Prevention of Pelvic Inflammatory Disease: A Case Study of Bwari Local Government Area, FCT

Prevention of Pelvic Inflammatory Disease: A Case Study of Bwari Local Government Area, FCT

Chapter One

Aim and Objectives

Aim:

The aim of this study is to determine the prevention of pelvic inflammatory disease and associated factors among undergraduates attending Bwari General Hospital in order to institute preventive measures through health education that might lead to behavioral change among this vulnerable group to reduce the scourge of the disease and its attendant sequelae.

Specific Objectives:

The specific objectives of the study were

To determine the prevalence of pelvic inflammatory disease among undergraduates attending Bwari General Hospital.
To identify risk factors for the development of pelvic inflammatory disease among undergraduates attending BGH from clinical assessment.
To ascertain if there is association between the identified risk factors and the prevention of pelvic inflammatory disease in the study population.

CHAPTER TWO

LITERATURE REVIEW

Definition

Pelvic Inflammatory Disease (PID) was defined by Sweet²⁵ as a disease which manifests with a spectrum of upper genital tract infections that include endometritis, salpingitis, tubo-ovarian abscess and/or pelvic peritonitis and is associated with lower genital tract inflammation. This definition is in tandem with that of the Centre for Disease Control and Prevention (CDC)⁶ and that of Evans, Jaleel and Kinsella²⁶ which defined PID as ascending infection of the upper genital tract from the vagina and cervix and includes endometritis, salpingitis, tubo- ovarian abscess and/or pelvic peritonitis.

Li and McDermott²⁷ defined PID as inflammation of the upper genital tract including the endometrium, fallopian tubes and/or contiguous structures that follow infection from micro- organisms that ascend from the cervix and/or vagina.

Soper¹¹ defined PID as an infection – caused inflammatory continuum from the cervix to the peritoneal cavity, which is most importantly, associated with fallopian tube inflammation which can lead to infertility, ectopic pregnancy and chronic pelvic pain.

Pelvic inflammatory disease has also been defined as a syndrome caused by the ascending spread of microorganisms from the vagina or the uterine cervix to the upper genital tract and including any combination of endometritis, salpingitis, tubo-ovarian abscess, or pelvic peritonitis.¹³

Bartlett, Levison and Munday²⁸ described PID as due to infection of the upper female genital tract resulting in a wide range of pelvic pathology, from mild endometritis to pelvic peritonitis caused by organisms that are either sexually transmitted (such as C trachomatis, N gonorrhoeae, Mycoplasma genitalium) or endogenous vaginal organisms (for example, Bacteroides species) that ascend into the pelvic area from the lower genital tract through the cervix.

Another definition of PID is that of Okon et al,¹ who defined PID as an infection of the upper genital tract in women that include endometritis, parametritis, salpingitis, oophoritis, tubo- ovarian abscess and peritonitis.

For the purpose of this study, PID is defined based on Shepherd’s⁴ definition as infection of the upper female genital tract comprising of endometritis, salpingitis, parametritis, oophoritis, tubo-ovarian abscess and/or pelvic peritonitis commonly due to sexually transmitted infections with Chlamydia trachomatis and Neisseria gonorrhoea arising from an ascending infection from the vagina and cervix (commonly) or through lymphatic or haematogenous spread.

Epidemiology of PID

Pelvic Inflammatory Disease is a common cause of gynaecological morbidity worldwide.^12,28,29 Over 800,000 cases of PID are diagnosed annually in the United States of America.^11,30 In the United Kingdom, PID was found to contribute to about 2% of annual visit to general practitioners.²⁶ A Jamaican study reported a PID prevalence of 17% among women of reproductive age with majority of them from low socioeconomic status.³¹ The study also found PID to be higher among those who were sexually assaulted.³¹ This is supported by another study also in Jamaica which found PID to be higher among sexually assaulted women from low socio economic status.³²

Prevalence of PID in Nigeria is high, particularly among young adults. A study done in Port Harcourt, Nigeria put the prevalence among undergraduates at 11%.⁵ Prasad et al²⁴ in a similar study reported a prevalence of 14% among young women in India. This is small compared to the study by Olowe, Alabi and Akindele¹⁰ in Osogbo, South-Western Nigeria which reported a PID prevalence of 70% and that of Okon et al,¹ in Nguru, North-Eastern

