solutions affecting the electrolyte balance, plasma substitutes, and plasma fractions)) should be administered at a volume of 1.5-2.5 L/day. The duration of therapy is individual (on average 4-7 days). Prophylaxis of venous thromboembolic events (VTE) is carried out with low-molecular-weight heparins (according to ATC: Heparin group).
As symptomatic therapy, antianemic drugs, vitamins, etc., are used [4].
It is recommended that female patients with PID avoid unprotected sexual intercourse until the end of treatment [2, 3].
GCR CLOE 5Grade of Recommendation C, Level of Evidence – 5.
3.2 Surgical Treatment
Surgical management tactics for female patients with PID, the choice of the extent and approach of surgical intervention depend on age, reproductive function goals, severity of the inflammatory process, and presence of complications. With the advent of modern antibacterial drugs, organ-preserving surgical interventions have become possible.
Main indications for surgical treatment methods [4, 41]:
— Presence of a purulent tubo-ovarian mass.
— Lack of effect from ongoing medical therapy.
It is recommended to perform surgical treatment for complicated forms of PID; the extent, approach, and frequency are determined by the spread of the process and the severity of the patient's condition [4-6].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comment: Principle of surgical treatment: timely and adequate extent of surgical intervention aimed at removing the focus of destruction while maximizing the preservation of ovarian tissue in patients of reproductive age.
The choice of surgical access depends on the prevalence of the inflammatory process, the presence of concomitant gynecological and extragenital diseases, the anticipated scope of intervention, and the conditions and capabilities available for their performance.
When possible, the decision regarding the scope and surgical access is made by a medical board after obtaining informed consent from the patient.
It is recommended to perform drainage palliative surgeries (posterior fornix drainage, colpotomy – according to the Federal Nomenclature of Medical Services: Opening and drainage of phlegmon (abscess), Drainage of female pelvic abscess) in female patients with complicated forms of PID when there is no possibility or condition for adequate surgical intervention [4].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comment: Drainage palliative surgeries are performed under ultrasound guidance. In some cases, they serve as a preparatory stage for primary surgical treatment, which cannot be performed in a given clinical situation due to the lack of conditions or the presence of contraindications [4].
4. Medical Rehabilitation and Sanatorium-Resort Treatment
The peak incidence of PID occurs at the age of 17-28 years, which has a significant impact on women's physical and reproductive health and reduces their quality of life [43]. An important component of effective treatment for this most common gynecological disease is medical rehabilitation, which accelerates functional recovery, shortens hospital stay, and reduces the rate of complications.
Rehabilitation includes inpatient and outpatient stages, preformed physical factors, therapeutic exercise (physiotherapy), and, at later stages, balneological (resort) factors [43].
It is advisable to adhere to the general principles of rehabilitation following antibacterial therapy and surgical treatment [44-45]:
1) comprehensive assessment of the patient's baseline condition and formulation of a rehabilitation program;
2) multidisciplinary approach to the organization of rehabilitation care;
3) monitoring the effectiveness of therapy during recovery treatment and at the end of the rehabilitation course.
Rehabilitation protocols take into account the clinical diagnosis, the duration and intensity of antibiotic therapy, and the extent of surgical intervention. During adequate antibiotic therapy for PID and in the early postoperative period, non-pharmacological rehabilitation is carried out regardless of the days of the menstrual cycle. Following the completion of antibiotic therapy and in the late postoperative period, rehabilitation is performed taking into account the days of the menstrual cycle.
It is recommended that all patients undergo an examination (consultation) by a physical therapy physician to determine a rehabilitation program [43-45].
LoR CLoE 5 Level of Recommendation C (Level of Evidence – 5)
In the early postoperative period, with the aim of preventing postoperative complications, promoting faster physical recovery, and reducing the length of hospital stay as the first stage of rehabilitation after surgical treatment of PID, the following are recommended [45-47, 55, 56]:
— breathing exercises 2–3 times a day, with a course of 10–12 sessions.
