Basics
Description
- Pelvic inflammatory disease (PID) refers to a spectrum of upper female genital tract inflammatory disorders, including endometritis, salpingitis, tubo-ovarian abscess (TOA), and peritonitis.
- Definitive diagnosis of PID can be made by laparoscopy; however, diagnosis is usually made based on clinical findings.
- Centers for Disease Control (CDC) guidelines state that empiric PID therapy should be initiated in sexually active young women with pelvic or lower abdominal pain, if no other cause for the illness can be identified and the patient has the following:
- Uterine tenderness, OR
- Adnexal tenderness, OR
- Cervical motion tenderness
- Additional criteria enhance the specificity of the diagnosis of PID, but are not required for the diagnosis:
- Oral temperature >38.3 °C (101 °F)
- Abnormal cervical or vaginal discharge
- Abundant WBCs on a wet mount of vaginal secretions
- Elevated ESR or CRP
- Laboratory-documented evidence of infection with Neisseria gonorrhoeae or Chlamydia trachomatis
- Definitive diagnostic criteria:
- Histopathologic evidence of endometritis on endometrial biopsy
- Transvaginal sonography or MRI showing thickened fluid-filled tubes with or without free pelvic fluid or TOA
- Laparoscopic abnormalities consistent with PID
Epidemiology
- There are an estimated 750,000 cases of PID annually in the United States.
- In 2011, there were 90,000 initial visits to physician offices for PID:
- Visits for PID declined between 2002 and 2011.
- Increased screening and treatment of chlamydia likely led to this decline.
- Cases of PID are disproportionately higher among adolescent girls and racial minorities
Risk Factors
- Factors that increase PID risk include the following:
- Multiple sexual partners
- Intercourse with a partner who has multiple sexual partners
- Prior history of sexually transmitted infection (STI) or PID
- Intercourse without condoms
- Douching
- Recent (within past 20 days) insertion of intrauterine device (IUD)
- Cases of PID are highest among the following:
- Sexually active adolescents and young women younger than age 25 years
- Women in communities with high prevalence of gonorrhea and chlamydia
- Patients presenting to STD clinics
General Prevention
- Consistent condom use
- Regular STI screening
- Partner screening for STIs
- Limit number of sexual partners.
- Avoid douching.
Pathophysiology
- Ascending infection spreading from vagina/cervix to upper genital tract by the following:
- Migration
- Sperm transport
- Refluxed menstrual blood flow
- Up to 75% of cases occur within 7 days of menses.
Etiology
- Polymicrobial origin
- Many cases are associated with N. gonorrhoeae (GC) and C. trachomatis (CT).
- Mycoplasma genitalium and Ureaplasma urealyticum have been associated with laparoscopic PID and infertility.
- Other vaginal, enteric, and respiratory flora associated with PID include the following:
- Gardnerella vaginalis, Escherichia coli,Bacteroides species, Haemophilus influenzae, group B " D streptococci, Streptococcus pneumoniae, and group A Streptococcus.
Diagnosis
Alert
- Clinical criteria for PID are designed to have high sensitivity because the consequences for untreated PID are significant.
- If PID is suspected based on clinical presentation and examination, treatment should be initiated prior to results of other supportive testing.
History
- Should be taken from the patient in a private interview:
- Confidentiality policies should be reviewed with the patient in advance of history.
- Abdominal or pelvic pain is a common presenting complaint:
- "Classic " presentation of shuffling gait or "chandelier sign " is rare.
- Some cases may be mild with relatively few symptoms:
- Subclinical or "silent " PID can result in infertility and chronic pelvic pain.
- Other presenting symptoms may include the following:
- Vaginal discharge
- Abnormal vaginal bleeding
- Dyspareunia
- Dysuria
- Right upper quadrant pain
- Complete history should be taken including past medical, gynecologic, gastrointestinal, and urinary history
- Sexual history should be elicited in a sensitive manner; and should include number of partners, new partners, condom use, contraceptive method use, history of sexual assault.
Physical Exam
- Evaluate the patient for signs of general discomfort.
- Review vital signs for fever, tachycardia.
- Careful abdominal exam to evaluate for tenderness, rebound, or guarding
- Evaluate right upper quadrant for tenderness associated with perihepatitis.
