Pelvic Inflammatory Disease (PID)

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

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

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

Medications

• Antibiotic treatment should not be delayed while awaiting culture results

• The sexual partner should be examined and treated appropriately

INPATIENT REGIMENS

• Cefotetan 2 g intravenously every 12 hours or cefoxitin 2 g intravenously every 6 hours plus doxycycline 100 mg orally or intravenously every 12 hours

• Clindamycin 900 mg intravenously every 8 hours plus gentamycin, a loading dose 2 mg/kg intravenously or intramuscularly followed by a maintenance dose of 1.5 mg/kg every 8 hours (or as a single daily dose, 3–5 mg/kg)

• These regimens should be continued for a minimum of 24 hours after the patient shows significant clinical improvement

• Then, an oral regimen should be started to complete a total of 14 days of therapy with either doxycycline, 100 mg orally twice a day, or clindamycin, 450 mg orally four times a day

• If a tubo-ovarian abscess is present, clindamycin or metronidazole should be used with doxycycline to complete the 14-day treatment for better anaerobic coverage

OUTPATIENT REGIMENS

• Single dose of cefoxitin, 2 g intramuscularly, with probenecid, 1 g orally, plus doxycycline 100 mg orally twice daily for 14 days; or ceftriaxone 250 mg intramuscularly plus doxycycline, 100 mg orally twice daily, for 14 days

• Adding metronidazole (500 mg orally twice daily for 14 days) to either of these regimens treats bacterial vaginosis that is frequently associated with PID

Surgery

• Tubo-ovarian abscesses may require surgical excision or transcutaneous or transvaginal aspiration

• Unilateral adnexectomy is acceptable for unilateral abscess

• Hysterectomy and bilateral salpingo-oophorectomy may be necessary for overwhelming infection or in cases of chronic disease with intractable pelvic pain

Follow-Up

• Inpatient therapy for tubo-ovarian abscess should be monitored by ultrasound

Complications

• In spite of treatment, one-fourth of women with acute disease develop long-term sequelae, including

  • Repeated episodes of infection

  • Chronic pelvic pain

  • Dyspareunia

  • Ectopic pregnancy

  • Infertility

• The risk of infertility increases with repeated episodes of salpingitis: it is estimated at 10% after the first episode, 25% after a second episode, and 50% after a third episode

Prognosis

• Early treatment with effective antibiotics is essential to prevent long-term sequelae

• For tubo-ovarian abscess, unless rupture is suspected, high-dose antibiotic therapy in the hospital is effective in 70% of cases. In 30%, there is inadequate response in 48–72 hours, and surgical intervention is required

When to Admit

• Admit for intravenous antibiotic therapy if

  • Patient has a tubo-ovarian abscess

  • Patient is pregnant

  • Patient is unable to follow or tolerate an outpatient regimen

  • Patient has not responded clinically to outpatient therapy within 72 hours

  • Patient has severe illness, nausea and vomiting, or high fever

  • Surgical emergencies, such as appendicitis, cannot be ruled out