— general pulsed magnetotherapy paravertebrally 1 time a day, course of 5 sessions.
— general low-frequency pulsed magnetotherapy using an abdominal or abdomino-vaginal technique. Procedures are performed 1–3 times a day, with a course of up to 20–30 sessions, regardless of the day of the menstrual cycle;
— magnetolaser therapy for diseases of the female genital organs using a cutaneous technique over reflexogenic zones. Procedures are performed 1 time a day, with a course of up to 10 sessions, regardless of the day of the menstrual cycle.
— transcutaneous electrical nerve stimulation paravertebrally;
— medical gymnastics.
GRS CLOE 5Grade of Recommendation Strength C (Level of Evidence – 5)
Comments: The goals of restorative treatment are: achieving analgesic and anti-inflammatory effects, reducing the pharmacological burden, preventing postoperative complications, and accelerating the physical recovery of patients [48-52].
To reduce the drug load and prevent the inflammatory process from becoming chronic in the medical treatment of PID (acute inflammatory process), the following physiotherapy methods are recommended [45- 47, 55, 56]:
— general low-frequency pulsed magnetotherapy using an abdominal or abdomino-vaginal technique. Procedures are performed 1–3 times a day, with a course of up to 20–30 sessions, regardless of the day of the menstrual cycle;
— magnetolaser therapy for diseases of the female genital organs using a cutaneous technique over reflexogenic zones. Procedures are performed 1 time a day, with a course of up to 10 sessions, regardless of the day of the menstrual cycle.
GRS CLOE 5Grade of Recommendation Strength C (Level of Evidence – 5)
Comments: Physical modalities do not replace but complement antibiotic therapy. Against the background of complex conservative therapy for PID, the use of physical modalities with anti-inflammatory [53-54] and analgesic effects helps reduce the pharmacological burden and prevent the chronization of the inflammatory process.
The following physiotherapeutic rehabilitation methods are recommended for patients after the completion of medical treatment and discharge from the hospital [45-47, 55, 56]:
— interference therapy using a 4-electrode technique. Procedures are performed 2–3 times a day, with a course of up to 30 sessions;
— transcutaneous electrical nerve stimulation paravertebrally. Procedures are performed 2–3 times a day, with a course of up to 30 sessions;
— pulsed current therapy ( diadynamic therapy – A17.30.003, interference therapy – A17.30.005, sinusoidal modulated current therapy – A17.30.004, electrical stimulation – A17.20.004, phonophoresis – A17.30.033). Procedures are performed 2–3 times a day, with a course of up to 30 sessions;
— ultra-high-frequency electromagnetic field therapy using an abdominal technique (microwave therapy – A17.20.008). Procedures are performed 1–2 times a day, with a course of up to 15–20 sessions;
— general low-frequency pulsed magnetotherapy using an abdominal or abdomino-vaginal technique. Procedures are performed 2–3 times a day, with a course of up to 30 sessions;
— medical gymnastics (A19.20.001, A19.20.001.001). Daily sessions of 20–30 minutes with a progressive increase in load. Sessions are held 1–2 times a day.
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: Physiotherapy is performed strictly taking into account the days of the menstrual cycle — treatment always starts on days 5–6–7 of the cycle; intensive multi-component courses of physiotherapy are used; the presence of hormone-dependent diseases (uterine myoma, external genital endometriosis, relative or absolute hyperestrogenemia) is taken into account when choosing the physiotherapy regimen [45-49]. General contraindications to the use of physical modalities must be considered [45]. Medical gymnastics and physical activity (a combination of strength training, aerobic exercise, and stretching) are mandatory for all patients, as this significantly improves their quality of life and allows for weight control. Medical gymnastics regimens are selected in conjunction with a physical therapy physician.
