Basics
Description
- Pelvic inflammatory disease (PID) is an acute, community-acquired, sexually transmitted infection of the upper genital tract, including the uterus, fallopian tubes, ovaries, or adjacent structures
- Most frequent gynecologic cause for ED visits (350,000 per year)
- Represents a spectrum of infection:
- No single diagnostic gold standard
- Requires low clinical threshold for considering the diagnosis and starting empiric antibiotic therapy
- Progressive disease can lead to tubo-ovarian abscess (TOA)
- Fitz-Hugh " “Curtis syndrome is a capsular inflammation of the liver associated with PID:
- Sharp right upper quadrant abdominal pain
- Worse with inspiration, movement, or coughing
Etiology
- Risk factors:
- Age <25 yr
- Multiple or symptomatic sexual partners
- Previous episode of PID
- Nonbarrier contraception
- Oral contraception
- African American ethnicity
- Most common causes of PID are Chlamydia trachomatis and Neisseria gonorrhea
- Other organisms include groups A and B streptococci, staphylococci, gram-negative rods (commonly Klebsiella spp., Escherichia coli, and Proteus spp.), and anaerobes
Diagnosis
Signs and Symptoms
- Lower abdominal pain, usually bilateral
- Vaginal discharge
- Abnormal uterine bleeding
- Dysmenorrhea
- Dysuria
- Dyspareunia
- Nausea and vomiting
- Fever and chills
- Proctitis
- Lower abdominal tenderness
- Decreased bowel sounds
- Bilateral adnexal tenderness
- Cervical motion tenderness
- Purulent endocervical discharge
- Adnexal mass or fullness
- Right upper quadrant tenderness
History
- Lower abdominal pain is the most common symptom in PID, ranging from subtle to severe pain
- Abdominal pain that worsens during intercourse or onset of pain shortly after or during menses is suggestive of PID
- Abdominal pain is usually bilateral and usually present for ≤2 wk
- New vaginal discharge, urethritis, fever, and chills are common symptoms but are neither sensitive nor specific for the diagnosis
PID is rare during pregnancy, but if present usually occurs during the 1st trimester before hormonal changes such as mucus plug formation can protect the uterus from ascending bacteria. ‚
Physical Exam
- Only 50% of patients with PID have fever
- Abdominal exam reveals diffuse tenderness worse in the lower quadrants, usually but not always symmetric
- Rebound tenderness and decreased bowel sounds are commonly found
- Right upper quadrant tenderness is suggestive of perihepatitis (Fitz-Hugh " “Curtis syndrome) in the setting of PID
- Pelvic exam can reveal a purulent endocervical discharge, cervical motion tenderness, or adnexal tenderness
- If uterine or adnexal tenderness is not prominent, one must consider other diagnoses
Essential Workup
- History and physical exam including pelvic exam
- Pregnancy test to rule out ectopic pregnancy or complications of an intrauterine pregnancy
- Cervical culture for N. gonorrhea and C. trachomatis
- Minimum criteria for clinical diagnosis:
- Lower abdominal tenderness or
- Uterine/adnexal tenderness or
- Cervical motion tenderness
- Supportive criteria for diagnosis:
- Fever >38.3 ‚ °C (101 ‚ °F)
- Abnormal cervical/vaginal discharge
- Intracellular gram-negative diplococci on endocervical Gram stain
- Leukocytosis >10,000/mm3
- Elevated erythrocyte sedimentation rate (ESR) or C-reactive protein
- WBCs or bacteria in peritoneal fluid obtained by culdocentesis or laparoscopy
Diagnosis Tests & Interpretation
Lab
- CBC
- Gram stain of endocervix
- Urine polymerase chain reaction tests for Chlamydia and Gonococcus
- Microscopic exam of vaginal discharge in saline
- Liver enzymes may be elevated in Fitz-Hugh " “Curtis syndrome
- Positive urinalysis or occult blood in stool decreases the probability of PID
- ESR or C-reactive protein may be elevated, but not routinely recommended
Imaging
- Patients with adnexal fullness or an adnexal mass on exam should have a transvaginal US to exclude TOA
- Consider obtaining a pelvic US in patients who use an intrauterine device, fail outpatient antibiotic therapy for PID, or who have inadequate pelvic exams due to pain or obesity
Diagnostic Procedures/Surgery
Laparoscopy may be useful in confirming PID in a patient with a high suspicion of competing diagnosis or who failed outpatient treatment for PID ‚
Differential Diagnosis
- Ectopic pregnancy (must be excluded with a pregnancy test in any woman suspected of having PID)
