OCCURRENCE OF PELVIC INFLAMMATORY DISEASE AND ASSOCIATED FACTORS AMONG UNDERGRADUATES ATTENDING IRRUA SPECIALIST TEACHING HOSPITAL, IRRUA

OCCURRENCE OF PELVIC INFLAMMATORY DISEASE AND ASSOCIATED FACTORS AMONG UNDERGRADUATES ATTENDING IRRUA SPECIALIST TEACHING HOSPITAL, IRRUA

SUMMARY

Background: Pelvic Inflammatory Disease (PID) is a major cause of gynaecological morbidity globally. It is a spectrum of infections that arise commonly from the lower genitalia (vagina and cervix) and ascending to the upper genital tract causing endometritis, salpingitis, oophoritis, tubo-ovarian abscess and/or pelvic peritonitis. Complications from PID include infertility, ectopic pregnancy and chronic pelvic pain. Major risk factors for PID include low socioeconomic status, early coitarche, multiple sex partners, poor or no barrier contraceptive use, young age, history of induced abortion, low parity and past history of PID or Sexually Transmitted Infections.

Objective: The aim of this study was to determine the occurrence of PID and associated factors among undergraduates attending Irrua Specialist Teaching Hospital, Irrua.

Methodology: The study was a hospital based descriptive cross-sectional study. Three hundred and sixty undergraduates attending the General Out-Patient Department (GOPD), Accident and Emergency (A & E) and the gynaecological clinics of the hospital, irrespective of what they presented with, were consecutively selected and clinically assessed for the presence of PID using the World Health Organisation (WHO) and the Centres for Disease Control and Prevention (CDC) criteria for clinical assessment of PID. Respondents were classified as having PID if they had lower abdominal pain in addition to one or more of the following: cervical excitation tenderness, uterine tenderness or adnexal tenderness. They were also evaluated for the presence of risk factors for PID and their socioeconomic status was determined using Oyedeji’s social class tool. A semi-structured questionnaire was used to collect data. The data was analysed using epi-info statistical software and the results presented in tables, charts, frequency distribution and percentages. Chi-Square was used to test for association between occurrence of PID and presence of risk factors as well as association between socioeconomic status of parents and presence of risk factors among the study participants.

Results: Of the 360 female undergraduates studied, 229 (63.6%) had PID. Risk factors identified by the study for the occurrence of PID were multiple sex partners (p < 0.001), previous history of STI/PID (p = 0.02), non/poor condom use (p < 0.001), and history of induced abortion (p = 0.01) particularly surgical abortion via dilatation and curettage (p =

0.03). There was no association between socioeconomic status of parents and occurrence of PID (p = 0.14), though the study found PID to be highest among students in the middle socioeconomic class (67.4%). There was however a significant association between low socioeconomic class and multiple sex partners (p = 0.02), previous history of STI/PID (p = 0.05), low condom use (p < 0.001), history of induced abortion (p < 0.001) and history of repeated abortions (p < 0.001).

Conclusion: There was a high prevalence of PID among undergraduates attending Irrua

Specialist Teaching Hospital with students with multiple sex partners, previous history of STI/PID, low condom use, history of induced abortion and surgical termination of pregnancy at significantly higher risk of developing the disease. 

Recommendations: Efforts should be made to reduce the risk factors of PID in vulnerable groups through health education, promotion of safe sex and instituting measures aimed at improving living standards such as better education for the populace. 

 

SUMMARY

Background: Pelvic Inflammatory Disease (PID) is a major cause of gynaecological morbidity globally. It is a spectrum of infections that arise commonly from the lower genitalia (vagina and cervix) and ascending to the upper genital tract causing endometritis, salpingitis, oophoritis, tubo-ovarian abscess and/or pelvic peritonitis. Complications from PID include infertility, ectopic pregnancy and chronic pelvic pain. Major risk factors for PID include low socioeconomic status, early coitarche, multiple sex partners, poor or no barrier contraceptive use, young age, history of induced abortion, low parity and past history of PID or Sexually Transmitted Infections.

Objective: The aim of this study was to determine the occurrence of PID and associated factors among undergraduates attending Irrua Specialist Teaching Hospital, Irrua.