It is recommended to carry out a comprehensive health-resort (sanatorium-and-spa) stage of rehabilitation in patients with severe adhesions and chronic pelvic pain syndrome, which significantly improves the psychoemotional and physical condition of the patient and enhances quality of life [56].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended to provide health-resort (sanatorium-and-spa) treatment for patients with chronic salpingitis/oophoritis no earlier than 2 months after the completion of antibiotic therapy [56].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comments: Health-resort treatment may be used 1–2 times a year. Treatment begins on days 5–6–7 of the cycle while using barrier methods of contraception [39].
5. Prevention and Dispensary Observation
As part of PID prevention, the following are recommended:
1) early diagnosis of STIs to prevent PID (performing annual screening for chlamydia and gonorrhea in all sexually active women younger than 25 years and in sexually active women aged 25 and older with an increased risk of STI acquisition [1-3]).
2) use of barrier contraception methods to reduce the risk of STI infection [4, 12].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
6. Organization of Medical Care
Indications for admission to a medical organization [1, 7]:
1) severe condition, nausea, vomiting, temperature ≥380C, which are often signs of complicated forms of PID, as well as any form of PID with manifestations of systemic inflammatory response syndrome;
2) ineffectiveness or impossibility of outpatient treatment;
3) pregnancy;
4) presence of immunodeficiency (HIV infection, immunosuppressive therapy, etc.);
5) inability to rule out acute surgical pathology (appendicitis, ectopic pregnancy, etc.).
Indications for discharge from a medical facility:
- Clinical recovery
7. Additional Information
Not applicable.
Criteria for Evaluating the Quality of Medical Care
№ | Quality criteria | Performance assessment (yes/no) |
|---|---|---|
1 | Visual inspection of the external genitalia, physical examination (assessment of skin and mucous membranes, body temperature, heart rate, respiratory rate, superficial orienting abdominal palpation, speculum examination of the cervix, bimanual pelvic examination) performed | Yes/no |
2 | A complete blood count (differential) was performed | Yes/no |
3 | Serum C-reactive protein determination was performed | Yes/no |
4 | Microscopic examination of vaginal smears performed | Yes/no |
5 | Molecular biological examination of female genital mucosal discharge for the detection of sexually transmitted pathogens (Neisseria gonorrhoeae, Trichomonas vaginalis, Chlamydia trachomatis, Mycoplasma genitalium) performed | Yes/no |
6 | Microbiological (culture) examination of female genital discharge for aerobic and facultative anaerobic microorganisms performed | Yes/no |
7 | Serum human chorionic gonadotropin (free beta-subunit) level determination performed in women with suspected tubo-ovarian abscess and/or menstrual irregularities to rule out ectopic pregnancy | Yes/no |
8 | Antibiotic therapy was administered | Yes/no |
9 | Surgical treatment performed in the presence of a purulent tubo-ovarian mass and/or lack of response to ongoing medical therapy | Yes/no |
References
Show references
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The British Association for Sexual Health and HIV (BASHH). Pelvic inflammatory disease. Guideline. 2019.
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Krasnopolsky V.I., Buyanova S.N., Shchukina N.A. Purulent Gynecology. Guidelines. Moscow. Medpress. 2001. P. 288.
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Appendix A1. Working Group Composition
Leyla V. Adamyan – Academician of the RAS, MD, Professor, Deputy Director of the V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health, Honored Worker of Science of Russia, Head of the Department of Obstetrics, Gynecology and Reproductive Medicine at the Russian University of Medicine, Chief Freelance Gynecologist of the Russian Ministry of Health, member of the Society for Reproductive Medicine and Surgery, Russian Association of Gynecological Endoscopists, Russian Association of Endometriosis, Russian Society of Obstetricians and Gynecologists.
