Causes of Pelvic Inflammatory Disease

List of causes of Pelvic Inflammatory Disease

Following is a list of causes or underlying conditions (see also Misdiagnosis of underlying causes of Pelvic Inflammatory Disease) that could possibly cause Pelvic Inflammatory Disease includes:

• Chlamydia
• Gonorrhea
• Gardnerella vaginalis infection
• Bacteroides infection
• Appendicitis - occasionally causes bacterial transfer to cause PID.
• Childbirth - PID can occur as a complication
• Abortion - PID can occur as a complication
• Reproductive surgery - PID can occur as a complication
• Ruptured appendix
• Appendix surgery
• HIV - PID that does not respond to treatment can indicate HIV.

More causes: see full list of causes for Pelvic inflammatory disease

Causes of Pelvic Inflammatory Disease (Diseases Database):

The follow list shows some of the possible medical causes of Pelvic Inflammatory Disease that are listed by the Diseases Database:

• Bacteroides
• Enterococcus
• Actinomycosis
• Chlamydia trachomatis
• Escherichia coli
• Neisseria gonorrhoea
• Streptococcus Group B

Source: Diseases Database

Causes of Pelvic Inflammatory Disease: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the causes of Pelvic Inflammatory Disease.

Dysmenorrhea: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Primary dysmenorrhea
  –Symptoms develop before age 25
  –Pain occurs with onset of bleeding, then gradually diminishes

• Secondary dysmenorrhea
  –Endometriosis (uterosacral ligament nodules, severe dysmenorrhea)
  –Adenomyosis (enlarged uterus, menorrhagia, age 40–50, parous)
  –Acute PID (acute adnexal and cervical motion tenderness, fever, discharge, and/or new-onset dysmenorrhea)
  –Chronic PID (due to scarring)
  –Uterine leiomyoma/fibroids (enlarged, mobile uterus, menorrhagia)
  –Ovarian cysts (new dysmenorrhea, unilateral fullness)

• Mental health issues
  –Somatization
  –Substance abuse
  –Depression
  –Sexual abuse
• Extrapelvic disorders
  –Irritable bowel syndrome
  –Appendicitis
  –Urinary tract infection
  –Inflammatory bowel disease
  –Diverticulitis
  –Cholecystitis
• Fibromyalgia
• Malformations of the müllerian ducts
• Interstitial cystitis
• Intestinal or uteropelvic junction obstruction
• Malignancy (e.g., uterine, ovarian)
• Ectopic pregnancy

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Vaginal Discharge: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Physiologic
  –Many women will have a consistent, slightly clear, non-odor-producing discharge, either midcycle or premenstrually, particularly if they are on oral contraceptives
  –A change in odor, consistency, or color of discharge may signify that evaluation is necessary
  –Increased discharge is associated with pregnancy
• Sexually transmitted disease
  –Trichomonas vaginalis: “Strawberry cervix” with punctate erythema, flagellated oval organisms on wet mount
  –Gonorrhea/Chlamydia may be associated with pelvic pain/dysmenorrhea and dyspareunia
• Bacterial vaginosis
  –Various organisms and changes in normal flora with a characteristic fishy odor
  –Not considered an STD
  –Increases the risk of preterm delivery in pregnant women

• Alteration of normal vaginal flora and/or inflammatory response
  –Candida albicans overgrowth is more common with recent antibiotic use, poorly controlled diabetes, and/or pregnancy; presents with intensely pruritic, inflamed, and erythematous introitus
  –Doderlein's cytolysis (caused by an overgrowth of lactobacilli)

• Atrophic vaginitis
  –Common in postmenopausal women, especially those not on HRT
  –Poor coital lubrication, dyspareunia
  –Dysuria due to atrophic urethral tissue
• Foreign body vaginitis (e.g., retained tampon)
• Noninfectious irritant/allergic contact vaginitis (e.g., soaps, feminine pads, perfumes)
• Cervicitis (usually due to gonorrhea or Chlamydia)
• Cervical dysplasia, cancer, or polyps
• Vaginal or vulvar trauma or cancer

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Pelvic Pain - Female: Differential Diagnosis
(In a Page: Signs and Symptoms)

Acute pain (<6 months)

• Pregnancy-related
  –Ectopic pregnancy
  –Threatened abortion
  –Incomplete abortion
  –Septic abortion
  –Ruptured corpus luteal cyst
• Gynecologic (noncyclic)
  –Ovarian cyst
  –Pelvic inflammatory disease
  –Tubo-ovarian abscess
  –Vaginitis/cervicitis
  –Ovarian torsion
  –Uterine fibroids
  –Pelvic (ovarian, uterine, urinary) neoplasm
  –Pelvic floor prolapse (cystocele/rectocele)
• Gynecologic (cyclic pain)
  –Primary dysmenorrhea
  –Endometriosis
  –IUD
  –Mittelschmerz (midcycle ovulation)
• Nongynecologic
  –Irritable bowel syndrome
  –UTI/pyelonephritis
  –Nephrolithiasis
  –Appendicitis
  –Diverticulitis
  –Sexual abuse/trauma
  –Abdominal aortic aneurysm
  –Mesenteric ischemia/infarction
• 
  Chronic pain (>6 months)
• Very difficult to diagnose; differential includes gynecologic and nongynecologic etiologies (above), as well as the following
  –Pelvic adhesions
  –Interstitial cystitis
  –Inflammatory bowel disease
  –Adenomyosis
  –Leiomyoma (fibroids)
  –Hernia (femoral or inguinal)
  –Depression
  –Irritable bowel syndrome
  –Diverticulosis or diverticular abscess
  –Lymphoma
• Less common etiologies (“zebras”) include pelvic congestion syndrome, mesenteric adenitis, surgical adhesions, Asherman's syndrome, foreign body (e.g., tampon), abdominal wall nerve entrapment, and porphyria

