Pelvic Inflammatory Disease (PID)

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

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

  • 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

MINIMUM DIAGNOSTIC CRITERIA

• 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

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 ...