Elena N. Andreeva - Doctor of Medical Sciences, Professor, Deputy Director - Director of the Institute of Reproductive Medicine, Head of the Department of Endocrine Gynecology, Professor at the Department of Endocrinology of the National Medical Research Center for Endocrinology of the Russian Ministry of Health, Professor at the Department of Obstetrics, Gynecology and Reproductive Medicine of the Russian University of Medicine, President of the International Association of Obstetricians, Gynecologists and Endocrinologists, member of the Russian Association of Gynecological Endoscopists, Russian Association for Endometriosis, Russian Society of Obstetricians and Gynecologists, ROSGEM.
Natalya V. Artymuk - Doctor of Medical Sciences, Professor, Head of the Department of Obstetrics and Gynecology named after Professor G.A. Ushakova at Kemerovo State Medical University of the Russian Ministry of Health, Chief Freelance Specialist in Obstetrics and Gynecology of the Russian Ministry of Health in the Siberian Federal District (Kemerovo), member of the Presidium of the Board of the Russian Society of Obstetricians and Gynecologists, President of the Kemerovo Regional Public Organization "Association of Obstetricians and Gynecologists".
Tatyana E. Belokrinitskaya – MD, Professor, Head of the Department of Obstetrics and Gynecology at the Faculty of Continuing Professional Education, Chita State Medical Academy of the Russian Ministry of Health, Honored Doctor of the Russian Federation, Chief Freelance Obstetrician-Gynecologist of the Russian Ministry of Health in the Far Eastern Federal District (Chita), member of the Russian Society of Obstetricians and Gynecologists, President of the Trans-Baikal Society of Obstetricians and Gynecologists.
Vitaly F. Bezhenar - Doctor of Medical Sciences, Professor, Head of the Department of Obstetrics, Gynecology and Neonatology at the First Pavlov State Medical University of St. Petersburg of the Russian Ministry of Health, Chief Freelance Specialist in Obstetrics and Gynecology for the Healthcare Committee of St. Petersburg, member of the Society for Reproductive Medicine and Surgery, Russian Association of Gynecological Endoscopists, Russian Society of Obstetricians and Gynecologists.
Larisa V. Suturina – MD, Professor, Head of the Department of Reproductive Health Protection, Scientific Centre for Family Health and Human Reproduction Problems (Irkutsk), member of the Association of Gynecological Endocrinologists of Russia, member of the Russian Society of Obstetricians and Gynecologists.
Oleg S. Filippov – MD, Professor, Honored Doctor of the Russian Federation, Chief Freelance Obstetrician-Gynecologist of the FMBA of Russia, Deputy Director of the Federal Research and Clinical Center for Children and Adolescents of the FMBA of Russia, Professor at the Department of Obstetrics, Gynecology and Reproductive Medicine, Russian University of Medicine.
Galina E. Chernukha – Doctor of Medical Sciences, Professor, Chief Researcher at the Department of Gynecological Endocrinology at the V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health, President of the Interregional Public Organization "Association of Gynecological Endocrinologists".
Antonina A. Smetnik – PhD, Head of the Department of Gynecological Endocrinology, V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health
Gyuzal I. Tabeeva – PhD, Senior Researcher, Department of Gynecological Endocrinology, V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health
Tatyana V. Priputnevich – Corresponding Member of the RAS, MD, Associate Professor, Director of the Institute of Microbiology, Antimicrobial Therapy and Epidemiology, V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health
Vera V. Muravyeva – PhD in Biology, Senior Researcher, Institute of Microbiology, Antimicrobial Therapy and Epidemiology, V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health.
Natalya E. Shabanova – PhD, Associate Professor, Head of the Department of Clinical Pharmacology of Antimicrobial and Immunobiological Drugs, Institute of Microbiology, Antimicrobial Therapy and Epidemiology, V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health
Marina V. Ipatova – MD, Head of the Gynecological Department of Restorative Treatment, V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health
Tatyana B. Malanova – PhD, Head of Clinical Work, Gynecological Department of Restorative Treatment, V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health.