Methodology: The study was a hospital based descriptive cross-sectional study. Three hundred and sixty undergraduates attending the General Out-Patient Department (GOPD), Accident and Emergency (A & E) and the gynaecological clinics of the hospital, irrespective of what they presented with, were consecutively selected and clinically assessed for the presence of PID using the World Health Organisation (WHO) and the Centres for Disease Control and Prevention (CDC) criteria for clinical assessment of PID. Respondents were classified as having PID if they had lower abdominal pain in addition to one or more of the following: cervical excitation tenderness, uterine tenderness or adnexal tenderness. They were also evaluated for the presence of risk factors for PID and their socioeconomic status was determined using Oyedeji’s social class tool. A semi-structured questionnaire was used to collect data. The data was analysed using epi-info statistical software and the results presented in tables, charts, frequency distribution and percentages. Chi-Square was used to test for association between occurrence of PID and presence of risk factors as well as association between socioeconomic status of parents and presence of risk factors among the study participants.

Results: Of the 360 female undergraduates studied, 229 (63.6%) had PID. Risk factors identified by the study for the occurrence of PID were multiple sex partners (p < 0.001), previous history of STI/PID (p = 0.02), non/poor condom use (p < 0.001), and history of induced abortion (p = 0.01) particularly surgical abortion via dilatation and curettage (p =

0.03). There was no association between socioeconomic status of parents and occurrence of PID (p = 0.14), though the study found PID to be highest among students in the middle socioeconomic class (67.4%). There was however a significant association between low socioeconomic class and multiple sex partners (p = 0.02), previous history of STI/PID (p = 0.05), low condom use (p < 0.001), history of induced abortion (p < 0.001) and history of repeated abortions (p < 0.001).

Conclusion: There was a high prevalence of PID among undergraduates attending Irrua

Specialist Teaching Hospital with students with multiple sex partners, previous history of STI/PID, low condom use, history of induced abortion and surgical termination of pregnancy at significantly higher risk of developing the disease. 

Recommendations: Efforts should be made to reduce the risk factors of PID in vulnerable groups through health education, promotion of safe sex and instituting measures aimed at improving living standards such as better education for the populace. 

 

 

 

 

 

 

 

CHAPTER ONE

INTRODUCTION

1.1       Background of the Study

Pelvic Inflammatory Disease (PID) is a major clinical and public health problem globally accounting for 5 – 20% of hospital admissions for gynaecological problems worldwide.^1,2 It is one of the most frequent and important infections that occur among non-pregnant women of reproductive age.² It is a spectrum of infectious and inflammatory disorders of the upper female genital tract and includes endometritis, parametritis, salpingitis, oophoritis, tuboovarian abscess, and/or pelvic peritonitis.^1,3

 

 

Fig. 1: Common sites of infection in PID

 

It is caused by an ascending spread of microorganisms from the vagina or uterine cervix into the upper genital tract.^3,4 If untreated, lower genital tract infections commonly progress to PID.⁵ It is commonly associated with sexually transmitted organisms especially Neisseria gonorrhoea and Chlamydia tracchomatis⁶ and is in fact one of the most common and serious complications of sexually transmitted infections (STIs) in women.^1,2 It has however been associated also with microorganisms that comprise the vagina flora such as anaerobes, Gardnerella vaginalis, Haemophilus influenzae, enteric Gram-negative rods, and Streptococcus agalactiae.⁶ In some cases of PID, cytomegalovirus (CMV), Mycoplasma hominis, Ureoplasma urealyticum, and Mycoplasma genitalium have been implicated.⁶ When not promptly recognised and properly treated, it could lead to complications such as infertility; for example, more than 75, 000 women are reported to be infertile every year on account of PID in the United States of America (USA) accounting for 10 – 15% of infertility in the USA.^1,3 It can also lead to ectopic pregnancy, menstrual disturbances, pregnancy wastage, low birth weight babies or chronic pelvic pain.^7-9 Ovarian cancer has also been associated with PID.^1,3

