1. Introduction
Pelvic inflammatory disease (PID) is a complex condition which can present a number of challenges for clinicians, particularly around the diagnostic process. Defined as an infection of the upper genital tract in females, untreated PID can pose a real threat to future fertility [1] and so early recognition and treatment is paramount. However, treatment can be further complicated if a woman is using an intrauterine contraceptive device (IUCD). Current clinical guidance is not clear on whether or not removing IUCDs would be beneficial during PID treatment [2,3]. As many clinicians rely on this guidance, this discursive article will discuss how this combination of challenges requires clinicians to focus on other as pects of the decision making process, and how this will subsequently influence the outcome of clinical decisions.
2. Problems with Diagnosis
As PID can present with a range of potential signs and symptoms (Table 1), as well as often being asymptomatic [1], accurate diagnosis is a particularly challenging issue for clinicians. Symptoms can often vary in severity as well as being mistaken for other gynaecological or even gastrointestinal conditions.
PID can also be divided into two presentations; acute or chronic and each associated with a different presentation of symptoms [4]. Acute PID usually presents with sudden, more severe symptoms. In contrast, chronic PID usually has more subtle, or very few symptoms. It is important to note that this does not suggest that acute PID does more damage to reproductive health than chronic PID. Chronic PID can often be mistaken for other conditions, such as irritable bowel syndrome, and so often has the opportunity to do more internal damage due to the time taken to reach the correct diagnosis [4].
As the inflammatory response involved in PID can potentially damage the internal reproductive organs over time, late diagnosis can have catastrophic consequences for future fertility and reproductive health [2]. It is therefore of vital importance that clinicians are able to quickly identify and assess the potential risk of PID when a woman seeks advice. As there is no single test that has been proven to be sensitive and specific for PID [5], the clinician must do a thorough history and examination to confirm, or rule out, the likelihood of PID, and make prompt treatment options based on this.
Using the SIGN [6] grading system, expert opinion is level 4 evidence and, it could be argued that experienced clinicians apply their own clinical judgement in the diagnostic process. One study [7] that investigated this area produced overall results that suggested that there is a difference in the diagnostic rates between the more and less experienced staff working in sexual health clinics. Although the study achieved a large sample size (n=21,784), the retrospective methodology of analysing case notes for symptoms and swab results presents limitations for this research. This is due to the currently unavoidable issue of diagnosing PID at a clinical level, where a diagnosis can be suspected, but not guaranteed. The study did highlight a potential issue that requires further investigation, that there are inconsistencies in the thresholds for diagnosing PID treatment, especially when IUCDs are in-situ. Any clinician consulting with a woman who may have suspected or probable PID must have a sound knowledge base on this disease process and how to recognise and treat it in a prompt and efficient manner. As the diagnostic threshold can vary among clinicians, it is concerning that some women may be misdiagnosed with PID, or even worse, true cases are missed due to clinicians having a high threshold for diagnosis. It is therefore one of the recommendations of this article that further research and education on diagnostic criteria is provided to medical and nursing staff working in high risk areas for PID, such as sexual health, gynaecology and primary care settings.
Once it has been decided that PID is a likely possibility, a further challenge may present itself when the woman has an IUCD in-situ. Ideally, evidence based clinical guidelines would offer high quality recommendations on whether to remove an IUCD or not during treatment for PID. However, this is not the case as current guidelines offer conflicting advice for clinicians. Further randomised controlled trials investigating clinical outcomes in PID and IUCD use are therefore recommended in order to provide national recommendations for best practice.
Competing Interests
The authors declare that they have no competing interests.