Pelvic inflammatory disease (PID) comprises a spectrum of infections of the female upper reproductive tract. Most cases originate as lower genital tract infections that ascend to cause salpingitis, endometritis, myometritis, parametritis, tubo-ovarian abscess (TOA), perihepatitis, or focal pelvic peritonitis. Neisseria gonorrhea or Chlamydia trachomatis are common pathogens; however, 30% to 40% of infections are polymicrobial. Risk factors include multiple sexual partners, sexual abuse, adolescence, presence of other sexually transmitted diseases, douching, lack of condom use, delay in seeking care, and intrauterine device use. PID occurs less commonly in pregnancy, but first trimester infections can lead to fetal loss. Long-term sequelae include ectopic pregnancy, infertility, and chronic pain.
Lower abdominal pain is usually present. Other symptoms include vaginal discharge, vaginal bleeding, dyspareunia, urinary discomfort, fever, nausea, and vomiting. Peritoneal signs may be present. Occasionally, symptoms are minimal. An exquisitely tender unilateral mass may suggest TOA. The presence of right upper quadrant tenderness, especially with associated jaundice, may indicate Fitz-Hugh-Curtis syndrome (perihepatitis).
The clinical diagnosis of PID is imprecise. Diagnostic criteria for empiric treatment are listed in Table 64-1. Obtain a pregnancy test, wet prep, and endocervical swabs for gonorrhea and chlamydia. A pelvic ultrasound will help detect TOA and may differentiate PID from surgical conditions such as appendicitis, cholecystitis, and ovarian torsion. The differential diagnosis includes gastroenteritis, diverticulitis, ectopic pregnancy, spontaneous or septic abortion, ovarian cyst, pyelonephritis, and renal colic.
Table 64-1 Diagnostic Criteria for PID |Favorite Table|Download (.pdf)
Table 64-1 Diagnostic Criteria for PID
|1. Minimal criteria for diagnosis and empiric treatment:|
- Lower abdominal or pelvic pain without another identifiable cause PLUS
- Uterine tenderness or
- Adnexal tenderness or
- Cervical motion tenderness
|2. Additional criteria improving diagnostic specificity:|
- Oral temperature >101°F (38.3°C)
- Abnormal cervical or vaginal mucopurulent discharge
- Abundant numbers of WBC on saline microscopy of vaginal fluid
- Elevated erythrocyte sedimentation rate
- Elevated C-reactive protein
- Laboratory evidence of cervical infection with Neisseria gonorrhea or Chlamydia trachomatis (ie, culture or DNA probe techniques)
|3. Most specific criteria:|
- Transvaginal ultrasound (or MRI) showing thickened, fluid-filled tubes with or without free pelvic fluid or tuboovarian complex
- Laparoscopic confirmation*
- Endometrial biopsy showing endometritis*
Treatment guidelines of the Centers for Disease and Control Prevention are outlined in Tables 64-2 and 64-3. Patients with mild to moderate symptoms may be treated with oral therapy as outpatients. Adequate analgesia and hydration should be provided.
Table 64-2 Parenteral Treatment Regimens for Pelvic Inflammatory Disease |Favorite Table|Download (.pdf)
Table 64-2 Parenteral Treatment Regimens for Pelvic Inflammatory Disease
Cefotetan 2 grams IV q12h or cefoxitin 2 grams IV q6h
Doxycycline 100 milligrams IV or PO q12h
Clindamycin 900 milligrams IV q8h