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18-16: Pelvic Inflammatory Disease (Salpingitis, Endometritis)

Jason Woo; Rachel K. Scott

ESSENTIALS OF DIAGNOSIS

Uterine, adnexal, or cervical motion tenderness.
Abnormal discharge from the vagina or cervix.
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.

Tuberculous salpingitis is rare in the United States but more common in developing countries; it is characterized by pelvic pain and irregular pelvic masses not responsive to antibiotic therapy. It is not sexually transmitted.

CLINICAL FINDINGS

A. Symptoms and Signs

Patients with PID may have lower abdominal pain, chills and fever, menstrual disturbances, purulent cervical discharge, and cervical and adnexal tenderness. Right upper quadrant pain (Fitz-Hugh and Curtis syndrome) may indicate an associated perihepatitis. However, 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 should be considered to have PID and 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 18–19). 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. Endocervical culture should be performed routinely, but treatment should not be delayed while awaiting results.

eFigure 18–19.

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.)