Inherent defence mechanism exists to protect the upper female genital tract against microbial colonisation.^10,11 These mechanisms include the cervical mucus which serves as a mechanical barrier against ascending infection in addition to possessing antibacterial activity that protects against bacterial ascent.^10,11 Endometrial and oviductal secretions also protects the upper genitalia by washing out bacteria from the endometrium and fallopian tube respectively.¹⁰  In spite of the above inherent defensive mechanisms, pathogens still ascend to the endometrium and other structures that make up the upper genitalia causing PID.¹⁰ This may be facilitated by passive transport and through the aid of vectors such as spermatozoa and trichomoniads. Retrograde menstruation also aids the transportation of pathogens into the upper genitalia while uterine instrumentation and insertion of Intrauterine Uterine Contraceptive Device (IUCD) can inoculate the endometrium.¹⁰

Long term morbidity is associated with salpingitis much more than endometritis and cervicitis.¹¹ This is because inflammation of the fallopian tubes due to infection will lead to epithelial degeneration and deciliation of ciliated cells along the fallopian tube mucosa in association with sub mucosal inflammatory cell infilterates.¹¹ There is also tubal oedema and intraluminal agglutination causing dysfunctionality, obstruction which may be partial or total, ultimately leading to infertility or ectopic pregnancy.¹¹

Various risk factors have been associated with the occurrence of PID. These risk factors

include young age,^12-14 early coitarche,¹³ multiple sex partners,¹² previous history of sexually

transmitted infections (STI) or previous history of PID,¹⁰ inconsistent condom use,^13,15 inappropriate insertion of Intra Uterine Contraceptive Device (IUCD),¹⁶  low socioeconomic status,^6,15 induced abortion⁷ and being in school.¹⁷

Women of reproductive age are at increased risk of PID.¹² This is because most sexual activity occur during this period. The risk of developing PID is however much higher in younger women particularly those younger than 25 years compared to women in other age group.^3,12,13 It is estimated that one in five cases of PID occurs in women under the age of 19, and that one in eight adolescent females will develop PID compared to one in 80 for women older than 24 years of age.³

The high prevalence of PID among adolescents and young adults is attributable to behavioural anatomical and hormonal factors. They often engage in high-risk sexual behaviour such as having multiple sex partners, frequent and unprotected sexual intercourse and low contraceptive usage, particularly barrier contraceptive methods.³ They generally have higher number of sexual partners, higher number of concurrent partners and a higher frequency of partner change than older age groups.¹² They also do not have the skills and confidence to negotiate safer sex.¹² In addition, adolescents and young women do not commonly consider the long term effect of their risky sexual behaviours.^3,14 Most undergraduates fall into this age category.

Another factor that contributes to the high risk of acquiring PID among adolescents and young adults could be the anatomy of their developing cervix. The epithelium of their immature ectocervix is mainly columnar, exposing a relatively large surface area, which facilitates the attachment of microorganisms like C. trachomatis and N. gonorrhoeae.³ With increasing age, this columnar tissue undergoes squamous cell epithelisation which then

covers the normal adult ectocervix or simply regresses into the endocervical canal.³

Hormonal factors have also been implicated in the development of PID among adolescents and young adults. Oral contraceptives, frequently used by adolescents, interfere with the columnar-squamous cell epithelisation process and are thus considered to be a risk factor for C. trachomatis infection and PID.³ Anovulatory cycles, common after menarche, may be associated with high oestrogen levels, which facilitate cervical mucus penetration by microorganisms.³ In addition, low cervical secretory immunoglobulin A levels in the female adolescent genital tract, due to low prevalence of immunogenic triggers, may also contribute

to the adolescent's susceptibility to PID.³

Another risk factor associated with PID among women of reproductive age is having sexual debut at a young age. Early coitarche has been shown to increase the occurrence of PID.^13,14,15 Those who had sexual debut before the age of 15 years are more likely to develop PID compared to those who are 15 years and older.¹² The association between younger age and first sexual intercourse and increased risk of PID may reflect biological factors and sexual behaviour over a substantial period of time.^12,15 Young females were more likely to have their sexual initiation with significantly older partners.¹⁵ They do so seeking financial support or desiring intimate and emotional security.¹⁵ They are therefore more likely to engage in risky sexual behaviours such as poor/non condom use due to high power imbalance, as the older male partners make the sexual decisions and are more likely to have sexually transmitted infections (STIs).¹⁵ Also, early sexual intercourse is commonly associated with a higher number of lifetime sexual partners which further predisposes them to