- Acute appendicitis
- Adnexal torsion
- Endometriosis
- Cystitis
- Urolithiasis
- Ovarian tumor
- Adenomyosis uteri
- Chronic pelvic pain
- Benign ovarian cyst
- Diverticulitis
- Inflammatory bowel disease
- Mesenteric vascular disease
- Irritable bowel syndrome
Treatment
Pre-Hospital
- No specific pre-hospital considerations
- Appropriate pain management
Initial Stabilization/Therapy
- Resuscitation rarely indicated
- Pain control
Ed Treatment/Procedures
Outpatient
- Ceftriaxone or cefoxitin/probenecid + doxycycline; with metronidazole when anaerobes are a particular concern
- Alternatives include ceftriaxone + azithromycin.
- Must evaluate and treat sex partner as appropriate
Inpatient
- Doxycycline + cefoxitin or cefotetan
- Alternatives include gentamicin + clindamycin; or ampicillin/sulbactam + doxycycline
- Continue parenteral antibiotic administration for 24 hr after clinical improvement, then switch to oral antibiotics to finish 14 day course
- Laparoscopy can be used to lyse adhesions in the acute and chronic stages of Fitz-Hugh " “Curtis syndrome
- Add metronidazole when anaerobes are a particular concern
Medication
- Ampicillin/sulbactam: 3 g IV q6h
- Azithromycin: 1 g PO once per week for 2 wk
- Cefotetan: 2 g IV q12h
- Cefoxitin: 2 g IM single dose (outpatient); 2 g IV q6h (inpatient)
- Ceftriaxone: 250 mg IM single dose
- Clindamycin: 450 mg PO QID for 14 days (outpatient); 900 mg IV q8h (inpatient)
- Doxycycline: 100 mg PO BID for 14 days (outpatient); 100 mg IV or PO q12h (inpatient)
- Oral doxycycline is preferred due to pain of IV infusion
- IV and oral doxycycline have similar bioavailability
- Gentamicin: 2 mg/kg loading dose followed by 1.5 mg/kg IV q8h. Single daily IV dosing of gentamicin may also be used.
- Metronidazole: 500 mg PO BID for 14 days (outpatient); 500 mg IV q8h (inpatient)
- Probenecid: 1 g PO single dose
First Line
- For outpatient:
- Ceftriaxone or cefoxitin/probenecid + doxycycline
- With metronidazole when anaerobes are a particular concern, in suspected Trichomonas vaginalis infection
- Or in women with recent history of pelvic instrumentation
- Of note, oral cephalosporins are no longer a recommended treatment for gonococcal infections (CDC recommends combination therapy with single IM dose of ceftriaxone + oral azithromycin or doxycycline)
- For inpatient:
- Doxycycline + cefoxitin or cefotetan
Second Line
- For outpatient:
- Ceftriaxone + azithromycin with or without metronidazole
- For inpatient:
- Gentamicin + clindamycin; or ampicillin/sulbactam + doxycycline
Follow-Up
Disposition
Admission Criteria
- Uncertain diagnosis and toxic appearance
- Suspected pelvic abscess, including TOA
- Pregnancy
- Immunodeficiency
- Severe illness (e.g., vomiting or severe pain)
- Failure of outpatient therapy
- Probable noncompliance with outpatient therapy (e.g., adolescents)
- Consider admission if appropriate clinical follow-up cannot be arranged
Discharge Criteria
- Patients who do not meet admission criteria may be treated as outpatients
- Recent studies have shown that in women with mild to moderate PID, there was no difference in reproductive outcomes between women randomized to inpatient vs. outpatient treatment
Issues for Referral
TOAs may require drainage or surgical intervention in addition to antibiotics ‚
Follow-Up Recommendations
- If outpatient therapy is selected, it is important to have follow-up in 48 " “72 hr to assess for clinical improvement
- If the patient has not defervesced by 72 hr, inpatient treatment and further evaluation should be considered
Pearls and Pitfalls
- PID represents a spectrum of disease from simple endometritis to fatal intra-abdominal sepsis
- Quinolones and oral cephalosporins are no longer recommended in US for the treatment of gonorrhea or associated conditions such as PID, due to increasing rates of resistance
- Patients with PID should have extensive counseling and testing for other STDs, including HIV
- Male sex partners of women with PID should be treated if they had sexual contact with the patient during the previous 60 days prior to the patients onset of symptoms
Additional Reading
- Centers for Disease Control and Prevention (CDC). Update to CDCs sexually transmitted diseases treatment guidelines, 2006: Fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR Morb Mortal Wkly Rep. 2007;56:332 " “336.