Irina A. Salnikova – PhD, Researcher, Obstetrician-Gynecologist at the 2nd Gynecological Department (Children and Adolescents), V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health
Narine M. Tonoyan – PhD, Obstetrician-Gynecologist, Department of Operative Gynecology, V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health
Natalya A. Schukina – MD, Professor at the Department of Obstetrics and Gynecology, Faculty of Advanced Medical Training, Moscow Regional Research Clinical Institute named after M.F. Vladimirsky (MONIKI).
Elena V. Uvarova – MD, Professor, Head of the 2nd Gynecological Department (Children and Adolescents), V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health.
Maria I. Yarmolinskaya – Professor of the RAS, MD, Professor, Head of the Department of Gynecology and Reproductive Endocrinology, D.O. Ott Research Institute of Obstetrics and Gynecology, Professor at the Department of Obstetrics and Gynecology, North-Western State Medical University named after I.I. Mechnikov of the Russian Ministry of Health, member of the Russian Society of Obstetricians and Gynecologists.
Conflict of interest: All members of the working group declare no conflict of interest.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience for these clinical guidelines:
1. Obstetrician-gynecologists, general practitioners, family physicians
2. Students, residents, postgraduate students
3. Lecturers, researchers
Table 1. Scale for assessing levels of reliable evidence (LRE) for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Scale for assessing the levels of evidence (LE) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)
LoE | Definition |
|---|---|
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | There is only a rationale for the mechanism of action of the intervention (preclinical studies) or expert opinion |
Table 3. Scale for grading levels of recommendation certainty (LRC) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of evidence of proper quality; all considered efficacy criteria [outcomes] are unimportant, all studies have low methodological quality, and their conclusions regarding outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
These clinical guidelines have been developed taking into account the following regulatory and other documents:
1) Order of the Ministry of Health of the Russian Federation No. 1130n dated October 20, 2020 "On Approval of the Procedure for Providing Medical Care in the Field of 'Obstetrics and Gynecology'" (Registered on November 12, 2020, No. 60869);
2) Gynecology: National Guidelines. Edited by G.M. Savelieva, G.T. Sukhikh, V.N. Serov, V.E. Radzinsky, I.B. Manukhin. 2017.
3) Krasnopolsky V.I., Buyanova S.N., Schukina N.A. Purulent Gynecology: A Guide. Moscow: Medpress; 2001. p. 288.
4) SCAT Program (Antimicrobial Therapy Control Strategy) in inpatient medical care: Russian clinical guidelines / Ed. by S.V. Yakovlev, N.I. Briko, S.V. Sidorenko, D.N. Protsenko. – M.: Pero Publishing House, 2018. – 156 p.
5) Clinical Surgery: National Guidelines: in 3 vols. / ed. by V.S. Saveliev, A.I. Kirienko. - M.: GEOTAR-Media, 2010.
6) Woodward C, Fisher MA. Drug treatment of common STDs: Part II. Vaginal infections, pelvic inflammatory disease and genital warts. Am Fam Physician. 1999 Oct 15;60(6):1716-22. PMID: 10537386
7) Methodological recommendations on the health check-up (dispensary evaluation) of men and women of reproductive age for the assessment of reproductive health dated April 8, 2024 No. 17-6/I/2-6434
Table 1. Presumptive, additional, and specific criteria for PID
Presumptive criteria | Minor criteria | Specific criteria |
|---|---|---|
