Pelvic Inflammatory Disease

Other Names

• PID
• Pelvic Inflammatory Disease

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Background

• This page refers to pelvic inflammatory disease (PID)

History
Epidemiology

• 10-15% of women with Neisseria gonorrhoeae or Chlamydia trachomatis will go on to develop PID
• Often affects young, sexually active females aged 15-25
• Incidence has been decreasing secondary to early identification and treatment and prevention, however subclinical PID remains difficult to diagnose

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Introduction

• Upper genital tract infection in females, usually ascending from the lower genital tract
• Majority (85%) of cases in women are secondary to sexually transmitted infection
• Infection by above listed bacteria in the lower genital tract may ascend through the cervix into the upper genital tract
• Inflammation and scarring of the upper genital tract (uterus, fallopian tubes, ovaries) can ensue
• Inflammation and scarring specifically of the Fallopian tubes may result in infertility

Microbiology

• Most common bacteria isolated are Neisseria gonorrhoeae and/or Chlamydia trachomatis
• Other bacteria isolated: Mycoplasma genitalium, Peptostreptococcus species, Bacteroides species

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Risk Factors

• Unprotected intercourse
• Intercourse with multiple partners
• Untreated sexually transmitted infection
• Intrauterine device placement

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Differential Diagnosis

• Ectopic pregnancy
• Pelvic venous congestion syndrome
• Appendicitis
• Endometriosis
• Ovarian torsion
• Ruptured ovarian cyst
• Urinary tract infection/cystitis
• Cervicitis

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Clinical Features

History

• Abdominal pain may be insidious in onset
• May have history of untreated or unidentified sexually transmitted infection
• Abdominal pain is usually in the lower abdomen/pelvis
• Dyspareunia is a common complaint
• Abdominal pain may be associated with vaginal discharge, abnormal vaginal bleeding, or dysuria
• Systemic symptoms such as fever, nausea, vomiting can be present
• History of recent IUD placement

Physical Exam

• Abdominal tenderness to palpation in lower quadrants (right and/or left may be tender)
• Rebound, guarding, rigidity usually not present and may clue you into an alternative diagnosis (ectopic pregnancy)

Pelvic Exam

• Should be performed in all females with lower abdominal pain or suspected PID
• Evaluate for discharge, usually purulent and foul-smelling if present
• Evaluate for genital lesions (may be multiple sexually transmitted infections present
• Evaluate the cervix for friability or bleeding with cotton-tip applicator
• Bi-manual exam to evaluate for cervical motion tenderness (Chandelier Sign)

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Evaluation

• PID is a clinical diagnosis
• Labs such as CBC, CMP, UA with microscopy can aid in identification of other causes of abdominal pain
• Urine pregnancy test should be obtained in all females of child-bearing age with lower abdominal pain to rule-out ectopic pregnancy
• Cervical/vaginal swabs with pelvic exam - Gonococcal, Chlamydial, Trichomoniasis testing
  • Negative results do not exclude the diagnosis of PID
• Consider HIV and syphilis co-testing as well
• Transvaginal pelvic ultrasound to identify complications such as tubo-ovarian abscess or identify ectopic pregnancy

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Classification

• N/A

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Management

• Early identification and treatment based on clinical suspicion helps decrease risk of complications

Outpatient Treatment

• Doxycycline 100mg PO twice daily x14 days PLUS
• Ceftriaxone 500mg IM once OR
• Cefoxitin 2g IM with probenecid 1g PO once OR
• Another 3rd generation cephalosporin that is given IV or IM
• Add metronidazole 500mg PO twice daily x14 days if recent IUD insertion
• Remove IUD to prevent recurrent infection

Inpatient Treatment

• Cefotetan 2g IV every 12hrs PLUS doxycycline 100mg PO every 12hrs OR
• Cefoxitin 2g IV every 6hrs PLUS doxycycline 100mg PO every 12hrs OR
• Clindamycin 900mg IV every 8hrs PLUS gentamicin 3-5mg/kg IV daily

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Rehab and Return to Sport

Rehab

• Not applicable

Return to Sport/Work

• Athlete can usually return to play after completing antibiotic treatment unless systemically ill

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Prognosis and Complications

Prognosis

• Most patients do well if treated early and correctly

Complications

• Complications can occur even with appropriate antibiotic treatment
• Delayed or lack of treatment was found to lead to worse outcomes across the board
• Some associated complications include ectopic pregnancy (7.8%), recurrent PID, infertility (5-fold increase), chronic abdominal or pelvic pain (33.3%)
• Untreated infection may lead to tubo-ovarian abscess formation requiring removal of Fallopian tube/ovary or drainage of abscess, thus increasing infertility

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See Also

• OBGYN Main
• Abdominal Pain

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