developing PID.14,16,17

Multiple sex partners predispose women to the development of PID. The higher the number of sex partners a woman has, the higher the risk of developing PID. A higher number of concurrent partner as well as frequent partner change also significantly increase risk of PID.¹² Adolescents and young adults, who constitute majority of undergraduates, commonly have multiple sex partners which predispose them to developing PID.^3,12,18 They also have a higher number of concurrent partners as well as a higher frequency of partner change.¹² Also women whose partners are not faithful to them are also at increased risk of developing PID, especially if their partners engage in unprotected sex with other women.¹² It is important therefore that both partners must be faithful to each other as history of multiple sex partners by either the woman or her partner increases her risk of developing PID.³ Adolescents and young women from low socioeconomic backgrounds are more likely to have multiple sex partners as they succumb to unprotected sex through coercion, force, violence and

transactional reasons.¹²

Similarly, those women with previous history of PID/STI are at greater risk of developing PID.^10,13 This may be due to poor treatment leading to chronicity of the infection. It could also be due to reinfection after treatment.² Inaccurate information regarding PID and STIs among members of the public are also known risk factors for PID.^12,19 Living in an area with a high prevalence of sexually transmitted infection (STI) has been shown to increase the risk of developing PID.^5,10,12 This is because persons with PID and other STIs would easily transmit the infection to others. Thus, in a higher institution where prevalence of PID is high, the rate of spread of the infection will be high. Consequently, uninfected ladies who engage in risky sexual behaviours will easily contact the disease in such an environment.

Inconsistent use of barrier contraceptive is also a major risk for the development of PID.^12,13 Consistent condom use has been shown to significantly reduce the risk of developing PID as well as prevent unwanted pregnancy.¹⁵

Low socioeconomic status is a significant risk factor for PID.¹⁹ This is because students from poor family background are more likely to engage in risky sexual behaviour that predisposes them to PID. They do this in order to get money to augment whatever they get from their parents.¹⁸ On the other hand, students from high socioeconomic backgrounds whose financial needs are met by their parents may not engage in such activities.¹⁸ The higher incidence of PID in women of lower socioeconomic status may be due in part to a woman's lack of

education and awareness of health and disease and her accessibility to medical care.^20,21 They may also engage more in sex with older men (so called “sugar daddies”) for gifts, pocket money and school fees⁶ as majority of such girls are often responsible for their fees and even send money to their poor parents from such proceeds. These men who make the decisions that affect sexual risk almost universally do not like to use barrier contraceptives, thus sex in this vulnerable group is most likely to be unprotected.⁶ Lack of access to good health care facilities for patients with STIs from low socioeconomic backgrounds may also facilitate progression to PID in this group. They would rather patronise patent medicine dealers and quacks. They are also at higher risks of unwanted pregnancies from unprotected sex, making them engage in criminal abortion in the hands of quacks and under unsanitary conditions

further increasing their susceptibility to PID.¹⁸

The diagnosis of PID is primarily based on a history of abdominal or pelvic pain or cramping of varying intensity, new or abnormal vaginal discharge, fever or chills (which may be high grade), dyspareunia, heavy or prolonged menses or coital bleeding and clinical findings of lower genital tract inflammation associated with pelvic organ tenderness (cervical motion tenderness, uterine tenderness and adnexal tenderness).^9,19 Diagnosis of PID based on above clinical findings have been shown to have a positive predictive value of 65 – 90%.^9,21 The diagnostic criteria for PID according to the World Health Organisation (WHO) and the Centres for Disease Control and Prevention (CDC) include the presence of one or more of the following major criteria: cervical motion tenderness, uterine tenderness or adnexal tenderness

with no other apparent cause.^6,9,22

The following minor criteria are supportive but not required for the diagnosis: Fever greater than or equal to 38.3^oC, abnormal discharge per cervix or vagina, WBCs on Gram stain or

Saline of cervical swab, Gonorrhoea or Chlamydia testing positive, increased Erythrocyte Sedimentation Rate or C – reactive protein, and PID findings on diagnostic study.⁹

Most specific findings, though not required and rarely indicated unless refractory to management or unclear diagnosis: Laparoscopy findings consistent with PID which is the