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Vaginal Discharge: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Physiologic leukorrhea
  –In newborns for 2–3 weeks, due to maternal estrogen effect, and in pubertal girls
  –Discharge typically clear to white, sticky, and nonirritating
  –Newborns may have withdrawal bleeding

• Infections
  –Bacterial vaginosis: Previously known as nonspecific vaginitis; polymicrobial in etiology (coliforms, streptococci, Gardnerella); discharge may be gray and malodorous (fishy smell) but generally nonirritating
  –Candida: Discharge may be cheesy and white with erythematous, pruritic, irritated vulva; typical discharge is rarely seen in prepubertal children; discharge typically has no odor
  –Trichomonas: Discharge may be frothy, malodorous, creamy, green, bloody, or pruritic (or asymptomatic)
  –Chlamydia: Commonly asymptomatic or a nonspecific discharge
  –Gonorrhea: Infection is commonly asymptomatic or has a gray-white, thick, purulent discharge
  –Group A β-hemolytic streptococci: Discharge may be bloody
  –Shigella: Discharge may be bloody

• Irritation/hygiene
  –Due to bubble baths and other chemical irritants, tight clothing, obesity, poor wiping
• Foreign body
  –Commonly includes toilet paper, forgotten tampon
  –Discharge is often bloody and malodorous
• Anatomic
  –Ectopic urethra
  –Rectovaginal fistula
  –Urethral prolapse
• Urinary tract infection
• Masturbation
• Sarcoma botyroides
• Oral contraceptives (estrogen effect)

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Dysmenorrhea: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Adenomyosis.

In adenomyosis, endometrial tissue invades the myometrium, resulting in severe dysmenorrhea with pain radiating to the back or rectum, menorrhagia, and a symmetrically enlarged, globular uterus that's usually softer on palpation than a uterine myoma.

Cervical stenosis.

Cervical stenosis is a structural disorder that causes dysmenorrhea and scant or absent menstrual flow.

Endometriosis

Endometriosis typically produces steady, aching pain that begins before menses and peaks at the height of menstrual flow; however, the pain may also occur between menstrual periods. The pain may arise at the endometrial deposit site or may radiate to the perineum or rectum. Associated signs and symptoms include premenstrual spotting, dyspareunia, infertility, nausea and vomiting, painful defecation, and rectal bleeding and hematuria during menses. A tender, fixed adnexal mass is usually palpable on bimanual examination.

Pelvic inflammatory disease

Chronic infection produces dysmenorrhea accompanied by a fever; malaise; foul-smelling, purulent vaginal discharge; menorrhagia; dyspareunia; severe abdominal pain; nausea and vomiting; and diarrhea. A pelvic examination may reveal cervical motion tenderness and bilateral adnexal tenderness.

PMS

The cramping pain of PMS usually begins with menstrual flow and persists for several hours or days, diminishing with decreasing flow. Common associated effects precede menses by several days to 2 weeks: abdominal bloating, breast tenderness, palpitations, diaphoresis, flushing, depression, and irritability. Other findings include nausea, vomiting, diarrhea, and a headache. Because PMS usually follows an ovulatory cycle, it rarely occurs during the first 12 months of menses, which may be anovulatory.

Primary (idiopathic) dysmenorrhea

Increased prostaglandin secretion intensifies uterine contractions, apparently causing mild to severe spasmodic cramping pain in the lower abdomen, which radiates to the sacrum and inner thighs. The cramping abdominal pain peaks a few hours before menses. Patients may also experience nausea and vomiting, fatigue, diarrhea, and a headache.

Uterine leiomyomas

If these tumors twist or degenerate after circulatory occlusion or infection or if the uterus contracts in an attempt to expel them, the tumors may cause constant or intermittent lower abdominal pain that worsens with menses. Associated signs and symptoms include backache, constipation, menorrhagia, and urinary frequency or retention. Palpation may reveal the tumor mass and an enlarged uterus. The tumors are almost always nontender.

Other causes

Intrauterine devices (IUDs)

IUDs may cause severe cramping and heavy menstrual flow.

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Vaginal discharge: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Atrophic vaginitis

With atrophic vaginitis, a thin, scant, watery white vaginal discharge may be accompanied by pruritus, burning, tenderness, and bloody spotting after coitus or douching. Sparse pubic hair, a pale vagina with decreased rugae and small hemorrhagic spots, clitoral atrophy, and shrinking of the labia minora may also occur.

Bacterial vaginosis

Bacterial vaginosis (formerly called Gardnerella vaginalis and Haemophilus vaginalis) results from an ecozogic disturbance of the vaginal flora. Causing a thin, foul-smelling, green or gray-white discharge, it adheres to the vaginal walls and can be easily wiped away, leaving healthy-looking tissue. Pruritus, redness, and other signs of vaginal irritation may occur but are usually minimal.

Candidiasis

Infection with Candida albicans causes a profuse, white, curdlike discharge with a yeasty, sweet odor. Onset is abrupt, usually just before menses or during a course of antibiotics. Exudate may be lightly attached to the labia and vaginal walls and is commonly accompanied by vulvar redness and edema. The inner thighs may be covered with a fine, red dermatitis and weeping erosions. Intense labial itching and burning may also occur. Some patients experience external dysuria.

