Severe PID with and without endometriosis

June 1, 2020

A retrospective cohort analysis evaluating potential associations between endometriosis and pelvic inflammatory disease (PID) confirms a significantly higher prevalence of PID in endometriosis patients.

Intraoperative findings of PID with associated endometriosis also indicated more aggressive patterns.

The analysis in the Journal of Gynecology, Obstetrics and Human Reproduction comprised a sample size culled from 17,016 consecutive laparoscopies performed between January 2004 and June 2018 in the Department of Obstetrics and Gynecology at IRCCS Sacro Cuore Don Calabria Hospital, a tertiary care reference center for endometriosis in Negrar (Verona), Italy. Analysis was based on medical records and insurance coding.

The sample size needed was 376 for a confidence interval (CI) of 5% and 263 for a CI of 6%. In total, 311 women had surgery for PID and tubo-ovarian abscess (TOA). All of these patients underwent surgery after antibiotics therapy was judged ineffective.

The laparoscopies were performed in the modified dorsal lithotomy position under endotracheal general anesthesia, and a nasogastric probe was routinely used.

The women were divided into two groups: Group 1 were those who had an intraoperative diagnosis of only PID (n = 115; median age 35), whereas Group 2 were those with both PID and endometriosis (n = 196; median age 33).

Endometriosis had a prevalence of 63% in patients submitted to surgery for PID, which is significantly higher than the 6% to 15% reported in the general population, and even higher than reported for the hospital’s tertiary care endometriosis unit. The study also found a higher risk of being operated on for PID, if there was a concomitant endometriosis diagnosis (x2 = 20.769; P < 0.0001).

In Group 2, 175 of the 196 patients required eradication of deep endometriosis, while the remaining 21 patients underwent a second procedure.

Concerning fertility, a significantly higher number of unilateral and bilateral salpingectomies were needed in Group 2 patients: 208 versus 80; P < 0.0001). “This might reflect a previous undiagnosed impairment of the tubal anatomy due to endometriosis, over which the acute infective and inflammatory pathology acts in an unrecoverable fashion,” wrote the Italian authors.

Hospital stays were significantly longer in patients with both endometriosis and PID compared to PID-only patients: median 7 days vs. 4 days (P < 0.01). However, the number of procedures converted to laparotomy was similar for the two groups: one patient in Group 1 and two patients in Group 2.

The difference in the total number of complications between the two groups also was not statistically significant (P = 0.08). But there were significantly more bowel complications in Group 1 than in Group 2: 6 vs. 0 (P = 0.05). Four of the six patients had bowel perforations within 7 days after their first procedure, thus requiring reintervention and ileostomy, whereas the other two patients reported a bowel occlusion needing reintervention with adhesiolysis. There were also significantly more urinary complications in Group 1: again, 6 vs. 0 in Group 2 (P = 0.05).

The authors said future research should focus on finding “possible relationships between altered microbiota and endometriosis in order to act on a prevention field and perform surgery in a targeted fashion.”


Clarizia R, Capezzuoli T, Ceccarello M, et al. Inflammation calls for more: Severe pelvic inflammatory disease with or without endometriosis. Outcomes on 311 laparoscopically treated women [published online ahead of print, 2020 May 17]. J Gynecol Obstet Hum Reprod. 2020;101811. doi:10.1016/j.jogoh.2020.101811