1030
U N I T 1 1
Genitourinary and Reproductive Function
(which are not present in the normal endometrium) is
required for diagnosis. The clinical picture is variable,
but often includes abnormal vaginal bleeding, mild
to severe uterine tenderness, fever, malaise, and foul-
smelling discharge. Treatment involves oral or intrave-
nous antibiotic therapy, depending on the severity of the
condition.
Pelvic Inflammatory Disease.
Pelvic inflammatory
disease (PID) is a polymicrobial infection of the upper
reproductive tract (uterus, fallopian tubes, or ovaries)
associated with sexually transmitted and endogenous
organisms.
25–27
The organisms ascend through the endo-
cervical canal to the endometrial cavity, and then to the
fallopian tubes and ovaries (Fig. 40-9). The endocervical
canal is slightly dilated during menstruation, allowing
bacteria to gain entrance to the uterus and other pelvic
structures. After entering the upper reproductive tract,
the organisms multiply rapidly in the favorable environ-
ment of the sloughing endometrium and ascend to the
fallopian tube.
Factors that predispose women to the development of
PID include an age younger than 25 years; young age at
first intercourse (<15 years); use of nonbarrier contracep-
tion, especially IUD or oral contraception; history of new,
multiple, or symptomatic sex partners; and previous his-
tory of PID or sexually transmitted infection.
25
The symptoms of PID include lower abdominal pain,
which may start just after a menstrual period; dyspa-
reunia; back pain; purulent cervical discharge; and the
presence of lower abdominal tenderness and exquisitely
painful cervix on bimanual pelvic examination. New-
onset breakthrough bleeding in women who are on oral
contraceptives or medroxyprogesterone contraceptive
injection (Depo-Provera) has been associated with PID.
Fever (>101°F), increased erythrocyte sedimentation
rate, and an elevated white blood cell count (>10,000
cells/mL) commonly are seen, even though the woman
may not appear acutely ill. Elevated C-reactive protein
(CRP) levels equate with inflammation and can be used
as another diagnostic tool. Laparoscopy, which allows
for direct visualization of the ovaries, fallopian tubes,
and uterus, is one of the most specific procedures for
diagnosing PID, but is costly and carries the inherent
risks of surgery and anesthesia.
27
Minimal criteria for a
presumptive diagnosis of PID require only the presence
of lower abdominal pain, adnexal (area adjoining the
uterus, fallopian tubes, and ovaries) tenderness, and cer-
vical motion tenderness on bimanual examination with
no other apparent cause.
Treatment may involve hospitalization with intrave-
nous administration of antibiotics. If the condition is
diagnosed early, outpatient antibiotic therapy may be
sufficient. Treatment is aimed at preventing complica-
tions, which can include pelvic adhesions, infertility,
ectopic pregnancy, chronic abdominal pain, and tubo-
ovarian abscesses.
Endometriosis
Endometriosis is the condition in which functional
endometrial tissue is found in ectopic sites outside
the uterus.
28–30
The site may be the ovaries, posterior
broad ligaments, uterosacral ligaments, rectouterine
pouch, pelvis, vagina, vulva, perineum, or intestines
(Fig. 40-10).
The cause of endometriosis is largely unknown.
There appears to have been an increase in its incidence
in developed Western countries during the past four
Vaginitis
(e.g., Trichomonas
vaginalis)
Cervicitis
Postpartum
endometritis
Ascending infections
(e.g., Gonococcus, Staphylococcus, anaerobes,
Streptococcus, Chlamydia)
Endometritis
Adhesions
Salpingitis
FIGURE 40-9.
Pelvic inflammatory
disease. Microbial agents enter through
the vagina and ascend to involve the
uterus, fallopian tubes, and pelvic
structures.