- Centers for Disease Control and Prevention. 2010 STD Treatment Guidelines. Available at http://www.cdc.gov/std/treatment/2010/default.htm
- Judlin ‚ P, Liao ‚ Q, Liu ‚ Z, et al. Efficacy and safety of moxifloxacin in uncomplicated pelvic inflammatory disease: The MONALISA study. BJOG. 2010;117:1475 " “1484.
- Ness ‚ RB, Trautmann ‚ G, Richter ‚ HE, et al. Effectiveness of treatment strategies of some women with pelvic inflammatory disease: A randomized trial. Obstet Gynecol. 2005;106:573 " “580.
- Owusu-Edusei ‚ K Jr, Bohm ‚ MK, Chesson ‚ HW, et al. Chlamydia screening and pelvic inflammatory disease: Insights from exploratory time-series analyses. AM J Prev Med. 2010;38:652 " “657.
- Savaris ‚ RF, Teixeira ‚ LM, Torres ‚ TG, et al. Comparing ceftriaxone plus azithromycin or doxycycline for pelvic inflammatory disease: A randomized controlled trial. Obstet Gynecol. 2007;110:53 " “60.
- Short ‚ VL, Totten ‚ PA, Ness ‚ RB, et al. Clinical presentation of Mycoplasma genitalium Infection versus Neisseria gonorrhoeae infection among women with pelvic inflammatory disease. Clin Infect Dis. 2009;48:41 " “47.
- Soper ‚ DE. Pelvic inflammatory disease. Obstet Gynecol. 2010;116:419 " “428.
- Wiesenfeld ‚ HC, Hillier ‚ SL, Meyn ‚ LA, et al. Subclinical pelvic inflammatory disease and infertility. Obstet Gynecol. 2012;120:37 " “43.
- Workowski ‚ KA, Berman ‚ S, Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59:1 " “110.
Codes
ICD9
- 079.88 Other specified chlamydial infection
- 098.19 Other gonococcal infection (acute) of upper genitourinary tract
- 614.9 Unspecified inflammatory disease of female pelvic organs and tissues
- 614.3 Acute parametritis and pelvic cellulitis
- 614.0 Acute salpingitis and oophoritis
- 614.8 Other specified inflammatory disease of female pelvic organs and tissues
ICD10
- A54.24 Gonococcal female pelvic inflammatory disease
- A56.11 Chlamydial female pelvic inflammatory disease
- N73.9 Female pelvic inflammatory disease, unspecified
- N73.0 Acute parametritis and pelvic cellulitis
- N73.8 Other specified female pelvic inflammatory diseases
SNOMED
- 198130006 Female pelvic inflammatory disease (disorder)
- 188463006 Chlamydial pelvic inflammatory disease (disorder)
- 198242009 Female gonococcal pelvic inflammatory disease (disorder)
- 198154001 Acute parametritis and pelvic cellulitis
- 198133008 Acute perioophoritis (disorder)
- 45377007 Acute gonococcal salpingitis