Chancroid

Chancroid — a rare but highly contagious sexually transmitted disease — produces a mucopurulent, foul-smelling discharge and vulvar lesions that are initially erythematous and later ulcerated. Within 2 to 3 weeks, inguinal lymph nodes (usually unilateral) may become tender and enlarged, with pruritus, suppuration, and spontaneous drainage of nodes. Headache, malaise, and fever to 102.2° F (39° C) are common.

Chlamydial infection

Chlamydial infection causes a yellow, mucopurulent, odorless, or acrid vaginal discharge. Other findings include dysuria, dyspareunia, and vaginal bleeding after douching or coitus, especially following menses. Many women remain asymptomatic.

Endometritis

A scant, serosanguineous discharge with a foul odor can result from bacterial invasion of the endometrium. Associated findings include fever, lower back and abdominal pain, abdominal muscle spasm, malaise, dysmenorrhea, and an enlarged uterus.

Genital warts

Genital warts are mosaic, papular vulvar lesions that can cause a profuse, mucopurulent vaginal discharge, which may be foul-smelling if the warts are infected. Patients frequently complain of burning or paresthesia in the vaginal introitus.

Gonorrhea

Although 80% of women with gonorrhea are asymptomatic, others have a yellow or green, foul-smelling discharge that can be expressed from Bartholin’s or Skene’s ducts. Other findings include dysuria, urinary frequency and incontinence, bleeding, and vaginal redness and swelling. Severe pelvic and lower abdominal pain and fever may develop.

Gynecologic cancer

Endometrial or cervical cancer produces a chronic, watery, bloody or purulent vaginal discharge that may be foul-smelling. Other findings include abnormal vaginal bleeding and, later, weight loss; pelvic, back, and leg pain; fatigue; urinary frequency; and abdominal distention.

Herpes simplex (genital)

A copious mucoid discharge results from herpes simplex, but the initial complaint is painful, indurated vesicles and ulcerations on the labia, vagina, cervix, anus, thighs, or mouth. Erythema, marked edema, and tender inguinal lymph nodes may occur with fever, malaise, and dysuria.

Trichomoniasis

Trichomoniasis can cause a foul-smelling discharge, which may be frothy, green-yellow, and profuse or thin, white, and scant. Other findings include pruritus; a red, inflamed vagina with tiny petechiae; dysuria and urinary frequency; and dyspareunia, postcoital spotting, menorrhagia, or dysmenorrhea. About 70% of patients are asymptomatic.

Other causes

Contraceptive creams and jellies

Contraceptive creams and jellies can increase vaginal secretions.

Drugs

Drugs that contain estrogen, including hormonal contraceptives, can cause increased mucoid vaginal discharge. Antibiotics, such as tetracycline, may increase the risk of a candidal vaginal infection and discharge.

Radiation therapy

Irradiation of the reproductive tract can cause a watery, odorless vaginal discharge.

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Dysmenorrhea: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

Although primary dysmenorrhea has no known single cause, possible contributing factors include hormonal imbalances and psychogenic factors. The pain of dysmenorrhea probably results from increased prostaglandin secretion, which intensifies normal uterine contractions. (See Causes of pelvic pain, page 938.) Dysmenorrhea may also be secondary to such gynecologic disorders as endometriosis, cervical stenosis, uterine leiomyomas, uterine malposition, pelvic inflammatory disease, pelvic tumors, or adenomyosis.

Because dysmenorrhea almost always follows an ovulatory cycle, both the primary and secondary forms are rare during the anovulatory cycles of menses. After age 20, dysmenorrhea is generally secondary.

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Pelvic inflammatory disease: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

PID can result from infection with aerobic or anaerobic organisms. The organisms Neisseria gonorrhoeae and Chlamydia trachomatis are the most common cause because they most readily penetrate the bacteriostatic barrier of cervical mucus.

Normally, cervical secretions have a protective and defensive function. Therefore, conditions or procedures that alter or destroy cervical mucus impair this bacteriostatic mechanism and allow bacteria present in the cervix or vagina to ascend into the uterine cavity; such procedures include conization or cauterization of the cervix.

Uterine infection can also follow the transfer of contaminated cervical mucus into the endometrial cavity by instrumentation. Consequently, PID can follow insertion of an intrauterine device, use of a biopsy curet or an irrigation catheter, or tubal insufflation. Other predisposing factors include abortion, pelvic surgery, and infection during or after pregnancy.

Bacteria may also enter the uterine cavity through the bloodstream or from drainage from a chronically infected fallopian tube, a pelvic abscess, a ruptured appendix, diverticulitis of the sigmoid colon, or other infectious foci.

Common bacteria found in cervical mucus are staphylococci, streptococci, diphtheroids, chlamydiae, and coliforms, including Pseudomonas and Escherichia coli. Uterine infection can result from any one or several of these organisms or may follow the multiplication of normally nonpathogenic bacteria in an altered endometrial environment. Bacterial multiplication is most common during parturition because the endometrium is atrophic, quiescent, and not stimulated by estrogen.

 In the United States, nearly 1 million people develop PID each year; many cases go undiagnosed. About 1 in 8 active adolescents will develop PID before age 21.

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Dysmenorrhea: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Adenomyosis

In this disorder, endometrial tissue invades the myometrium, resulting in severe dysmenorrhea with pain radiating to the back or rectum, menorrhagia, and a symmetrically enlarged, globular uterus that’s usually softer on palpation than a uterine myoma.

Cervical stenosis

This structural disorder causes dysmenorrhea and scant or absent menstrual flow.