Nigeria which reported a prevalence of 62.8%. The disparity may be due to the difference in location, Port Harcourt being an urban centre as opposed to Nguru and Osogbo which are semi urban areas. Also variation in health-seeking behaviour and increased management of PID outside the hospital environment particularly in urban areas could also explain the variation as all the studies were hospital based.¹

Prevention of PID is common among sexually active women³ of childbearing age,³³ particularly adolescents¹³ and young women.^13,28 In the United States of America, however, PID is most common among adolescent girls aged 15 – 19 years.^3,34 This contrast with an English study which found PID to be most common among young women aged 20 to 24 years followed by those aged 25 to 29 years.³⁵ Okon et al,¹ in Nguru, North-Eastern Nigeria found PID to be highest among women aged 21 to 30 years. Kennedy, John and Sunny⁵ also reported similar findings with PID highest among students aged 20 – 30 years in their study among undergraduates in Port Harcourt. These findings are in line with the English study³⁵ above but differs from the American studies^3,34.

The cost of treating patients with PID is very high especially in resource poor settings like Nigeria as confirmed by a study done in Lagos, Nigeria by Suleiman and Tayo.³⁶ The study found that most of the patients with PID are in low socioeconomic status and cannot afford the high cost of treatment.

CHAPTER THREE

METHODOLOGY

Study Design

The study was a descriptive cross-sectional study.

Study Population

Sexually active female undergraduates of reproductive age (15 – 49 years) presenting to Bwari General Hospital, Bwari.

Inclusion Criteria

Female undergraduates aged 15 to 49 years,
who are sexually active,
who present to BGH and
have consented to participate in the

Exclusion Criteria

Students who were too ill to participate in the
Students with other competing diagnoses such as ectopic Patients with greater than four weeks’ history of amenorrhea were subjected to pregnancy test, and where positive, were excluded from the study. Patients with clinical findings that were highly suggestive of appendicitis or urinary tract infection were also excluded.

Students with history of pelvic surgeries such as myomectomy, salpingectomy, caesarean section.
Students who did not consent to participate in the

CHAPTER FOUR

RESULTS

Prevention of Pelvic Inflammatory Disease and associated factors among undergraduates attending Bwari General Hospital, Bwari was studied. A total of 372 female undergraduates were recruited out of which 360 consented to participate in the study. Twelve did not agree, giving a response rate of 96.8%. The 360 students who met the eligibility criteria and gave consent to participate were recruited for the study over a ten month period.

CHAPTER FIVE

DISCUSSIONS, CONCLUSION AND RECOMMENDATIONS

This study looked at the prevention of Pelvic Inflammatory Disease and associated factors among undergraduates attending Bwari General Hospital (BGH), Bwari, Abuja. It was a hospital based study conducted at the General Out-Patient Department (GOPD), Accidents and Emergency (A & E) unit and gynaecological clinic of BGH. A total of 360 respondents who were all female undergraduates from Ambrose Alli University, Ekpoma, Auchi Polytechnic, Auchi and College of Education, Igueben participated in the study.

Sociodemographic Characteristics of Patients

Majority of the respondents studied (54.4%) were aged 20 to 24 years followed by those aged 25 to 29 years who made up 27.2% of the respondents. Prevention of PID was highest among respondents aged 15 – 19 years with 73% of them having PID followed by respondents aged 20 to 24 years and 25 to 29 years with 65.8% and 58.2% of them having PID respectively. The difference between the age of respondents and prevention of PID was however not statistically significant. The findings of this study agree with findings of other studies that PID is highest among adolescents and young adults.^1,3,5,34,35 A study by Raya et al³ in Israel also found PID to be highest among girls aged 15 to 19 years. This is also similar to findings by Barrett and Taylor³⁴ that PID was commonest among girls 15 to 19 years in the UK. The study done in Nguru, North eastern Nigeria by Okon¹ found PID to be highest among young women aged 21 to 30 years. Similar findings were reported by Kennedy et al,⁵ who found PID to be highest among women in their 20s in Port Harcourt. French³⁵ in England also found PID to be highest among women aged 20 to 24 years.

