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Key Features

Essentials of Diagnosis

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

  • Absence of a competing diagnosis

General Considerations

  • A polymicrobial infection of the upper genital tract associated with

    • The sexually transmitted organisms Neisseria gonorrhoeae and Chlamydia trachomatis

    • Endogenous organisms, including anaerobes, Haemophilus influenzae, enteric gram-negative rods, and streptococci

    • Leading cause of infertility and ectopic pregnancy

Demographics

  • Most common in young, nulliparous, sexually active women with multiple partners

  • The use of barrier methods of contraception may provide significant protection

Clinical Findings

Symptoms and Signs

  • Symptoms may include

    • Lower abdominal pain

    • Abnormal uterine bleeding

    • Abnormal vaginal discharge

    • Fever typically indicates more severe disease, including pelvic abscess

  • Right upper quadrant pain (Fitz-Hugh and Curtis syndrome) may indicate an associated perihepatitis

  • Diagnosis is complicated by the fact that many women have mild symptoms, not readily recognized as PID, such as postcoital bleeding, urinary frequency, or low back pain

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.

  • The following criteria may be used to enhance the specificity of the diagnosis

    • Oral temperature > 38.3°C

    • Abnormal cervical or vaginal discharge with white cells on saline microscopy (> 1 leukocyte per epithelial cell)

    • Elevated erythrocyte sedimentation rate

    • Elevated C-reactive protein

    • Laboratory documentation of cervical infection with N gonorrhoeae or C trachomatis

    • Treatment should not be delayed while awaiting results

Differential Diagnosis

  • Ectopic pregnancy

  • Appendicitis

  • Septic abortion

  • Hemorrhagic or ruptured ovarian cyst or tumor

  • Ovarian torsion

  • Tubo-ovarian abscess

  • Degeneration of myoma

  • Acute enteritis

Diagnosis

Laboratory Tests

  • Abnormal cervical or vaginal discharge may show white blood cells on saline microscopy

  • Endocervical culture for N gonorrhoeae and saline wet mount for C trachomatis

  • Erythrocyte sedimentation rate and C-reactive protein may be elevated

Imaging Studies

  • Pelvic and vaginal ultrasound can differentiate ectopic pregnancy of over 6 weeks

Diagnostic Procedures

  • Laparoscopy

    • Can diagnose PID

    • It is imperative if the diagnosis is not certain or if the patient has not responded to antibiotic therapy after 48 hours

    • The appendix should be visualized at laparoscopy to rule out appendicitis

    • Cultures obtained at the time of laparoscopy are often helpful

Treatment

Medications

  • Antibiotic treatment should not be delayed while awaiting culture results

  • The sexual partner should be examined and treated appropriately

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