Endometriosis

In this disorder, steady, aching pain typically begins before menses and peaks at the height of menstrual flow, but it may also occur between menstrual periods. The pain may arise at the endometrial deposit site or may radiate to the perineum or rectum. Associated signs and symptoms include premenstrual spotting, dyspareunia, infertility, nausea and vomiting, painful defecation, and rectal bleeding and hematuria during menses. A tender, fixed adnexal mass is usually palpable on bimanual examination.

Pelvic inflammatory disease

Chronic infection produces dysmenorrhea accompanied by fever; malaise; a foul-smelling, purulent vaginal discharge; menorrhagia; dyspareunia; severe abdominal pain; nausea and vomiting; and diarrhea. A pelvic examination may reveal cervical motion tenderness and bilateral adnexal tenderness.

PMS

The cramping pain of PMS usually begins with menstrual flow and persists for several hours or days, diminishing as flow decreases. Abdominal bloating, breast tenderness, palpitations, diaphoresis, flushing, depression, and irritability commonly precede menses by several days to 2 weeks. Other findings include nausea, vomiting, diarrhea, and headache. Because PMS usually follows an ovulatory cycle, it rarely occurs during the first 12 months of menses, which may be anovulatory.

Primary (idiopathic) dysmenorrhea

Increased prostaglandin secretion intensifies uterine contractions, apparently causing mild to severe spasmodic cramping pain in the lower abdomen, which radiates to the sacrum and inner thighs. The cramping abdominal pain peaks a few hours before menses. Patients may also experience nausea and vomiting, fatigue, diarrhea, and headache.

Uterine leiomyomas

If these tumors twist or degenerate after circulatory occlusion or infection or if the uterus contracts in an attempt to expel them, they may cause constant or intermittent lower abdominal pain that worsens with menses. Associated signs and symptoms include backache, constipation, menorrhagia, and urinary frequency or retention. Palpation may reveal the tumor mass and an enlarged uterus. The tumors are almost always nontender.

Other causes

Intrauterine devices

These devices may cause severe cramping and heavy menstrual flow.

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Vaginal discharge: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Atrophic vaginitis

In this disorder, a scant, watery white vaginal discharge may be accompanied by pruritus, burning, tenderness, and bloody spotting after coitus or douching. Sparse pubic hair, a pale vagina with decreased rugae and small hemorrhagic spots, clitoral atrophy, and shrinking of the labia minora may also occur.

Bacterial Vaginosis

This infection, caused by Gardnerella vaginalis (formerly called Haemophilus vaginalis), results from an ecozogic disturbance of the vaginal flora. It produces a thin, foul-smelling, green or gray-white discharge that adheres to the vaginal walls and can be easily wiped away, leaving healthy-looking tissue. Pruritus, redness, and other mild signs of vaginal irritation may also occur.

Candidiasis

Infection with Candida albicans causes a profuse, white, curdlike discharge with a yeasty, sweet odor. Onset is abrupt, usually just before menses or during a course of antibiotics. Exudate may be lightly attached to the labia and vaginal walls and is commonly accompanied by vulvar redness and edema. The inner thighs may be covered with a fine red dermatitis and weeping erosions. Intense labial itching and burning may also occur. Some patients experience external dysuria.

Chancroid

This rare but highly contagious sexually transmitted disease produces a mucopurulent, foul-smelling discharge and vulvar lesions that are initially erythematous and later ulcerated. Within 2 to 3 weeks, inguinal lymph nodes (usually unilateral) may become tender and enlarged, with pruritus, suppuration, and spontaneous drainage of nodes. Headache, malaise, and a fever as high as 102.2° F (39° C) are common.

Chlamydial infection

This infection causes a yellow, mucopurulent, odorless or acrid vaginal discharge. Other findings include dysuria, dyspareunia, and vaginal bleeding after douching or coitus, especially after menses. Many women, however, remain asymptomatic.

Endometritis

A scant serosanguineous discharge with a foul odor can result from bacterial invasion of the endometrium. Associated findings include fever, low back and abdominal pain, abdominal muscle spasm, malaise, dysmenorrhea, and an enlarged uterus.

Genital warts

These mosaic, papular vulvar lesions can cause a profuse mucopurulent vaginal discharge, which may be foul smelling if the warts are infected. Patients commonly complain of burning or paresthesia in the vaginal introitus.

Gonorrhea

Although 80% of women with gonorrhea are asymptomatic, others have a foul-smelling yellow or green discharge that can be expressed from Bartholin’s or Skene’s ducts. Other findings include dysuria, urinary frequency and incontinence, bleeding, and vaginal redness and swelling. Severe pelvic and lower abdominal pain and fever may develop.

Gynecologic cancer

Endometrial or cervical cancer produces a chronic, watery, bloody or purulent vaginal discharge that may be foul smelling. Other findings include abnormal vaginal bleeding and, later, weight loss; pelvic, back, and leg pain; fatigue; urinary frequency; and abdominal distention.

Herpes simplex (genital)

A copious mucoid discharge results from this disorder, but the initial complaint is painful, indurated vesicles and ulcerations on the labia, vagina, cervix, anus, thighs, or mouth. Erythema, marked edema, and tender inguinal lymph nodes may occur with fever, malaise, and dysuria.

Trichomoniasis

This infection can cause a foul-smelling discharge, which may be frothy, green-yellow, and profuse or thin, white, and scant. Other findings include pruritus; an inflamed, erythematous vagina with tiny petechiae; dysuria and urinary frequency; dyspareunia; postcoital spotting; and menorrhagia or dysmenorrhea. About 70% of patients are asymptomatic.

Other causes

Contraceptive creams and jellies

These products can increase vaginal secretions.

Drugs

Drugs that contain estrogen, including hormonal contraceptives, can cause a mucoid vaginal discharge. Antibiotics such as tetracycline may increase the risk of a candidal vaginal infection and associated discharge.