Most of the respondents were single (93.9%). This is due to the fact that most female undergraduates are adolescents and young women. In Abuja, like most parts of Southern Nigeria, women commonly marry after graduation from the tertiary institution. Most undergraduates are therefore unmarried in this part of the country. The proportion of married women with PID (71.4%) was more than the proportion among those who were single (63.3%). The difference was not statistically significant. This however differed from a study by Simms et al,¹² which found PID to be significantly higher in single ladies than married ones. It however agreed with findings of Prasad et al,²³ who found PID to be higher among young married women in India compared to single ladies. The difference may be due to extra marital affairs on the part of either of the partners,²³ or the practice of polygamy which is accepted by most cultures in Nigeria and therefore a common practice in the country.¹⁶ Majority of the respondents were of “Esan” tribe (45.3%) followed by Afenmai (34.4%). This is due to the fact that the hospital and two of the schools (Ambrose Alli University, Ekpoma and College of Education, Igueben) are in Esan land while the third (Auchi Polytechnic, Auchi) is in Etsako. Students from other parts of Abuja and Nigeria also attend these institutions as can be seen in the ethnicity of the patients.

Most of the students were from Ambrose Alli University, Ekpoma. The high number of respondents with PID among university undergraduates compared to those from Polytechnic and College of Education may be due to the fact that, of the three schools, it is the closest to the hospital hence patients from the school will access care more from this hospital compared to students from the other institutions who will have to consider cost and will therefore come to the hospital when it becomes really necessary. However, the proportion of PID from Polytechnic students was higher than those from the University and College of Education. The increase, like that of the Muslims, could be due to the distance of the polytechnic from the study location compared to the other schools, necessitating presentation of serious or chronic cases that could not be managed in Auchi among other reasons. There was, however, no statistically significant relationship between prevention of PID and type of institution attended (p = 0.28).

Sponsorship was mainly from parents (89.2%). However, respondents were more among students who got less money from their parents (less than N10, 000) (58.3%) compared to those who got more. These students with less allowance are more likely to engage in sex for monetary gains as a way of supplementing what they got from their parents.⁶

Socioeconomic Characteristics of Parents

Half of the respondents were from parents with low socioeconomic status (53.3%). Simms et al¹² and Dehne²¹ in separate studies found PID to be highest among ladies with low socioeconomic status. The World Health Organisation¹⁹ also recognises low socioeconomic status as a risk factor for PID. Suleiman³⁶ and Isibor⁴⁶ in separate studies in Lagos and Bwari, respectively found PID to be highest among women of low social class. The increased prevalence of PID among women of low social class have been attributed to, among other things, their inability to access standard medical care when they have sexually transmitted infection thus aiding its progression to PID.³⁶

This study was however at variance with the above studies as it did not find any significant association between the prevention of PID and the socioeconomic status of parents of the respondents (p = 0.14). The study also found PID to be highest among respondents whose parents were of middle socioeconomic status (67.4%) followed by those of low (65.6%) and high (53.9%) socioeconomic status respectively. The findings of this study showed that female undergraduates with PID cut across the various socioeconomic classes. This therefore means that socioeconomic status of parents cannot be used as an independent risk factor in predicting the prevention of PID among undergraduates attending Bwari General Hospital.

Clinical Features

All the respondents with PID complained of lower abdominal pain. They had varying degrees of menstrual irregularity such as dysmenorrhoea (54.2%), menorrhagia (20%), metrorrhagia (13.6%), oligomenorrhea (6.1%) and inter-menstrual bleeding (2.8%). Some of the respondents (30.3%) reported abnormal vaginal discharge while 53.3% of them experienced dyspareunia.

The examination findings were also consistent with those of clinical PID. Fever was present in 25.6% of the respondents. Fever here is defined as body temperature greater than or equal to 38.3^oC.⁶ Jaiyeba and Soper³⁷ in their study recognised a temperature greater than or equal to 38.3^oC as one of the signs of PID. This is similar to the findings of Haggerty and Ness³³ as well as the CDC guidelines⁶ for the diagnosis of PID.