- Pelvic exam is essential to PID diagnosis and must be performed for any sexually active female with abdominal pain or genital complaints.
- External genital exam should assess for external lesions, inguinal adenopathy.
- Speculum exam should note vaginal discharge or lesions, signs of cervical friability or discharge.
- Collect vaginal swabs for pH and wet prep.
- Collect cervical swabs for STI testing.
- Collect swab for Gram stain if materials and equipment available.
- Bimanual exam to evaluate for cervical motion tenderness, uterine tenderness, and adnexal tenderness or fullness.
Diagnostic Tests & Interpretation
Lab
- Urine ²-hCG
- Vaginal pH (pH >4.5 is abnormal)
- Wet mount and KOH (>10 WBC/HPF is suggestive of infection)
- Nucleic acid amplification test for GC, CT, and Trichomonas vaginalis
- If the patient reports sexual assault or abuse at the time of evaluation, bacterial cultures should also be obtained.
- Urinalysis and culture
- Consider collecting CBC, CRP to support the diagnosis.
- Testing for other STIs including HIV and syphilis should also be done.
Imaging
- In patients with adnexal fullness or other signs suggestive of TOA, obtain transvaginal ultrasound.
- Signs of PID on imaging include the following:
- Thickened or fluid-filled fallopian tubes
- Free pelvic fluid
- Tubo-ovarian abscess
Diagnostic Procedures/Other
- Laparoscopy
- Endometrial biopsy
- These tests can provide definitive evidence of PID, but are not routinely used.
Differential Diagnosis
- Pelvic pain may be the presenting complaint for a variety of disease processes.
- Gynecologic
- Ectopic pregnancy
- Intrauterine pregnancy
- Endometriosis
- Hemorrhagic ovarian cyst
- Ovarian cyst
- Ovarian tumor
- Ovarian torsion
- Tubal torsion
- Septic abortion
- Vaginal foreign body
- Hematometrocolpos
- Chemical irritants
- Urinary
- Urinary tract infection
- Acute pyelonephritis
- Gastrointestinal
- Acute appendicitis
- Acute cholecystitis
- Heme/vascular
- Other:
- Functional abdominal pain
- Sexual assault
- Sexual abuse
Treatment
Alert
- All CDC-recommended treatment regimens for PID require 14-day treatment duration.
- Fluoroquinolones not recommended for PID treatment because of GC resistance
Medication
Parenteral treatment regimens:
- Regimen A:
- Cefotetan 2 g IV every 12 h OR cefoxitin 2 g IV every 6 h PLUS
- Doxycycline 100 mg PO b.i.d. 14 days
- May add metronidazole 500 mg PO b.i.d. 14 days for severe cases or suspected anaerobes
- Regimen B:
- Clindamycin 900 mg IV every 8 hours PLUS
- Gentamicin loading dose IV or IM (2 mg/kg), followed by a maintenance dose (1.5 mg/kg) every 8 hours OR
- Gentamicin 3 " 5 mg/kg every 24 hours
- After 24 hours or clinical improvement, can switch to oral doxycycline 100 mg PO b.i.d. or clindamycin 450 mg PO q.i.d. to complete 14 days of total therapy
- Alternative regimen:
- Ampicillin/sulbactam 3 g (ampicillin) IV q6h PLUS
- Doxycycline 100 mg PO b.i.d. 14 days
Oral treatment regimens:
- Regimen A:
- Ceftriaxone 250 mg IM (single dose) PLUS
- Doxycycline 100 mg PO b.i.d. 14 days
- May add metronidazole 500 mg PO b.i.d. 14 days
- Regimen B:
- Cefoxitin 2 g IM (single dose) PLUS
- Probenecid 1 g PO (single dose) PLUS
- Doxycycline 100 mg PO b.i.d. 14 days
- May add metronidazole 500 mg PO b.i.d. 14 days
- Alternate regimen:
- Other parenteral 3rd-generation cephalosporin PLUS
- Doxycycline 100 mg PO b.i.d. 14 days
- May add metronidazole 500 mg PO b.i.d. 14 days
Additional Treatment
General Measures
- Criteria for hospitalization:
- Surgical emergency
- Pregnancy
- Lack of response to outpatient therapy
- Inability to tolerate or follow outpatient regimen
- Severe illness (e.g., fever, nausea/vomiting)
- Suspected or confirmed TOA
- Strong consideration of hospitalization should be given for early and middle adolescents who may require additional supports for optimal management.