Radiation therapy

Irradiation of the reproductive tract can cause a watery, odorless vaginal discharge.

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Abdominal/Pelvic Mass: Differential Overview
(Field Guide to Bedside Diagnosis)

Abdominal Mass

❑ Liver enlargement

❑ Spleen enlargement

❑ Fecal mass

❑ Diverticulitis

❑ Colon cancer

❑ Gallbladder enlargement

❑ Pancreatic pseudocyst

❑ Crohn disease

❑ Abdominal aortic aneurysm

❑ Renal enlargement

Pelvic Mass

❑ Distended bladder

❑ Pregnant uterus

❑ Salpingitis

❑ Ovarian cyst

❑ Uterine fibromyoma

❑ Ovarian cancer

❑ Endometrial cancer

❑ Ectopic pregnancy

❑ Malignant deposit

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Vaginal Discharge: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Physiologic discharge

❑ Candida vulvovaginitis

❑ Bacterial vaginosis

❑ Trichomonas vaginitis

❑ Atrophic vaginitis

❑ Irritant dermatitis

❑ Gonorrheal cervicitis

❑ Chlamydial cervicitis

❑ Herpes simplex

❑ Cervical cancer

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Pelvic inflammatory disease: Causes
(Handbook of Diseases)

PID can result from infection with aerobic or anaerobic organisms. The aerobic organism Neisseria gonorrhoeae is its most common cause because it readily penetrates the bacteriostatic barrier of cervical mucus.

Normally, cervical secretions have a protective and defensive function. Therefore, conditions or procedures that alter or destroy cervical mucus (including conization or cauterization of the cervix) impair this bacteriostatic mechanism and allow bacteria present in the cervix or vagina to ascend into the uterine cavity.

Uterine infection can also follow the transfer of contaminated cervical mucus into the endometrial cavity by instrumentation. Consequently, PID can follow insertion of an intrauterine device (IUD), use of a biopsy curet or an irrigation catheter, or tubal insufflation. Other predisposing factors include abortion, pelvic surgery, and infection during or after pregnancy.

Bacteria may also enter the uterine cavity through the bloodstream or in drainage from a chronically infected fallopian tube, pelvic abscess, ruptured appendix, diverticulitis of the sigmoid colon, or other infectious foci.

The most common bacteria found in cervical mucus are staphylococci, streptococci, diphtheroids, chlamydiae, and coliforms, including Pseudomonas and Escherichia coli.

Uterine infection can result from one or several of these organisms or it may follow the multiplication of normally nonpathogenic bacteria in an altered endometrial environment. Bacterial multiplication is most common during parturition, because the endometrium is atrophic, quiescent, and not stimulated by estrogen.

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Vaginal discharge: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Atrophic vaginitis

With atrophic vaginitis, a thin, scant, watery white vaginal discharge may be accompanied by pruritus, burning, tenderness, and bloody spotting after coitus or douching. Sparse pubic hair, a pale vagina with decreased rugae and small hemorrhagic spots, clitoral atrophy, and shrinking of the labia minora may also occur.

Bacterial vaginosis

Bacterial vaginosis results in a thin, foul-smelling, green or gray-white discharge that adheres to the vaginal walls and can be easily wiped away, leaving healthy-looking tissue. Pruritus, redness, and other signs of vaginal irritation may occur but are usually minimal.

Candidiasis

Infection with Candida albicans causes a profuse, white, curdlike discharge with a yeasty, sweet odor. Onset is abrupt, usually just before menses or during a course of antibiotics. Exudate may be lightly attached to the labia and vaginal walls and is commonly accompanied by vulvar redness and edema. The inner thighs may be covered with a fine, red dermatitis and weeping erosions. Intense labial itching and burning may also occur. Some patients experience external dysuria.

Chlamydial infection

A chlamydial infection causes a yellow, mucopurulent, odorless, or acrid vaginal discharge. Other findings include dysuria, dyspareunia, and vaginal bleeding after douching or coitus, especially following menses. Many women remain asymptomatic.

Endometritis

A scant, serosanguineous discharge with a foul odor can result from bacterial invasion of the endometrium. Associated findings include fever, lower back and abdominal pain, abdominal muscle spasm, malaise, dysmenorrhea, and an enlarged uterus.

Genital warts

Genital warts are mosaic, papular vulvar lesions that can cause a profuse, mucopurulent vaginal discharge, which may be foul-smelling if the warts are infected. Patients with genital warts frequently complain of burning or paresthesia in the vaginal introitus.

Gonorrhea

Although 80% of women with gonorrhea are asymptomatic, others have a yellow or green, foul-smelling discharge that can be expressed from Bartholin’s or Skene’s ducts. Other findings include dysuria, urinary frequency and incontinence, bleeding, and vaginal redness and swelling. Severe pelvic and lower abdominal pain and fever may develop.

Gynecologic cancer

Endometrial or cervical cancer produces a chronic, watery, bloody or purulent vaginal discharge that may be foul-smelling. Other findings include abnormal vaginal bleeding and, later, weight loss; pelvic, back, and leg pain; fatigue; urinary frequency; and abdominal distention.

Herpes simplex (genital)

A copious mucoid discharge results from genital herpes, but the initial complaint is painful, indurated vesicles and ulcerations on the labia, vagina, cervix, anus, thighs, or mouth. Erythema, marked edema, and tender inguinal lymph nodes may occur with fever, malaise, and dysuria.

