Pelvic inflammatory disease and persistent pelvic pain
This information is intended to summarize the approach to treatment for those who develop persistent pelvic pain following treatment for short term ( acute ) pelvic inflammatory disease.
The patient information leaflet produced by the Royal College of Obstetricians and Gynaecologists about acute pelvic inflammatory disease can be read here.
Infections in the pelvis are common in women mainly in the reproductive years. They generally arise from infections that spread upwards via the vagina to the uterus, (endometritis), to the Fallopian tubes (salpingitis) , to the ovaries (oophoritis), to both Fallopian tubes and ovaries (tubo-ovarian abscess) or to the pelvic and abdominal peritoneum (pelvic peritonitis). They are usually due to sexually transmitted infections (STIs) but can arise from other infections following diagnostic or therapeutic procedures that involve the penetration of the cervix. Examples of this include insertion of an intra- uterine contraceptive device (IUD), following a termination of pregnancy, or following a miscarriage where the remaining products have had to be removed surgically. This type of procedure can also be used following pregnancy if there has been a uterine infection and or if a woman requires a D&C.
Adhesions are associated with PID and may also be associated with persistent pelvic pain.
It has been recognised for some time that PID is associated with persistent pelvic pain. It occurs in 15-20% of women who have previously suffered with PID (SOGC Guideline 2005). An in depth review of existing research (a systematic review) of those with persistent pelvic pain found that previous PID infection was significantly associated with symptoms of noncyclic pelvic pain of longer than 3 months duration and of painful intercourse. A further study (Ness,2004) showed that consistent use of condoms was associated with lower rates of PID sequelae including persistent pelvic pain (SOGC Guideline 2005).
In some cases there is a clear history of a preceding infection that has resulted in a persistent pain state. Previous acute pelvic infectious disease from confirmed Chlamydia or Gonorrhoea are not uncommon but there may also be a history of post abortion infection, post delivery endometritis, or a ruptured appendix. However, in many cases there are no indications of previous infections. A number of new bacteria have been identified as possible causes of PID (eg Mycoplasma, Atopobium or Leptotrichia) but their importance has not yet been proven. Some types of pelvic infections (e.g. Chlamydia) are not easy to diagnose. Some women will have no obvious symptoms, whilst others may have many tests before the cause of an infection is identified. We suggest that you persist in seeing your doctor if you still have symptoms.
Management of persistent pelvic pain
Most women are initially treated with antibiotics and some may be given analgesia. Then if the problem persists more antibiotics may be prescribed in varying combinations until either the problem goes away or the symptoms and pain persist but there are no signs of infection. If there is active disease such as a tubo-ovarian abscess active management and possible surgery and hospitalization can often be needed. It can be difficult to understand that pain may persist even when an existing infection has been treated.
Medical management for persisting pain when an existing infection has been treated involves pain management with simple analgesics such as paracetamol and suppressing menstruation with continuous oral contraception or GnRH with add-back therapy. Neuropathic pain medications may also be used eg amitriptyline. In some cases opioid medication may be needed. However, medical management may not be sufficient and additional input may be needed from multidisciplinary teams (SOGC Guideline 2005). These teams involve pain specialists, gynaecologists, physiotherapists, psychologists and nurses. This additional management may include physiotherapy and cognitive behavioral therapy (CBT) (Morley, 1999). The latter is delivered by psychologists in a hospital setting or by counsellors in a generalist setting. The goal of this approach is to reduce pain and improve function. (SOGC Guideline 2005).
A recent trial of short wave diathermy in the management of persistent pelvic inflammatory disease pain demonstrated a significant improvement in pain and inflammation. The trial concluded that this may be an effective and non invasive therapy in the management of persistent pelvic inflammatory disease pain (Lamina,, 2011). Shortwave diathermy uses high-frequency electromagnetic energy to generate heat. It may be applied in pulsed or continuous energy waves. Two electrodes are positioned near the affected area. It can reach areas as deep as two inches from the skin's surface. The diathermy machine does not apply heat directly to the body. Instead, the current from the machine allows the body to generate heat from within the targeted tissue. Diathermy may be part of a complete physical therapy or rehabilitative programme. To our knowledge this is not routinely available in the UK.
We are aware of a randomized controlled study that has looked at using a guide with GPs to help women choose self-management techniques that are most suitable for them.
Some patients may find support organizations and online forums to be helpful with self-management.
References and further reading:
Morley S, Eccleston C, Williams A. Systematic review and meta-analysis of
randomized controlled trials of cognitive behaviour therapy and behaviour
therapy for chronic pain in adults, excluding headache pain Pain 1999
Ness RB, Randall H, Richter HE, Peipert JF, Montagno A, Soper DE, et al; PEACH study investigators. Condom use and the risk of recurrent pelvic inflammatorydisease, chronic pelvic pain, or infertility following an episode of pelvic inflammatory disease. Am J Public Health 2004
SOGC Consensus guideline for the management of chronic pelvic pain 2005
Issue date: March 2014
Review date: March 2017