- Patients should be counseled to:
- Abstain from intercourse for at least 14 days.
- Notify their partners for STI testing and treatment.
- Use condoms consistently and correctly.
- Limit number of sexual partners.
- Consider contraception if not currently using and not desiring pregnancy.
- Return if worsening symptoms or not able tolerate the prescribed treatment.
Ongoing Care
Follow-up Recommendations
- All patients diagnosed with PID should have follow-up within 72 hours to assess the following:
- Treatment tolerance/adherence
- Symptom improvement
- If patients are not improving additional evaluation may be necessary including the following:
- Bimanual examination
- Pelvic imaging
- Hospitalization
- Return for repeat STI testing in 3 months.
Prognosis
- Dependent on treatment adherence and number of episodes of PID
- Women with documented GC or CT infection have higher rates of reinfection within 6 months of treatment.
- Each additional episode of PID increases risk of infertility and chronic pelvic pain.
Complications
- Short-term
- Perihepatitis (in 15% of patients)
- Periappendicitis
- Long-term
- Ectopic pregnancy
- Infertility (10 " 15% of cases of PID)
- Chronic pelvic pain
Additional Reading
- Goyal M, Hersh A, Luan X, et al. National trends in pelvic inflammatory disease among adolescents in the emergency department. J Adolesc Health. 2013;53(2):249 " 252. [View Abstract]
- Haggerty CL, Ness RB. Newest approaches to treatment of pelvic inflammatory disease: a review of recent randomized clinical trials. Clin Infect Dis. 2007;44(7):953 " 960. [View Abstract]
- Soper DE. Pelvic inflammatory disease. Obstet Gynecol. 2010;116(2, Pt 1):419 " 428. [View Abstract]
- Trent M. Pelvic inflammatory disease. Pediatr Rev. 2013;34(4);163 " 172. [View Abstract]
- Trent M, Haggerty CL, Jennings JM, et al. Adverse adolescent reproductive health outcomes after pelvic inflammatory disease. Arch Pediatr Adolesc Med. 2011;165(1):49 " 54. [View Abstract]
Codes
ICD09
- 614.9 Unspecified inflammatory disease of female pelvic organs and tissues
- 615.9 Unspecified inflammatory disease of uterus
- 614.2 Salpingitis and oophoritis not specified as acute, subacute, or chronic
- 614.5 Acute or unspecified pelvic peritonitis, female
ICD10
- N73.9 Female pelvic inflammatory disease, unspecified
- N71.9 Inflammatory disease of uterus, unspecified
- N70.93 Salpingitis and oophoritis, unspecified
- N73.5 Female pelvic peritonitis, unspecified
SNOMED
- 442506007 inflammatory disease of female genital structure (disorder)
- 78623009 Endometritis (disorder)
- 88157006 Salpingitis (disorder)
- 32923006 Female pelvic peritonitis
- 58949002 Tubo-ovarian abscess (disorder)
FAQ
- Q: My patient has negative testing for GC and CT, should I have her discontinue the medications if she has clinically improved?
- A: No. PID is a polymicrobial infection and the patient 's improvement is likely secondary to broad-spectrum antibiotic treatment. The patient should continue antibiotics as prescribed.
- Q: My patient has problems with adherence, could I use directly observed doses of azithromycin in the office?
- A: Although use of azithromycin is not considered a standard and/or recommended therapy by the CDC, one RCT in Brazil successfully used ceftriaxone 250 mg and azithromycin 1 g at baseline and then repeated the dose in 1 week. Although patients had good results, this has not been replicated and the CDC currently recommends that metronidazole 500 mg b.i.d. be administered with azithromycin to improve anaerobic coverage.
- Q: My patient is 6 weeks pregnant. Can she really have PID?
- A: PID is less common during pregnancy given the bactericidal protection afforded by the cervical mucous plug. However, it is possible for sperm to transport bacteria into the uterus during fertilization, infection to occur in the interim between implantation and full establishment of the mucous plug, and early loss of the mucous plug later in pregnancy. Caution should be used in caring for pregnant patients with PID because fetal wastage can occur due to infection. As such, the CDC recommends that these women be hospitalized for initial treatment.