Gold Standard for diagnosis, Endometrial Biopsy with histology suggestive of Endometritis, Imaging such as Transvaginal Ultrasound or Magnetic Resonance Imaging with classic findings – Thickened, fluid filled tubes, Free pelvic fluid may be present, Tubo-ovarian complex, Tubal hyperaemia on Doppler Ultrasound.⁹ The differential diagnoses include ectopic pregnancy, appendicitis, cervicitis, urinary tract infection, and adnexal tumours.⁴

1.2       Statement of the Problem

Pelvic Inflammatory Disease is said to be high among undergraduates.^5,23 This could be due to the fact that undergraduates are mostly adolescents and young adults and tend to engage in risky sexual behaviour such as having sex for pecuniary gains particularly with older partners who may be harbouring sexually transmitted infections,^18,23 have multiple sex partners, higher number of concurrent partners, higher frequency of partner change and do not have the skills and confidence to negotiate safer sex.¹² They are also less likely to use barrier contraceptives, engage in unsafe abortions, and less likely to seek standard medical intervention.^12,22 All these characteristics of the female undergraduate predispose them to the development of PID with its attendant complications later in life.

From hospital records, a good number of the patients who present to Irrua Specialist Teaching Hospital with features of PID were young undergraduates. This study therefore sought to determine the occurrence of pelvic inflammatory disease as well as determine the associated factors among undergraduates attending Irrua Specialist Teaching Hospital

(ISTH), Irrua, Edo State.

1.3        Aim and Objectives

1.3.1 Aim: The aim of this study is to determine the occurrence of pelvic inflammatory disease and associated factors among undergraduates attending Irrua Specialist Teaching Hospital in order to institute preventive measures through health education that might lead to behavioural change among this vulnerable group to reduce the scourge of the disease and its attendant sequelae.

1.3.2    Specific Objectives: The specific objectives of the study were

1. To determine the prevalence of pelvic inflammatory disease among undergraduates attending Irrua Specialist Teaching Hospital.
2. To identify risk factors for the development of pelvic inflammatory disease among undergraduates attending ISTH from clinical assessment.
3. To ascertain if there is association between the identified risk factors and the occurrence of pelvic inflammatory disease in the study population.

1.4        Justification of the Study

Edo State has one of the highest concentrations of young people in Nigeria with young adults and adolescents making up about 32.9% of its total population.²⁴ There are high rates of unplanned pregnancies and unsafe abortions, sex trafficking and prostitution, STI/HIV/AIDS and poor health seeking behaviour of youths in the state. There are also high levels of youth unemployment and breakdown of parent-child communications among young adults and

²⁴  adolescents in the state which is one of the highest in Nigeria.

Pelvic Inflammatory Disease is a significant cause of morbidity which can lead to adverse events like infertility, ectopic pregnancy and chronic pelvic pain later in life. The occurrence of this disease and its associated factors among undergraduates has not been studied in this area (Edo Central). This has highlighted the need for reference data to ascertain the role of these risk factors in the occurrence of PID among undergraduates in the study area.

CHAPTER ONE

INTRODUCTION

1.1       Background of the Study

Pelvic Inflammatory Disease (PID) is a major clinical and public health problem globally accounting for 5 – 20% of hospital admissions for gynaecological problems worldwide.^1,2 It is one of the most frequent and important infections that occur among non-pregnant women of reproductive age.² It is a spectrum of infectious and inflammatory disorders of the upper female genital tract and includes endometritis, parametritis, salpingitis, oophoritis, tuboovarian abscess, and/or pelvic peritonitis.^1,3

 

 

Fig. 1: Common sites of infection in PID

 

