Pelvic Inflammatory Disease (PID)

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

Diagnosis

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

Treatment

• 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, ...