The Effects of Undetected and Untreated Sexually Transmitted Diseases: Pelvic Inflammatory Disease and Ectopic Pregnancy in Canada
MacDonald, Noni E., Brunham, Robert, The Canadian Journal of Human Sexuality
Key words. Pelvic Inflammatory Disease Sexually transmitted disease Tubal infertility Chlamydia trachomatis Ectopic pregnancy
The Report of the Royal Commission on New Reproductive Technologies (1993) emphasized the relationship between infertility, pelvic inflammatory disease (PID) and sexually transmitted diseases (STDs), and placed a high priority on prevention and treatment of STDs and PID to minimize the prevalence of infertility, The documentation in support of this view indicated that one third to one half of women who acquire an STD will develop PID, that this group of women represents about 80% of all cases of PID (Goeree & Gully, 1993), and that current or prior PID is associated with a sizeable percentage of cases of tubal infertility and ectopic pregnancy (Rootman, 1992; Westrom, 1980). This paper examines the relationships between STDs and PID, and between PID and reproductive sequelae such as ectopic pregnancy and tubal infertility. We identify goals for reducing the prevalence of these sequelae through interrelated strategies for prevention, diagnosis, and treatment of STDs and PID.
PELVIC INFLAMMATORY DISEASE
Definition Pelvic inflammatory disease (PID) is a serious syndrome of the female reproductive system which results from the spread of infections (most often sexually transmitted infections such as Chlamydia trachomatis and Nisseria gonnorrhoea), from the vagina and endocervix to the uterus, fallopian tubes and ovaries. PID commonly manifests as endometritis (infection of the lining of the uterus) or salpingitis (infection of the fallopian tubes) and less commonly as pelvic peritonitis and/or inflammation of contiguous structures (MacDonald & Bowie, 1995; Westrom & Mar &, 1990).
Diagnosis PID is best understood as a syndrome; it has a variety of symptoms that can vary in occurrence and severity including: lower abdominal pain; dysuria; urinary frequency; purulent endocervical discharge; dyspareunia; adnexal tenderness (pressure sensitivity of tissues adjacent to the uterus); cervical motion tendemess; and fever (Table 1). Clinical diagnosis of PID is difficult because of the wide variation in symptoms and signs, and the high rate of asymptomatic infection, particularly among adolescents (Paradise & Grant, 1992). In the classic study by Jacobson and Westrom (1969), only 65% of 814 women with clinically diagnosed PID had infection confirmed by laparoscopy, 23% had no observable abnormality, and 12% had other findings such as ectopic pregnancy, endometriosis, and appendicitis. Unfortunately, no single or combined set of symptoms, signs, or laboratory test results is highly sensitive and specific for PID (Kahn, Walker, Washington, Landers, & Sweet, 1991).
Table 1 Symptoms and signs in 623 patients with laparoscopically proven Pelvic Inflammatory Disease(*)
Symptom or Sign % Lower abdominal pain of recent onset 95 Marked adnexal tenderness 90 Increased vaginal discharge 55 Irregular menstrual bleeding 35 Fever > 38[degrees]C 35 Urinary tract symptoms (cystitis-urethritis) 20 Vomiting 10 Proctitis symptoms 5
(*) Adapted with permission from Jacobson & Westrom (1969).
Given the present limitations of clinical evaluation, laparoscopy is the only tool that can provide a definitive diagnosis. Unfortunately, this is a surgical procedure and is therefore not a useful tool for routine diagnosis. Despite the low sensitivity and specificity of clinical examination for detection of PID, the importance of detecting even mild cases has led to the identification of accepted minimum criteria for clinical diagnosis (MacDonald & Bowie, 1995; MMWR, 1991) (see Table 2). These minimum criteria detect only about 60% of laparoscopically proven cases (Westrom & Mardh, 1990). …