It is caused by an ascending spread of microorganisms from the vagina or uterine cervix into the upper genital tract.^3,4 If untreated, lower genital tract infections commonly progress to PID.⁵ It is commonly associated with sexually transmitted organisms especially Neisseria gonorrhoea and Chlamydia tracchomatis⁶ and is in fact one of the most common and serious complications of sexually transmitted infections (STIs) in women.^1,2 It has however been associated also with microorganisms that comprise the vagina flora such as anaerobes, Gardnerella vaginalis, Haemophilus influenzae, enteric Gram-negative rods, and Streptococcus agalactiae.⁶ In some cases of PID, cytomegalovirus (CMV), Mycoplasma hominis, Ureoplasma urealyticum, and Mycoplasma genitalium have been implicated.⁶ When not promptly recognised and properly treated, it could lead to complications such as infertility; for example, more than 75, 000 women are reported to be infertile every year on account of PID in the United States of America (USA) accounting for 10 – 15% of infertility in the USA.^1,3 It can also lead to ectopic pregnancy, menstrual disturbances, pregnancy wastage, low birth weight babies or chronic pelvic pain.^7-9 Ovarian cancer has also been associated with PID.^1,3

Inherent defence mechanism exists to protect the upper female genital tract against microbial colonisation.^10,11 These mechanisms include the cervical mucus which serves as a mechanical barrier against ascending infection in addition to possessing antibacterial activity that protects against bacterial ascent.^10,11 Endometrial and oviductal secretions also protects the upper genitalia by washing out bacteria from the endometrium and fallopian tube respectively.¹⁰  In spite of the above inherent defensive mechanisms, pathogens still ascend to the endometrium and other structures that make up the upper genitalia causing PID.¹⁰ This may be facilitated by passive transport and through the aid of vectors such as spermatozoa and trichomoniads. Retrograde menstruation also aids the transportation of pathogens into the upper genitalia while uterine instrumentation and insertion of Intrauterine Uterine Contraceptive Device (IUCD) can inoculate the endometrium.¹⁰

Long term morbidity is associated with salpingitis much more than endometritis and cervicitis.¹¹ This is because inflammation of the fallopian tubes due to infection will lead to epithelial degeneration and deciliation of ciliated cells along the fallopian tube mucosa in association with sub mucosal inflammatory cell infilterates.¹¹ There is also tubal oedema and intraluminal agglutination causing dysfunctionality, obstruction which may be partial or total, ultimately leading to infertility or ectopic pregnancy.¹¹

Various risk factors have been associated with the occurrence of PID. These risk factors

include young age,^12-14 early coitarche,¹³ multiple sex partners,¹² previous history of sexually

transmitted infections (STI) or previous history of PID,¹⁰ inconsistent condom use,^13,15 inappropriate insertion of Intra Uterine Contraceptive Device (IUCD),¹⁶  low socioeconomic status,^6,15 induced abortion⁷ and being in school.¹⁷

Women of reproductive age are at increased risk of PID.¹² This is because most sexual activity occur during this period. The risk of developing PID is however much higher in younger women particularly those younger than 25 years compared to women in other age group.^3,12,13 It is estimated that one in five cases of PID occurs in women under the age of 19, and that one in eight adolescent females will develop PID compared to one in 80 for women older than 24 years of age.³

The high prevalence of PID among adolescents and young adults is attributable to behavioural anatomical and hormonal factors. They often engage in high-risk sexual behaviour such as having multiple sex partners, frequent and unprotected sexual intercourse and low contraceptive usage, particularly barrier contraceptive methods.³ They generally have higher number of sexual partners, higher number of concurrent partners and a higher frequency of partner change than older age groups.¹² They also do not have the skills and confidence to negotiate safer sex.¹² In addition, adolescents and young women do not commonly consider the long term effect of their risky sexual behaviours.^3,14 Most undergraduates fall into this age category.

Another factor that contributes to the high risk of acquiring PID among adolescents and young adults could be the anatomy of their developing cervix. The epithelium of their immature ectocervix is mainly columnar, exposing a relatively large surface area, which facilitates the attachment of microorganisms like C. trachomatis and N. gonorrhoeae.³ With increasing age, this columnar tissue undergoes squamous cell epithelisation which then

covers the normal adult ectocervix or simply regresses into the endocervical canal.³

