- • No set of signs or symptoms is pathognomonic for
pelvic inflammatory disease (PID), and most laboratory tests are
nonspecific for its diagnosis.
- • Because clinically mild and subclinical PID causes
most cases of postinfectious tubal factor infertility, ectopic pregnancy,
and chronic pelvic pain due to pelvic scarring in women, a low threshold
should be used to make the diagnosis of PID.
- • All sexually active young women and other women
at risk for sexually transmitted diseases (STDs) who complain of
acute lower abdominal or pelvic pain; demonstrate uterine, adnexal,
or cervical motion tenderness on examination; and have no other
causes for these symptoms, should be diagnosed and treated for PID.
PID is the most common serious infection acquired by sexually
active women in the United States. Between 750,000 and one million
women develop PID annually, with a 1.5% annual incidence
among adolescents and higher rates among nonwhite populations. Since
the early 1990s, the numbers of hospitalizations and initial visits
to outpatient facilities including physicians’ offices
for PID has steadily declined. Nevertheless, PID led to 123,000
initial visits to physicians’ offices in 2003, a figure
that underestimates the true number of new outpatient PID cases
in the United States because the nature of physician office reporting
is inherently incomplete, and excludes emergency department visits.
Postinfectious tubal factor infertility is the second most common
cause of female infertility in the United States. Yet the majority
of women with this condition do not have a clear history of PID, suggesting
that many cases of PID are subclinical and therefore go untreated.
Several studies have shown that upon in-depth questioning, 70–80% of
patients with tubal factor infertility have a history of lower abdominal
pain. Demographic and microbiologic factors associated with acute
and subclinical PID are similar, supporting the hypothesis that
they share the same pathophysiologic mechanisms. Therefore, until
improved tests are available to diagnose subclinical disease, clinicians
should use a low threshold in making the diagnosis of PID, and women
at risk of an STD should be educated to recognize the symptoms of
PID and to seek immediate care and treatment.
Neisseria gonorrhoeae and Chlamydia trachomatis are common causes
of PID. In a recent US multicenter study of women with mild to moderate PID,
these pathogens accounted for 20% and 21% of cases,
respectively; coinfection with N gonorrhoeae and C trachomatis was found in 6% of
cases. These bacteria initially cause an endocervical infection;
however, as a result of poorly defined anatomic, pathologic, and
immunologic changes, between 10% and 20% of primary
endocervical gonococcal and chlamydial infections will lead to an
ascending infection of the endometrium and fallopian tubes. Over
the past two decades, the proportion PID cases caused by N gonorrhoeae and C
trachomatis has declined in parallel with the overall reduction
of these STDs in the US population.
In many studies, neither gonorrhea nor chlamydia is detected
in 60% or more of women with PID. Anaerobic ...