- lower abdominal tenderness on palpation - cervical motion tenderness during bimanual pelvic examination - adnexal tenderness on palpation during bimanual pelvic examination | - elevated temperature above 38.0°C - high leukocyte count in vaginal discharge; - elevated ESR - elevated CRP levels - detection of Neisseria gonorrhoeae and/or Chlamydia trachomatis and/or Trichomonas vaginalis and/or Mycoplasma genitalium and/or opportunistic microorganisms – obligate and facultative anaerobes and their associations | - endometrial biopsy with pathohistological signs of endometritis - detection by pelvic ultrasound or MRI of thickened, fluid-filled fallopian tubes, encysted ovarian masses combined with free fluid in the pelvic cavity - detection of signs of pelvic inflammatory disease according to diagnostic laparoscopy data. |
Recommended antibiotic treatment regimens for PID (adult patients) [2, 19, 38, 57-58]
Outpatient treatment recommended regimens:
INN | Dosing regimen | |
|---|---|---|
Regimen 1 [19] | #Ceftriaxone** Doxycycline** #Metronidazole** | 1 g IM, IV as a single dose PLUS 100 mg orally twice daily for 14 days PLUS 500 mg orally twice daily for 14 days |
Regimen 2 [2] | #Ceftriaxone** Doxycycline** #Metronidazole** | 500 mg IM as a single dose PLUS 100 mg orally every 12 hours PLUS 500 mg every 12 hours for 14 days |
Regimen 3 [20] | Ofloxacin** #Metronidazole ** #Ceftriaxone** | 400 mg orally every 12 hours PLUS 500 mg orally every 12 hours for 14 days With or WITHOUT 1 g IM, IV as a single dose |
Regimen 4 [20] | #Levofloxacin** #Metronidazole** #Ceftriaxone** | 500 mg orally every 24 hours PLUS 500 mg orally every 12 hours for 14 days With or WITHOUT 1 g IM, IV as a single dose |
Alternative outpatient regimens [19,20,57]:
INN | Dosing regimen | |
|---|---|---|
Regimen 1 [2, 57] | #Levofloxacin** #Metronidazole ** | 500 mg orally once daily or With or WITHOUT 500 mg orally twice daily for 14 days |
Regimen 2 [2] | #Ceftriaxone** #Azithromycin** | 500 mg IM single dose PLUS oral 1 g single dose followed by a second dose of oral azithromycin** 1 g 1 week later |
Regimen 3 [2, 10, 57] | Moxifloxacin** | 400 mg orally every 24 hours for 14 days |
Inpatient treatment recommended regimens:
INN | Dosing regimen | |
|---|---|---|
Regimen 1 [57] | Clindamycin** #Gentamicin** Doxycycline** Clindamycin** | 900 mg IV every 8 hours PLUS 2 mg/kg per day followed by a maintenance dose of 1.5 mg/kg every 8 hours (or 3-5 mg/kg every 24 hours) Switch to: 100 mg orally every 12 hours Or 450 mg orally every 6 hours |
Regimen 2 [57] | Clindamycin** #Gentamicin** Clindamycin** Doxycycline** #Metronidazole** | 900 mg IV every 8 hours plus 2 mg/kg per day followed by a maintenance dose of 1.5 mg/kg every 8 hours (or 3-5 mg/kg every 24 hours) Switch to: or oral 450 mg every 6 hours OR oral 100 mg every 12 hours PLUS 500 mg orally twice every 12 hours |
Diagram 3 [2, 19] | #Ceftriaxone** Doxycycline** #Metronidazole | 1 g IM, IV as a single dose 100 mg orally twice daily for 14 days 500 mg orally twice daily for 14 days |
Alternative inpatient regimens (adult female patients):
INN | Dosing regimen | |
|---|---|---|
Regimen 1 [19, 57] | Ampicillin+[Sulbactam]** #Doxycycline** | 3 g IV every 6-8 hours PLUS 100 mg orally every 12 hours |
Regimen 2 [19] | #Levofloxacin** Metronidazole** | 500 mg every 24 hours IV PLUS 500 mg IV every 8 hours for 14 days |
Regimen 3 [57] | Azithromycin** Metronidazole** | Azithromycin** as monotherapy for 1 week (500 mg IV for one or two doses followed by 250 mg every 24 hours orally for 5-6 days) or Azithromycin** 500 mg IV every 8 hours for 14 days, combined with a 12-day course of metronidazole** |
Regimen 4 [57] | #Ciprofloxacin** #Doxycycline** Metronidazole** | 200 mg IV every 12 hours PLUS 100 mg IV (or orally) every 12 hours PLUS 500 mg IV every 8 hours for 14 days |
Note: The spectrum of third-generation cephalosporins is limited against anaerobes; therefore, it is important to consider adding imidazole derivatives (metronidazole**, ornidazole, tinidazole) to treatment regimens for PID [33].
