Clinical Practice Guideline

for

PELVIC INFLAMMATORY DISEASE

Developed for the

Aerospace Medical Association

by their constituent organization

American Society of Aerospace Medicine Specialists

 

Overview: Pelvic Inflammatory Disease (PID) refers to the clinical syndrome, unrelated to pregnancy or surgery that result when cervical microorganisms ascend to the endometrium, fallopian tubes, and adjacent pelvic structures.  Inflammation of pelvic organs results in one or more of the following: endometritis, salpingitis, pelvic peritonitis, or tubovarian abscess.  Each year as many as 1 million women in the United States experience an episode of symptomatic PID.  PID results from the spread of organisms from the endocervix to the mucosa of the endometrium and fallopian tubes.  N. gonorrhea and C. trachomatis both commonly cause endocervicitis, with up to 40% of inadequately treated females subsequently developing symptoms of PID.  Despite improvements in decreasing the incidence of N. gonorrhea, there are over 4 million cases of C. trachomatis each year in the United States alone.  A recent study in Korea revealed a prevalence of C. trachomatis infection of 8% among asymptomatic active duty military females.  Risk factors for PID include young age, history of multiple sexual partners, and new partners within the previous 30 days.

 

Aeromedical Concerns: Flight surgeons need to have a strong incidence of suspicion for pelvic inflammatory disease.  Intrauterine devices, strongly advocated by some physicians for deployed military females, increase the risk of perihepatitis (Fitz-Hugh-Curtis syndrome) in women infected with C. trachomatis.  Aeromedical concerns include distraction from flying duties secondary to pain, discomfort with restraining/escape devices or, in severe cases, collapse.  The prognosis for those women who have been adequately treated is excellent, however a large percentage of women with a history of PID have subsequent fertility problems.

 

Medical Work-up: Adequate treatment may require hospitalization and intravenous antibiotics, and most cases respond to adequate treatment.  Surgical treatment of complications, including adhesions may be needed.  Outpatient management remains controversial, but many authorities feel outpatient care should be limited to those who remain afebrile, have WBC<11,000mm3, have minimal evidence of peritonitis, active bowel sounds and can tolerate oral nourishment.  Zithromycin 1 gram p.o. may be used in lieu of Doxycycline (100mg po bid x 7-10 days).  Rocephin 250 mg IM is also recommended for N. gonorrhea coverage.  Obviously any sexual partners should be treated as well.

 

Aeromedical Disposition (military): GYN consultation may be advisable.  Chronic pelvic pain, which may be a possible sequela, should have GYN consultation.  Endometriosis and other causes need to be identified.  Concerns for ectopic pregnancy in PID should be noted.

 

Aeromedical Disposition (civilian): For the granting of medical certification in the civilian sector the airman with PID should be off any sedating or narcotic analgesics.  The airman should be symptom free when placed back on flight status.  A report from the treating physician is required.  Any sequelae would be evaluated on a case-by-case basis.  Generally, there is no problem gaining full medical certification privileges after adequate treatment.  The Aviation Medical Examiner is not required to report this condition until the time of the next examination. 

 

Waiver Experience (military): Acute infection is cause for grounding in the military, but a history of PID is not disqualifying.  To be considered for a waiver, patients must be symptom free and not undergoing treatment.

 

Waiver Experience (civilian): There are no statistical data for this medical condition available at this time from the FAA.  

 

References:

 

AFI 48-123, A2.19 Complications or residuals of sexually transmitted disease, of such chronicity or degree of severity the individual is incapable of performing duty. Page 86.

 

Baumgardner, DJ. Abdominal Pain: Chlamydia as a culprit. Postgraduate Medicine, 1989; 85:281-8.

 

Chlamydia trachomatis genital infections—United States, MMWR, Mar 7, 1997;46 (9):193-8

 

Hiatt, JR. Management of the acute abdomen. Postgraduate Medicine, 1990;87:38-51.

 

McKeon, J. Asymptomatic C. trachomatis in an active duty military female population, unpublished report.

 

Mead, PP. Infections of the Female Pelvis, In: Principles and Practice of Infectious Diseases, 4th Ed. Churchill Livingstone, 1995.

 

Recommendations for the Prevention and Management of Chlamydia trachomatis infections, 1993. MMWR, Aug 6, 1993; 42(RR-12):1-37.

 

 

November 19, 2002