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ESSENTIALS OF DIAGNOSIS

  • Lower abdominal pain with uterine, adnexal, or cervical motion tenderness.

  • Absence of a competing diagnosis.

GENERAL CONSIDERATIONS

Pelvic inflammatory disease (PID) is a polymicrobial infection of the upper genital tract associated with the sexually transmitted organisms Neisseria gonorrhoeae and Chlamydia trachomatis as well as endogenous organisms, including anaerobes, Haemophilus influenzae, enteric gram-negative rods, and streptococci. It is most common in young, nulliparous, sexually active women with multiple partners and is a leading cause of infertility and ectopic pregnancy. The use of barrier methods of contraception may provide significant protection.

CLINICAL FINDINGS

A. Symptoms and Signs

Patients with PID most commonly present with lower abdominal pain. Additional complaints may include abnormal uterine bleeding and abnormal vaginal discharge. Systemic features such as fever typically indicate more severe disease, including pelvic abscess. Right upper quadrant pain (Fitz-Hugh and Curtis syndrome) may indicate an associated perihepatitis. Diagnosis of PID is complicated by the fact that many women may have subtle or mild symptoms that are not readily recognized as PID, such as postcoital bleeding, urinary frequency, or low back pain.

B. Minimum Diagnostic Criteria

Women with cervical motion, uterine, or adnexal tenderness meet diagnostic criteria for PID and should be treated with antibiotics unless there is a competing diagnosis, such as ectopic pregnancy or appendicitis.

C. Additional Criteria

No single historical, physical, or laboratory finding is definitive for acute PID (eFigure 18–17). The following criteria may be used to enhance the specificity of the diagnosis: (1) oral temperature higher than 38.3°C, (2) abnormal cervical or vaginal discharge with white cells on saline microscopy (greater than 1 leukocyte per epithelial cell), (3) elevated erythrocyte sedimentation rate, (4) elevated C-reactive protein, and (5) laboratory documentation of cervical infection with N gonorrhoeae or C trachomatis. Testing for gonorrhea and chlamydia should be performed routinely, but treatment should not be delayed while awaiting results.

eFigure 18–17.

Pelvic inflammatory disease. A: Transverse sonogram of the pelvis demonstrating multiple irregular abscesses containing internal low-level echoes (arrows). B: Sagittal sonogram of a multiloculated abscess (A) containing septations and low-level echoes. B, bladder; U, uterus. (Reproduced, with permission from Krebs CA, Giyanani VL, Eisenberg RL. Ultrasound Atlas of Disease Processes. Originally published by Appleton & Lange. Copyright © 1993 by The McGraw-Hill Companies, Inc.)

DIFFERENTIAL DIAGNOSIS

Appendicitis, ectopic pregnancy, septic abortion, hemorrhagic or ruptured ovarian cysts or tumors, torsion of an ovarian cyst, degeneration of a myoma, and acute enteritis must be considered. PID is more likely to occur when there is a prior history of PID, recent sexual contact, recent onset ...

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