Treatment of PID in children and adolescents
PID is considered a polymicrobial disease. The most common causative agents are C. trachomatis and/or N. gonorrhoeae [19].
Treatment of PID in children and adolescents is carried out taking into account age and body weight, in accordance with the drug's package insert.
Fluoroquinolones (ATC: Fluoroquinolones) are contraindicated in patients under 18 years of age due to the inability to rule out the risk of damage to cartilage growth plates in children [59].
Doxycycline** is contraindicated in children under 8 years of age due to the potential formation of insoluble complexes with calcium ions and their deposition in the skeletal system, enamel, and dentin of teeth [59].
Treatment of children and adolescents
INN | Dosing regimen | |
|---|---|---|
Regimen 1 [19, 60] | #Ceftriaxone** #Cefotaxime** #Erythromycin** #Azithromycin** #Doxycycline** | Gonococcal PID in infants and children with body weight ≤45 kg 25-50 mg/kg IV or IM once, maximum 250 mg IM bacteremia or arthritis in children with body weight ≤45 kg 50 mg/kg of body weight (maximum dose: 2 g) IM or IV as a single dose daily every 24 hours for 7 days in children weighing more than 45 kg 1 g IM or IV once every 24 hours for 7 days Or 25 mg/kg per day IV or IM every 12 hours for 7 days (with a duration of 10-14 days if meningitis is documented) Chlamydial infection in infants and children weighing <45 kg 50 mg/kg body weight/day orally, divided into 4 doses per day for 14 days For children weighing ≥45 kg, but aged <8 years: 1 g orally as a single dose For children aged ≥8 years: 1 g orally as a single dose. Or 100 mg orally 2 times/day for 7 days |
Note: antibiotic therapy is adjusted based on the results of molecular biological testing.
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
Pelvic inflammatory disease (PID) is a group of inflammatory diseases of the upper female reproductive tract. PID develops as a result of the spread of infection from the vagina and cervix into the uterine cavity, ovaries, or fallopian tubes.
Pathogens of PID include gonococci, chlamydia, Trichomonas, as well as opportunistic microbes in immunocompromised states. The mixed nature of the infection and the high frequency of uncontrolled repeated use of antibacterial drugs contribute to the development of antibiotic resistance, which makes the treatment of this group of diseases complex. In the absence of timely diagnosis and treatment, long-term consequences of PID can develop, such as infertility, miscarriage, adhesions, chronic pelvic pain, and ectopic pregnancy.
Risk factors for PID include young age (under 25), frequent change of sexual partners, sexually transmitted infections (STIs) in the woman or her partner, obstetric and gynecological surgeries and intrauterine diagnostic procedures, and intrauterine device placement (within the past 3 weeks).
Main symptoms of PID: purulent vaginal discharge, acyclic spotting from the genital tract, lower abdominal pain of varying intensity, fever and chills, painful urination, nausea and vomiting, and pain during sexual intercourse. The presence of one or more of these symptoms does not mean you have PID. It may be a sign of other serious pathological conditions, such as appendicitis or ectopic pregnancy. If you have any of the listed symptoms, you should consult a gynecologist and undergo an examination (vaginal and cervical smears, blood tests, ultrasound, and in some cases MRI, endometrial biopsy, laparoscopy).
The main treatment is antibiotic therapy (1 or more types of drugs). You must follow your doctor's recommendations and complete the prescribed therapy. Hospitalization and surgical intervention may be required if necessary.
Sexual partners of women with STIs should receive treatment, even in the absence of symptoms. To prevent PID, condoms should be used to reduce the risk of STIs, and the number of sexual partners should be limited.