Hormonal factors have also been implicated in the development of PID among adolescents and young adults. Oral contraceptives, frequently used by adolescents, interfere with the columnar-squamous cell epithelisation process and are thus considered to be a risk factor for C. trachomatis infection and PID.³ Anovulatory cycles, common after menarche, may be associated with high oestrogen levels, which facilitate cervical mucus penetration by microorganisms.³ In addition, low cervical secretory immunoglobulin A levels in the female adolescent genital tract, due to low prevalence of immunogenic triggers, may also contribute

to the adolescent's susceptibility to PID.³

Another risk factor associated with PID among women of reproductive age is having sexual debut at a young age. Early coitarche has been shown to increase the occurrence of PID.^13,14,15 Those who had sexual debut before the age of 15 years are more likely to develop PID compared to those who are 15 years and older.¹² The association between younger age and first sexual intercourse and increased risk of PID may reflect biological factors and sexual behaviour over a substantial period of time.^12,15 Young females were more likely to have their sexual initiation with significantly older partners.¹⁵ They do so seeking financial support or desiring intimate and emotional security.¹⁵ They are therefore more likely to engage in risky sexual behaviours such as poor/non condom use due to high power imbalance, as the older male partners make the sexual decisions and are more likely to have sexually transmitted infections (STIs).¹⁵ Also, early sexual intercourse is commonly associated with a higher number of lifetime sexual partners which further predisposes them to

developing PID.14,16,17

Multiple sex partners predispose women to the development of PID. The higher the number of sex partners a woman has, the higher the risk of developing PID. A higher number of concurrent partner as well as frequent partner change also significantly increase risk of PID.¹² Adolescents and young adults, who constitute majority of undergraduates, commonly have multiple sex partners which predispose them to developing PID.^3,12,18 They also have a higher number of concurrent partners as well as a higher frequency of partner change.¹² Also women whose partners are not faithful to them are also at increased risk of developing PID, especially if their partners engage in unprotected sex with other women.¹² It is important therefore that both partners must be faithful to each other as history of multiple sex partners by either the woman or her partner increases her risk of developing PID.³ Adolescents and young women from low socioeconomic backgrounds are more likely to have multiple sex partners as they succumb to unprotected sex through coercion, force, violence and

transactional reasons.¹²

Similarly, those women with previous history of PID/STI are at greater risk of developing PID.^10,13 This may be due to poor treatment leading to chronicity of the infection. It could also be due to reinfection after treatment.² Inaccurate information regarding PID and STIs among members of the public are also known risk factors for PID.^12,19 Living in an area with a high prevalence of sexually transmitted infection (STI) has been shown to increase the risk of developing PID.^5,10,12 This is because persons with PID and other STIs would easily transmit the infection to others. Thus, in a higher institution where prevalence of PID is high, the rate of spread of the infection will be high. Consequently, uninfected ladies who engage in risky sexual behaviours will easily contact the disease in such an environment.

Inconsistent use of barrier contraceptive is also a major risk for the development of PID.^12,13 Consistent condom use has been shown to significantly reduce the risk of developing PID as well as prevent unwanted pregnancy.¹⁵

Low socioeconomic status is a significant risk factor for PID.¹⁹ This is because students from poor family background are more likely to engage in risky sexual behaviour that predisposes them to PID. They do this in order to get money to augment whatever they get from their parents.¹⁸ On the other hand, students from high socioeconomic backgrounds whose financial needs are met by their parents may not engage in such activities.¹⁸ The higher incidence of PID in women of lower socioeconomic status may be due in part to a woman's lack of

education and awareness of health and disease and her accessibility to medical care.^20,21 They may also engage more in sex with older men (so called “sugar daddies”) for gifts, pocket money and school fees⁶ as majority of such girls are often responsible for their fees and even send money to their poor parents from such proceeds. These men who make the decisions that affect sexual risk almost universally do not like to use barrier contraceptives, thus sex in this vulnerable group is most likely to be unprotected.⁶ Lack of access to good health care facilities for patients with STIs from low socioeconomic backgrounds may also facilitate progression to PID in this group. They would rather patronise patent medicine dealers and quacks. They are also at higher risks of unwanted pregnancies from unprotected sex, making them engage in criminal abortion in the hands of quacks and under unsanitary conditions

further increasing their susceptibility to PID.¹⁸

The diagnosis of PID is primarily based on a history of abdominal or pelvic pain or cramping of varying intensity, new or abnormal vaginal discharge, fever or chills (which may be high grade), dyspareunia, heavy or prolonged menses or coital bleeding and clinical findings of lower genital tract inflammation associated with pelvic organ tenderness (cervical motion tenderness, uterine tenderness and adnexal tenderness).^9,19 Diagnosis of PID based on above clinical findings have been shown to have a positive predictive value of 65 – 90%.^9,21 The diagnostic criteria for PID according to the World Health Organisation (WHO) and the Centres for Disease Control and Prevention (CDC) include the presence of one or more of the following major criteria: cervical motion tenderness, uterine tenderness or adnexal tenderness

with no other apparent cause.^6,9,22

The following minor criteria are supportive but not required for the diagnosis: Fever greater than or equal to 38.3^oC, abnormal discharge per cervix or vagina, WBCs on Gram stain or

