INTRODUCTION

Pelvic Inflammatory Disease (PID) is common among women of reproductive age globally.¹ It is an infectious and inflammatory disorder affecting the upper female genital tract.² PID could involve the endometrium, both fallopian tubes, ovaries and the peritonium.³ PID commonly results from infections of the lower female genitalia that ascend to the upper genital tract.³ It is among the commonest infections that occur among non-pregnant women of childbearing age. It is and remains a major public health concern.³ Sexually Transmitted Infections (STIs) in women, if not promptly treated can, and usually progress to PID¹ which if not diagnosed and treated early could lead to infertility, ectopic pregnancy, or chronic pelvic pain.^1,4  

PID is commonly associated with sexually transmitted organisms especially Neisseria gonorrhoea and Chlamydia tracchomatis⁵ and is in fact one of the most common and serious complications of sexually transmitted infections (STIs) in women. It has however been associated with microorganisms that comprise the vagina flora such as anaerobes, Gardnerella vaginalis, Haemophilus influenzae, enteric Gram-negative rods, and Streptococcus agalactiae.⁵ In some cases of PID, cytomegalovirus (CMV), M. hominis, Ureoplasma urealyticum, and M. genitalium have been implicated.⁵

There is increased occurrence of PID in our society, particularly among youth with a quarter of sexually active female adolescents having STI annually.⁶ The prevalence of PID among undergraduates was found to be 11% in a study done in Port Harcourt, Nigeria.⁷ Another study conducted by Olowe et al in Osogbo, South-Western Nigeria found the prevalence of PID to be as high as 70%.⁶

The reasons for increased prevalence of PID among students, particularly those in tertiary institutions may be due to their engagement in sexual behaviours that expose them to risks of developing PID. Most students are adolescents and young adults who engage in sexual adventures as a result of the freedom from direct parental control in school. Other possible reasons for increased likelihood of PID in adolescents and young adults include biological factors like increased permeability of the cervical mucous, a large zone of cervical ectopy, reduced protective antichlamydial antibodies, and greater tendencies to take risks.⁸ Occurrence of PID during the adolescent and youthful age increases the risk of developing complications from the disease (infertility, ectopic pregnancy, chronic pelvic pain etc) later in life (after marriage when fertility is desired).

Diagnosis of PID is difficult particularly in rural settings due to dearth of facilities or manpower or both.³ Clinical diagnosis is therefore strongly relied upon. This is also difficult as it may be asymptomatic or may present with atypical symptoms. A good history including history of lower abdominal pain, dyspareunia, abnormal discharge per vaginum, fever, abnormal vaginal bleeding and clinical examination to elicit cervical excitation tenderness, uterine tenderness and adnexal tenderness are key to clinical diagnosis of PID.^3,9,10 The above clinical features have a positive predictive value of 65 – 90% in the diagnosis of PID.⁹ The World Health Organisation (WHO) and the Centre for Disease Control (CDC) have identified the presence of cervical excitation tenderness, uterine tenderness and adnexal tenderness in a patient with no other identifiable cause as diagnostic of PID.^3,8,11

From hospital records, majority of patients with PID in Irrua Specialist Teaching Hospital are adolescents and young adults. Majority of undergraduates are adolescents and young adults. Clinical diagnosis of PID is usually relied upon in ISTH being in a rural community with inhabitants mainly from low socioeconomic class.  Even those who can afford laboratory and radiological investigations are treated empirically based on clinical diagnosis, while the outcome of the laboratory and radiological investigations is awaited.  This study therefore seeks to determine the correlation between the menstrual abnormalities and the development of pelvic inflammatory disease among undergraduates attending Irrua Specialist Teaching Hospital (ISTH), Irrua, Edo State in order to determine if its presence is significant in patients with PID.

METHODOLOGY

Study Design

It was a descriptive cross-sectional study conducted among female undergraduates presenting to the Family Medicine Clinic, Accident and Emergency Unit and Gynaecology Clinic.

