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Key Features

Essentials of Diagnosis

  • Lower abdominal or pelvic pain

  • 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

  • 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


  • 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

    • Chills and fever

    • Menstrual disturbances

    • Purulent cervical discharge

    • Cervical and adnexal tenderness

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

  • 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


  • Women with cervical motion, uterine, or adnexal tenderness should be treated as PID 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

    • Endocervical culture should be performed routinely, but treatment should not be delayed while awaiting results

Differential Diagnosis

  • Ectopic pregnancy

  • Appendicitis

  • Septic abortion

  • Ruptured ovarian cyst or tumor

  • Ovarian torsion

  • Tubo-ovarian abscess

  • Degeneration of leiomyoma (fibroid)

  • Diverticulitis

  • Cystitis

  • Tuberculous salpingitis

  • Actinomycosis with prolonged intrauterine device use


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 ...

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