Saline of cervical swab, Gonorrhoea or Chlamydia testing positive, increased Erythrocyte Sedimentation Rate or C – reactive protein, and PID findings on diagnostic study.⁹

Most specific findings, though not required and rarely indicated unless refractory to management or unclear diagnosis: Laparoscopy findings consistent with PID which is the

Gold Standard for diagnosis, Endometrial Biopsy with histology suggestive of Endometritis, Imaging such as Transvaginal Ultrasound or Magnetic Resonance Imaging with classic findings – Thickened, fluid filled tubes, Free pelvic fluid may be present, Tubo-ovarian complex, Tubal hyperaemia on Doppler Ultrasound.⁹ The differential diagnoses include ectopic pregnancy, appendicitis, cervicitis, urinary tract infection, and adnexal tumours.⁴

1.2       Statement of the Problem

Pelvic Inflammatory Disease is said to be high among undergraduates.^5,23 This could be due to the fact that undergraduates are mostly adolescents and young adults and tend to engage in risky sexual behaviour such as having sex for pecuniary gains particularly with older partners who may be harbouring sexually transmitted infections,^18,23 have multiple sex partners, higher number of concurrent partners, higher frequency of partner change and do not have the skills and confidence to negotiate safer sex.¹² They are also less likely to use barrier contraceptives, engage in unsafe abortions, and less likely to seek standard medical intervention.^12,22 All these characteristics of the female undergraduate predispose them to the development of PID with its attendant complications later in life.

From hospital records, a good number of the patients who present to Irrua Specialist Teaching Hospital with features of PID were young undergraduates. This study therefore sought to determine the occurrence of pelvic inflammatory disease as well as determine the associated factors among undergraduates attending Irrua Specialist Teaching Hospital

(ISTH), Irrua, Edo State.

1.3        Aim and Objectives

1.3.1 Aim: The aim of this study is to determine the occurrence of pelvic inflammatory disease and associated factors among undergraduates attending Irrua Specialist Teaching Hospital in order to institute preventive measures through health education that might lead to behavioural change among this vulnerable group to reduce the scourge of the disease and its attendant sequelae.

1.3.2    Specific Objectives: The specific objectives of the study were

1. To determine the prevalence of pelvic inflammatory disease among undergraduates attending Irrua Specialist Teaching Hospital.
2. To identify risk factors for the development of pelvic inflammatory disease among undergraduates attending ISTH from clinical assessment.
3. To ascertain if there is association between the identified risk factors and the occurrence of pelvic inflammatory disease in the study population.

1.4        Justification of the Study

Edo State has one of the highest concentrations of young people in Nigeria with young adults and adolescents making up about 32.9% of its total population.²⁴ There are high rates of unplanned pregnancies and unsafe abortions, sex trafficking and prostitution, STI/HIV/AIDS and poor health seeking behaviour of youths in the state. There are also high levels of youth unemployment and breakdown of parent-child communications among young adults and

²⁴  adolescents in the state which is one of the highest in Nigeria.

Pelvic Inflammatory Disease is a significant cause of morbidity which can lead to adverse events like infertility, ectopic pregnancy and chronic pelvic pain later in life. The occurrence of this disease and its associated factors among undergraduates has not been studied in this area (Edo Central). This has highlighted the need for reference data to ascertain the role of these risk factors in the occurrence of PID among undergraduates in the study area.

OCCURRENCE OF PELVIC INFLAMMATORY DISEASE AND ASSOCIATED FACTORS AMONG UNDERGRADUATES ATTENDING IRRUA SPECIALIST TEACHING HOSPITAL, IRRUA

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