Trichomoniasis

Trichomoniasis can cause a foul-smelling discharge, which may be frothy, green-yellow, and profuse or thin, white, and scant. Other findings include pruritus; a red, inflamed vagina with tiny petechiae; dysuria and urinary frequency; and dyspareunia, postcoital spotting, menorrhagia, or dysmenorrhea. About 70% of patients are asymptomatic.

Other causes

Contraceptive creams and jellies

These products can increase vaginal secretions.

Drugs

Drugs that contain estrogen, including hormonal contraceptives, can cause increased mucoid vaginal discharge. Antibiotics, such as tetracycline, may increase the risk of a candidal vaginal infection and discharge.

Radiation therapy

Irradiation of the reproductive tract can cause a watery, odorless vaginal discharge.

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Vaginal Discharge: Principal Causes of Vaginal Discharge
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

1. Prepubertalonset
   1. Physiologicleukorrhea
   2. Vulvovaginitis
      1. Nonspecificcauses
      2. Specific infections
   3. Foreign body
2. Pubertal and postpubertal onset
   1. Physiologicleukorrhea
   2. Vulvovaginitis
      1. Nonspecificcauses
      2. Specific infections
         1. Bacterialvaginosis
         2. Candida species
         3. Trichomonas vaginalis
         4. Herpes simplex virus
   3. Cervicitis
      1. Chlamydia trachomatis
      2. Neisseria gonorrhoeae
   4. Pelvic inflammatory disease
   5. Foreign body

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Dysmenorrhea: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Adenomyosis.In adenomyosis, endometrial tissue invades the myometrium, resulting in severe dysmenorrhea with pain radiating to the back or rectum, menorrhagia, and a symmetrically enlarged, globular uterus that's usually softer on palpation than a uterine myoma.

Cervical stenosis.Cervical stenosis causes dysmenorrhea and scant or absent menstrual flow.

Endometriosis.Endometriosis typically produces steady, aching pain that begins before menses and peaks at the height of menstrual flow; however, the pain may also occur between menstrual periods. The pain may arise at the endometrial deposit site or may radiate to the perineum or rectum. Associated signs and symptoms include premenstrual spotting, dyspareunia, infertility, nausea and vomiting, painful defecation, and rectal bleeding and hematuria during menses. A tender, fixed adnexal mass is usually palpable on bimanual examination.

Pelvic inflammatory disease.Chronic uterine infection produces dysmenorrhea accompanied by a fever; malaise; foul-smelling, purulent vaginal discharge; menorrhagia; dyspareunia; severe abdominal pain; nausea and vomiting; and diarrhea. A pelvic examination may reveal cervical motion tenderness and bilateral adnexal tenderness.

PMS.The cramping pain of PMS usually begins with menstrual flow and persists for several hours or days, diminishing with decreasing flow. Common associated effects precede menses by several days to 2 weeks: abdominal bloating, breast tenderness, palpitations, diaphoresis, flushing, depression, and irritability. Other findings include nausea, vomiting, diarrhea, and a headache. Because PMS usually follows an ovulatory cycle, it rarely occurs during the first 12 months of menses, which may be anovulatory.

Primary (idiopathic) dysmenorrhea.Increased prostaglandin secretion intensifies uterine contractions, apparently causing mild to severe spasmodic cramping pain in the lower abdomen, which radiates to the sacrum and inner thighs. The cramping abdominal pain peaks a few hours before menses. Patients may also experience nausea and vomiting, fatigue, diarrhea, and a headache.

Uterine leiomyomas.If these tumors twist or degenerate after circulatory occlusion or infection or if the uterus contracts in an attempt to expel them, the tumors may cause constant or intermittent lower abdominal pain that worsens with menses. Associated signs and symptoms include backache, constipation, menorrhagia, and urinary frequency or retention. Palpation may reveal the tumor mass and an enlarged uterus. The tumors are almost always nontender.

Other causes

Intrauterine devices (IUDs).IUDs may cause severe cramping and heavy menstrual flow.

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Vaginal discharge: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Atrophic vaginitis.With atrophic vaginitis, a thin, scant, watery white vaginal discharge may be accompanied by pruritus, burning, tenderness, and bloody spotting after coitus or douching. Sparse pubic hair, a pale vagina with decreased rugae and small hemorrhagic spots, clitoral atrophy, and shrinking of the labia minora may also occur.

Bacterial vaginosis.Bacterial vaginosis causes a thin, foul-smelling, green or gray-white discharge, it adheres to the vaginal walls and can be easily wiped away, leaving healthy-looking tissue. Pruritus, redness, and other signs of vaginal irritation may occur but are usually minimal.

Candidiasis.Infection with Candida albicans causes a profuse, white, curdlike discharge with a yeasty, sweet odor. Onset is abrupt, usually just before menses or during a course of antibiotics. Exudate may be lightly attached to the labia and vaginal walls and is commonly accompanied by vulvar redness and edema. The inner thighs may be covered with a fine, red dermatitis and weeping erosions. Intense labial itching and burning may also occur. Some patients experience external dysuria.

Chancroid.Chancroid produces a mucopurulent, foul-smelling discharge and vulvar lesions that are initially erythematous and later ulcerated. Within 2 to 3 weeks, inguinal lymph nodes (usually unilateral) may become tender and enlarged, with pruritus, suppuration, and spontaneous drainage of nodes. Headache, malaise, and fever to 102.2° F (39° C) are common.

Chlamydial infection.Chlamydial infection causes a yellow, mucopurulent, odorless, or acrid vaginal discharge. Other findings include dysuria, dyspareunia, and vaginal bleeding after douching or coitus, especially following menses. Many women remain asymptomatic.

