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Key Features

Essentials of Diagnosis

  • Defined as inflammation of the upper female genital tract and may include

    • Endometritis

    • Salpingitis

    • Tubo-ovarian abscess

    • Pelvic peritonitis

  • Predisposing risk factors include

    • Multiple sexual partners

    • Younger age of initiating sexual intercourse

    • Prior history of PID

    • Lack of condom use

  • Lack of protective antibody from previous exposure to sexually transmitted organisms and cervical ectopy contribute to the development of PID

General Considerations

  • Most common gynecologic disorder necessitating hospitalization for female patients of reproductive age in the United States

  • Incidence is highest in teenage girls

  • Causative agents

    • Neisseria gonorrhoeae

    • Chlamydia

    • Anaerobic bacteria that reside in the vagina

    • Genital mycoplasmas

Clinical Findings

Symptoms and Signs

  • Patients typically have lower abdominal pain, pelvic pain, or dysuria

  • Systemic symptoms such fever, nausea, or vomiting may be present

  • Vaginal discharge is variable

  • Cervical motion tenderness, uterine or adnexal tenderness, or signs of peritonitis are often seen

  • Mucopurulent cervicitis is present in 50% of patients

  • Tubo-ovarian abscesses can often be detected by careful physical examination (feeling a mass or fullness in the adnexa)

Differential Diagnosis

  • Ectopic pregnancy, threatened or septic abortion, adnexal torsion, ruptured and hemorrhagic ovarian cysts, dysmenorrhea, endometriosis, or mittelschmerz

  • Appendicitis, cholecystitis, hepatitis, gastroenteritis, or inflammatory bowel disease

  • Cystitis, pyelonephritis, or urinary calculi


Laboratory Findings

  • Elevated WBCs with a left shift and elevated acute phase reactants (erythrocyte sedimentation rate or C-reactive protein)

  • A positive test for N gonorrhoeae or Chlamydia trachomatis is supportive but not necessary for diagnosis

  • Pregnancy needs to be ruled out because patients with an ectopic pregnancy can present with abdominal pain

Diagnostic Procedures

  • Laparoscopy

    • Gold standard for detecting salpingitis

    • Performed if diagnosis is uncertain

    • Helps differentiate PID from an ectopic pregnancy, ovarian cysts, or adnexal torsion

  • Endometrial biopsy should be performed in women undergoing laparoscopy who do not have visual evidence of salpingitis since some women may only have endometritis

  • Pelvic ultrasonography is helpful in detecting tubo-ovarian abscesses, which are found in almost 20% of teenagers with PID

  • Transvaginal ultrasound is more sensitive than abdominal ultrasound


  • Broad-spectrum antibiotic regimens that can be used for outpatients

    • Ceftriaxone, 250 mg intramuscularly once, plus doxycycline, 100 mg orally twice a day for 14 days, with or without metronidazole, 500 mg orally twice a day for 14 days or

    • Cefoxitin, 2 g intramuscularly once, plus probenecid, 1 g orally as a single dose, plus doxycycline, 100 mg orally twice a day for 14 days, with or without metronidazole, 500 mg orally twice a day for 14 days or

    • Other parenteral third-generation cephalosporin (eg, ceftizoxime or cefotaxime) plus doxycycline, 100 mg orally twice a day for 14 days, ...

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