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Key Clinical Updates in Pelvic Inflammatory Disease (Salpingitis, Endometritis)

The recommended outpatient regimen is ceftriaxone (500 mg intramuscularly; 1 g for persons who weigh 150 kg or greater) plus doxycycline (100 mg orally twice a day for 14 days) with metronidazole 500 mg orally twice a day or a single dose of cefoxitin (2 g intramuscularly) with probenecid (1 g orally) plus doxycycline (100 mg orally twice daily for 14 days) and metronidazole 500 mg orally twice daily for 14 days.

Workowski KA et al. MMWR Recomm Rep. [PMID: 34292926]


  • Lower abdominal or pelvic pain.

  • Uterine, adnexal, or cervical motion tenderness.

  • Absence of a competing diagnosis.


Pelvic inflammatory disease is a polymicrobial infection of the upper genital tract associated with the sexually transmitted organisms N gonorrhoeae and C 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.


A. Symptoms and Signs

Patients with PID most commonly present with lower abdominal pain. Additional complaints may include AUB and abnormal vaginal discharge. Systemic features such as fever typically indicate more severe disease, including pelvic abscess. Right upper quadrant pain may indicate an associated perihepatitis (Fitz-Hugh-Curtis syndrome). Diagnosis of PID is complicated by the fact that 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

PID is diagnosed clinically. 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.

C. Additional Criteria

No single historical, physical, or laboratory finding is definitive for acute PID (eFigure 18–17). 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 ESR, (4) elevated CRP, and (5) laboratory documentation of cervical infection with N gonorrhoeae or C trachomatis. Testing for gonorrhea and chlamydia should be performed. Treatment should not be delayed while awaiting results.

eFigure 18–17.

Pelvic inflammatory disease with a characteristic pyosalpinx (Fallopian tube filled, even distended, with pus), most commonly caused by infection with chlamydia and/or gonorrhea. A. Transvaginal sonogram shows a pyosalpinx and both ovaries as part of a tuboovarian complex. TUBE, Fallopian tube, RT OV, right ovary, LT OV, left ovary; B. CT image shows a ...

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