Endometritis.A scant, serosanguineous discharge with a foul odor can result from bacterial invasion of the endometrium. Associated findings include fever, lower back and abdominal pain, abdominal muscle spasm, malaise, dysmenorrhea, and an enlarged uterus.

Genital warts.Genital warts are mosaic, papular vulvar lesions that can cause a profuse, mucopurulent vaginal discharge, which may be foul-smelling if the warts are infected. Patients frequently complain of burning or paresthesia in the vaginal introitus.

Gonorrhea.Although 80% of women with gonorrhea are asymptomatic, others have a yellow or green, foul-smelling discharge that can be expressed from Bartholin's or Skene's ducts. Other findings include dysuria, urinary frequency and incontinence, bleeding, and vaginal redness and swelling. Severe pelvic and lower abdominal pain and fever may develop.

Gynecologic cancer.Endometrial or cervical cancer produces a chronic, watery, bloody or purulent vaginal discharge that may be foul-smelling. Other findings include abnormal vaginal bleeding and, later, weight loss; pelvic, back, and leg pain; fatigue; urinary frequency; and abdominal distention.

Herpes simplex (genital).A copious mucoid discharge results from genital herpes simplex, but the initial complaint is painful, indurated vesicles and ulcerations on the labia, vagina, cervix, anus, thighs, or mouth. Erythema, marked edema, and tender inguinal lymph nodes may occur with fever, malaise, and dysuria.

Trichomoniasis.Trichomoniasis can cause a foul-smelling discharge, which may be frothy, green-yellow, and profuse or thin, white, and scant. Other findings include pruritus; a red, inflamed vagina with tiny petechiae; dysuria and urinary frequency; and dyspareunia, postcoital spotting, menorrhagia, or dysmenorrhea. About 70% of patients are asymptomatic.

Other causes

Contraceptive creams and jellies.Contraceptive creams and jellies increase vaginal secretions.

Drugs.Drugs that contain estrogen, including hormonal contraceptives, can cause increased mucoid vaginal discharge. Antibiotics, such as tetracycline, may increase the risk of a candidal vaginal infection and discharge.

Radiation therapy.Irradiation of the reproductive tract can cause a watery, odorless vaginal discharge.

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Pelvic Inflammatory Disease as a complication of other conditions:

Other conditions that might have Pelvic Inflammatory Disease as a complication may, potentially, be an underlying cause of Pelvic Inflammatory Disease. Our database lists the following as having Pelvic Inflammatory Disease as a complication of that condition:

• Bacterial vaginosis
• Chlamydia
• Gonorrhea
• HIV/AIDS
• Sexually Transmitted Diseases

Pelvic Inflammatory Disease as a symptom:

Conditions listing Pelvic Inflammatory Disease as a symptom may also be potential underlying causes of Pelvic Inflammatory Disease. Our database lists the following as having Pelvic Inflammatory Disease as a symptom of that condition:

• HIV/AIDS
• The clap

What causes Pelvic Inflammatory Disease?

Causes: Pelvic Inflammatory Disease: Vaginal infection going back up the female sexual tract; often occurs during menstruation.
PID occurs when bacteria move upward from a woman's vagina or cervix into the internal reproductive organs. Sexually active women in their childbearing years are most at risk. Many different organisms can cause PID, but most cases are associated with gonorrhea and chlamydia, two very common bacterial STDs. It is estimated that 10% to 80% of women with either of these STDs will develop symptomatic PID. (Source: excerpt from PID: DSTD)
Article excerpts about the causes of Pelvic Inflammatory Disease:

Pelvic Inflammatory Disease, NIAID Fact Sheet: NIAID (Excerpt)

PID occurs when disease-causing organisms migrate upward from the urethra and cervix into the upper genital tract. Many different organisms can cause PID, but most cases are associated with gonorrhea and genital chlamydial infections, two very common STDs. Scientists have found that bacteria normally present in small numbers in the vagina and cervix also may play a role.

Investigators are learning more about how these organisms cause PID. The gonococcus, Neisseria gonorrhea, probably travels to the fallopian tubes, where it causes sloughing (casting out) of some cells and invades others. Researchers think it multiplies within and beneath these cells. The infection then may spread to other organs, resulting in more inflammation and scarring.

Chlamydia trachomatis and other bacteria may behave in a similar manner. Researchers do not know how other bacteria that normally inhabit the vagina (e.g., organisms such as Gardnerella vaginalis and Bacteroides) gain entrance into the upper genital tract. The cervical mucus plug and secretions may help prevent the spread of microorganisms to the upper genital tract, but it may be less effective during ovulation and menses. In addition, the gonococcus may gain access more easily during menses, if menstrual blood flows backward from the uterus into the fallopian tubes, carrying the organisms with it. This may explain why symptoms of PID caused by gonorrhea often begin immediately after menstruation as opposed to any other time during the menstrual cycle. It is noteworthy that the co-incidence of menses and chlamydial infection is not a prominent feature of chlamydial PID.

Symptoms

The major symptoms of PID are lower abdominal pain and abnormal vaginal discharge. Other symptoms such as fever, pain in the right upper abdomen, painful intercourse, and irregular menstrual bleeding can occur as well. PID, particularly when caused by chlamydial infection, may produce only minor symptoms or no symptoms at all, even though it can seriously damage the reproductive organs.

Risk Factors for PID

• Women with STDs – especially gonorrhea and chlamydial infection – are at greater risk of developing PID; a prior episode of PID increases the risk of another episode because the body’s defenses are often damaged during the initial bout of upper genital tract infection.
• Sexually active teenagers are more likely to develop PID than are older women.
• The more sexual partners a woman has, the greater her risk of developing PID.