Location of study

The study was conducted in ISTH, a tertiary hospital in Irrua, the headquarters of Esan Central Local Government Area. It is a semi urban community and receives patients from three major tertiary institutions – Ambrose Alli University, Ekpoma, Auchi Polytechnic, Auchi and College of Education, Igueben. Patients with PID are usually seen in the Family Medicine Clinic (commonest), gynaecological clinic and the Accident and Emergency unit of the hospital.

Female undergraduates presenting to ISTH during the period of the study were recruited for the study. They were all evaluated for menstrual abnormalities using a semi structured pretested questionnaire. Patients with one or more of the complaints enunciated by WHO in its syndromic approach for the diagnosis of PID {Lower abdominal pain and Pelvic tenderness (Cervical Excitation Tenderness, Uterine Tenderness or Adnexal Tenderness)}^9,11 were categorised as those having PID. Patients who did not meet the WHO criteria for the clinical diagnosis PID were categorised as not having PID.

Study Population

The study population comprised undergraduates attending the Family Medicine Clinic, Gynaecological Clinic and Accident and Emergency unit of Irrua Specialist Teaching Hospital.

Sample Size

A sample size of 360 was used. The sample size was determined using the formula

N = Z²pq/d²  where

N = estimated sample size

Z = standard normal deviate corresponding to a confidence interval of 95% (1.96)

p = prevalence of PID (Olowe, Alabi and Akindele reported a PID prevalence of 70% among patients attending a tertiary hospital in Osogbo, South western Nigeria)⁶

q = the proportion of those without PID in the population = 1 – p = 1 – 0.70 = 0.30

d = allowable relative error (5%)

N = (1.96)² X 0.70 X 0.30/(0.05)²  = 0.806736/0.0025 = 323

Response Rate: A response rate of 90% was anticipated and so the sample size to be selected (n_s) was calculated using the formula

n_s = n/0.9  where

n_s = sample size to be selected,

 n = calculated sample size and

0.9 = anticipated response rate of 90%

n_s = n/0.9 = 323/0.9 = 359.

This was rounded up to 360

Sampling Method

Consecutive patients who meet the selection criteria during the period of the study were recruited for the study.

Selection Criteria

Female undergraduates between the ages of 15 to 45 who consented to participate were included in the study.

Chronically ill patients, patients with conditions with competing diagnosis such as ectopic pregnancy, appendicitis and urinary tract infection as well as patients with history of pelvic surgeries such as myomectomy, salpingectomy, caesarean section etc, were excluded from the study.

Data Analysis

Data was analysed using Epi info 3.5.4 statistical software designed by the Centre for Disease Control (CDC), Atlanta, USA. Results were presented using tables, charts, frequency distribution and percentages. Chi-square test was used to compare the variables, and P ≤ 0.05 was considered statistically significant.

Duration of Study

The study lasted for a period of six months. The study being a consecutive study continued until the required sample size was achieved.

Ethical Clearance

Ethical clearance was obtained from the Ethics and Research Committee of Irrua Specialist Teaching Hospital, while informed consent was obtained from patients after details of the study including the aim and objectives have been explained to them.

RESULTS

Table 1: Sociodemographic Characteristics of Respondents 

As shown in Table 1, majority of the respondents who had PID were aged 20 to 24 years (129) followed by 25 to 29 years (57) and 15 to 19 years (27) age-group. PID occurred least among those aged 30 years and above (16). However, within the age-groups, PID was highest among those aged 15 to 19 (73%) followed by 20 to 24 years (65.8%) and 25 to 29 years (58.2%). It was least among those aged 30 years and above (55.2%).  The difference between the ages of respondents and age-based occurrence of PID was not found to be statistically significant (χ² = 4.05, df = 3, p = 0.20)

Most of the respondents with PID were single. There were 214 (63.3%) respondents with PID compared to 124 (36.7%) of respondents without PID who were single. There were 15 (68.2%) married respondents with PID compared to 7 (31.8%) of married respondents without PID. The proportion of PID among married women was higher (71.4%) than that of single ladies (63.3%). There was however, no statistically significant difference between single and married respondents who had PID and those who did not (χ² = 0.67, df = 1, p = 0.72). See Table 1.