The finding of fluid in the pouch of Douglas on ultrasound scan does not always translate to the presence of pelvic inflammatory disease. The fluid could come from the mature egg during the time of egg release at ovulation. It might also be the menses. Pelvic inflammatory disease (PID) comprises a spectrum of inflammatory disorders of the upper female genital tract which usually ascends from the vagina or cervix. This includes any combination involving the inflammation of the lining of the womb called the endometrium(endometritis), inflammation of the fallopian tube(salpingitis), or the inflammation and formation of masses filled with pus involving the fallopian tube and ovary (tubo-ovarian abscess), and the inflammation of the membrane lining the pelvis (pelvic peritonitis). PID will affect about 2 out of 100 sexually active women per year.


The majority of PID cases are caused by sexually transmitted pathogens (Neisseria gonorrhoeae and Chlamydia trachomatis) or bacterial vaginosis-associated pathogens. Fewer proportion of acute PID cases are not cause by sexually transmitted organism instead, are associated with pathogens from the intestine that have colonized the lower genital tract (examples; Escherichia coli, Bacteroides fragilis, Group B streptococci, and Campylobacter spp) or respiratory pathogens (examples; Haemophilus influenzae, Streptococcus pneumoniae, Group A streptococci, and Staphylococcus aureus). PID usually involves multiple bacterial infection.


The risk factors for PID strongly reflect those of any sexually transmitted infection (STI) such as; young age <25years, multiple sexual partners (total lifetime sexual partner ≥ 4), lack of condom use, a partner with a sexually transmitted infection, and a history of previous PID or a sexually transmitted infection. Also, douching alters the normal vagina environment and the organisms that lives there naturally giving way for harmful ones. Douching could introduce infection to the upper genital tract.


PID can be classified into: Acute PID (acute onset of lower abdominal or pelvic pain, pelvic organ tenderness, and evidence of inflammation of the genital tract, within <30days). Subclinical PID (no symptoms but has future sequelae). Chronic PID (indolent presentation of PID with low-grade fever, weight loss, and abdominal pain. It is associated with tuberculosis and actinomyces species.


The diagnosis of acute PID is primarily based on historical and clinical findings. Acute PID is characterized by the acute onset of lower abdominal pain or pelvic pain which occurs during or shortly after menses rarely of more than two weeks’ duration. Abnormal uterine bleeding (bleeding after sexual intercourse, bleeding in between menses, heavy menstrual bleeding) occurs in one-third or more of patients with PID.  Other non-specific complaints include urinary frequency, abnormal vaginal discharge, nausea, vomiting, diarrhoea, painful sex, painful menses. You need to be evaluated by a doctor when you have the aforementioned symptoms. This should be treated with utmost urgency due to the possible complications of PID.

The following signs might be present when your doctor examine you; rebound abdominal tenderness, fever (>38.30c), and decreased bowel sounds are usually limited to women with more severe PID. The defining characteristic of acute symptomatic PID on pelvic examination includes; Pain when the cervix or mouth of the womb is moved by the doctor’s examining fingers in the vagina, tenderness of the womb and structures close to the side of the womb when pressure is applied by the examining hand on the lower abdomen and that in the vagina.


The complications of PID include; chronic pelvic pain, ectopic pregnancy, tubal factor infertility (inability to conceive due to blockage of the fallopian tubes), and implantation failure with in vitro fertilization attempts.


Most laboratory findings in PID are nonspecific. Although PID is usually an acute process, only a minority of PID patients with more severe disease exhibit peripheral blood leucocytosis (increase white cell count). Similarly, an elevated erythrocyte sedimentation rate and C-reactive protein, presence of cervical Neisseria gonorrhoeae and Chlamydia trachomatis from endocervical swab sample enhances diagnostic specificity. Additional testing can help to confirm the diagnosis of PID, although their absence does not rule out the possibility of PID: Pelvic imaging (transvaginal ultrasound, Computer Tomography scan, or Magnetic Resonance Imaging) findings consistent with PID include thickened, fluid-filled fallopian tubes with or without free pelvic fluid, or tubo-ovarian complex. Doppler studies may demonstrate tubal hyperemia (congestion of blood around the fallopian tubes) suggestive of pelvic infection. Laparoscopic findings showing redness of the fallopian tube, swelling, adhesions, purulent exudate or cul-de-sac fluid. Endometrial biopsy showing endometritis (inflammation of the endometrial/inner lining of the womb).


Treatment of pelvic inflammatory disease (PID) addresses the relief of acute symptoms, eradication of current infection, and minimization of the risk of long-term sequelae. The majority of women with a clinical diagnosis of PID have symptoms of mild to moderate severity that usually respond well to outpatient oral antibiotic therapy.

Hospitalization usually is warranted for women who are more severely ill, as well as the following cases: Patients in whom surgical emergencies (eg, appendicitis) cannot be excluded, patients who are pregnant, patients who have not responded well to outpatient oral therapy, patients who are unable to tolerate or comply with outpatient therapy, Patients who have severe illness, nausea and vomiting, or high fever, patients with tube-ovarian abscess. Treatment of patient on admission involves the use of antibiotics given via the vein.

You should know that non treatment or poorly treated PID could cost you your reproductive function. Therefore, treat as an emergency by promptly seeking appropriate healthcare to forestall such terrible consequences.