Recent data indicate that women who douche once or twice a month may be more likely to have PID than those who douche less than once a month. Douching may push bacteria into the upper genital tract. Douching also may ease discharge caused by an infection, so the woman delays seeking health care.

Diagnosis

PID can be difficult to diagnose. If symptoms such as lower abdominal pain are present, the doctor will perform a physical exam to determine the nature and location of the pain. The doctor also should check the patient for fever, abnormal vaginal or cervical discharge, and evidence of cervical chlamydial infection or gonorrhea. If the findings of this exam suggest that PID is likely, current guidelines advise doctors to begin treatment.

If more information is necessary, the doctor may order other tests, such as a sonogram, endometrial biopsy, or laparoscopy to distinguish between PID and other serious problems that may mimic PID. Laparoscopy is a surgical procedure in which a tiny, flexible tube with a lighted end is inserted through a small incision just below the navel. This procedure allows the doctor to view the internal abdominal and pelvic organs, as well as take specimens for cultures or microscopic studies, if necessary.

Treatment

Because culture of specimens from the upper genital tract are difficult to obtain and because multiple organisms may be responsible for an episode of PID, especially if it is not the first one, the doctor will prescribe at least two antibiotics that are effective against a wide range of infectious agents. The symptoms may go away before the infection is cured. Even if symptoms do go away, patients should finish taking all of the medicine. Patients should be re-evaluated by their physicians two to three days after treatment is begun to be sure the antibiotics are working to cure the infection.

About one-fourth of women with suspected PID must be hospitalized. The doctor may recommend this if the patient is severely ill; if she cannot take oral medication and needs intravenous antibiotics; if she is pregnant or is an adolescent; if the diagnosis is uncertain and may include an abdominal emergency such as appendicitis; or if she is infected with HIV (human immunodeficiency virus, the virus that causes AIDS).

Many women with PID have sex partners who have no symptoms, although their sex partners may be infected with organisms that can cause PID. Because of the risk of reinfection, however, sex partners should be treated even if they do not have symptoms.

Consequences of PID

Women with recurrent episodes of PID are more likely than women with a single episode to suffer scarring of the tubes that leads to infertility, tubal pregnancy, or chronic pelvic pain. Infertility occurs in approximately 20 percent of women who have had PID.

Most women with tubal infertility, however, never have had symptoms of PID. Organisms such as C. trachomatis can silently invade the fallopian tubes and cause scarring, which blocks the normal passage of eggs into the uterus.

A women who has had PID has a six-to-tenfold increased risk of tubal pregnancy, in which the egg can become fertilized but cannot pass into the uterus to grow. Instead, the egg usually attaches in the fallopian tube, which connects the ovary to the uterus. The fertilized egg cannot grow normally in the fallopian tube. This type of pregnancy is life-threatening to the mother, and almost always fatal to her fetus. It is the leading cause of pregnancy-related death in African-American women.

In addition, untreated PID can cause chronic pelvic pain and scarring in about 20 percent of patients. These conditions are difficult to treat but are sometimes improved with surgery.

Another complication of PID is the risk of repeated attacks of PID. As many as one-third of women who have had PID will have the disease at least one more time. With each episode of reinfection, the risk of infertility is increased.

Prevention

Women can play an active role in protecting themselves from PID by taking the following steps:

• Signs of discharge with odor or bleeding between cycles could mean infection. Early treatment may prevent the development of PID.
• If used correctly and consistently, male latex condoms will prevent transmission of gonorrhea and partially protect against chlamydial infection.

Research

Although much has been learned about the biology of the microbes that cause PID and the ways in which they damage the body, there is still much to learn. Scientists supported by the National Institute of Allergy and Infectious Diseases (NIAID) are studying the effects of antibiotics, hormones, and substances that boost the immune system. These studies may lead to insights about how to prevent infertility or other complications of PID. Topical microbicides and vaccines to prevent gonorrhea and chlamydial infection also are being developed. Clinical trials are in progress to test a suppository containing lactobacilli – the normal bacteria found in the vaginas of healthy women. These bacteria colonize the vagina and may be associated with reduced risk of gonorrhea and bacterial vaginosis, both of which can cause PID.

Rapid, inexpensive, easy-to-use diagnostic tests are being developed to detect chlamydial infection and gonorrhea. A recent study conducted by NIAID-funded researchers demonstrated that screening and treating women who unknowingly had chlamydial infection reduced cases of PID by more than 60 percent. Meanwhile, researchers continue to search for better ways to detect PID itself, particularly in women with "silent" or asymptomatic PID.

(Source: excerpt from Pelvic Inflammatory Disease, NIAID Fact Sheet: NIAID)

Pelvic Inflammatory Disease: NWHIC (Excerpt)

PID occurs when disease-causing organisms migrate upwards from the vagina and cervix into the upper genital tract. Many different organisms can cause PID, but most cases are associated with gonorrhea and chlamydial infections, two very common STDs. Scientists have found that bacteria normally present in the vagina and cervix may also play a role. (Source: excerpt from Pelvic Inflammatory Disease: NWHIC)

Medical news summaries relating to Pelvic Inflammatory Disease:

The following medical news items are relevant to causes of Pelvic Inflammatory Disease:

• Common, but silent STD

Related information on causes of Pelvic Inflammatory Disease:

As with all medical conditions, there may be many causal factors. Further relevant information on causes of Pelvic Inflammatory Disease may be found in:

• Risk factors for Pelvic Inflammatory Disease
• Contagiousness for Pelvic Inflammatory Disease
• Hidden causes of Pelvic Inflammatory Disease

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