Most of the respondents (63.3%) had abdominal tenderness, cervical excitation tenderness (61.9%), adnexal tenderness (55%) and uterine tenderness (23.3%). In a study by Bartlett, Levison and Munday,²⁸ diagnosis of PID was based on the presence of abdominal tenderness with or without cervical excitation tenderness or adnexal tenderness on bimanual examination. They also reported that the sensitivity of abdominal tenderness, cervical motion tenderness and adnexal tenderness when compared with diagnostic laparoscopy was 61.2%, 79.9% and 90.3% respectively.²⁸

The 229 respondents in whom diagnosis of PID was made all presented with abdominal pain and had one or more of the above clinical signs. This is in line with the recommended guidelines by CDC for clinical diagnosis of PID which states that empirical treatment for PID should be initiated in sexually active young women and other women at risk for STDs if they are experiencing pelvic or lower abdominal pain, if no cause for the illness other than PID can be identified, and if one or more of the following minimum criteria are present on pelvic examination: cervical motion tenderness or uterine tenderness or adnexal tenderness.^6,24

The other 131 patients had other clinical conditions including malaria, gastritis, respiratory tract infection, urinary tract infection, gastroenteritis, candidiasis, incomplete abortion and bartholin cyst.

Conclusion

This study found a PID prevalence of 63.6% among undergraduates attending Bwari General Hospital. Majority of these students were from low socioeconomic background with their parents mostly illiterates and mostly engaged in farming and petty trading. This was followed by those in the middle socioeconomic class whose parents had mainly secondary education and were mostly artisans, traders and intermediate civil servants. Those from high socioeconomic class whose parents were graduates and mostly civil servants were least in the study.

The study identified risk factors for the prevention of PID to include multiple sex partners, previous history of PID/STI and low barrier contraceptive (condom) use. History of induced abortion, multiple induced abortion as well as dilatation and curettage as preferred method of abortion were also identified as risk factors.

Recommendations

As family physicians, we should, as major stakeholders in the healthcare setting educate adolescent and young ladies on the dangers of PID (infertility, ectopic pregnancy and chronic pelvic pain) as well as the risk factors for the prevention of PID with a view to helping them avoid these risk factors in order to prevent PID from occurring. Our role as educators has already prepared us for this task.
Behavioural change with regard to engaging in sexual activities should be encouraged particularly among high risk populations. Such behavioural changes include the power to say no to sexual overtures, delaying sexual debut and using barrier contraception. These measures will go a long way in preventing the prevention of PID as well as unwanted pregnancies.
Promotion of safe sex (abstinence, faithfulness to partner as well as use of barrier contraception) should be done whenever the opportunity present itself such as during consultations even if the patient presents with another ailment other than PID. The family physician should use every opportunity to educate the people particularly the at risk population and promote safe sex.
Women of reproductive age, particularly young undergraduates should also be advised to present early to the hospital whenever they have symptoms of sexually transmitted infections as they commonly progress to PID if not promptly and properly treated. Prompt diagnosis and treatment of clinically suspicious PID should be instituted in line with the CDC guidelines to prevent complications from setting in.
Further studies that will include laboratory diagnosis should be done among the study population to identify patients with subclinical PID missed by this study.

REFERENCES

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Moses S. Pelvic Inflammatory Disease. Family Practice Notebook. Updated 15 April, 2012. Available at fpnotebook.com. Accessed 26 January, 2015.
Olowe OA, Alabi A, Akindele AA. Prevalence Pattern of Bacterial Isolates in Cases of Pelvic Inflammatory Disease Patients at a Tertiary Hospital in Osogbo, Nigeria. Environmental Research Journal 2012; 6(4): 308-311
Soper Pelvic inflammatory disease. Obstet Gynecol 2010; 116: 419-428
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Ugboma HAA, Nwagwu VO, Jeremiah Genital chlamydia trachomatis infection among female undergraduate students of university of Port Harcourt, Nigeria. Nigerian Medical Journal 2014; 55(1): 9-13
Fatusi A, Blum R. Predictors of early sexual initiation among a nationally representative sample of Nigerian adolescents. BMC public health. 2008; 8(1): 136.
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Ebisi The impacts of culture on the transmission of infectious diseases in Nigeria: The case of Awka south, Anambra state. African Journal of Social Sciences. 2012; 2(4): 173-190.

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