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  • • Lower abdominal pain

    • Fever and chills

    • Menstrual disturbances

    • Purulent cervical discharge

    • Cervical and adnexal tenderness

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Epidemiology

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  • • Also referred to as salpingitis or endometritis

    • PID is a polymicrobial infection of the upper genital tract

    • Associated with the sexually transmitted organisms Neisseria gonorrhoeae or Chlamydia trachomatis, as well as endogenous organisms including anaerobes, Haemophilus influenza, enteric gram-negative rods, and streptococci

    • Most common in young, nulliparous, sexually active women with multiple partners

    • PID is more likely to occur when there is a history of PID, recent sexual contact, sexual contact with a partner who has a sexually transmitted disease, recent onset of menses, or when an intrauterine device is used for contraception

    • Other risk markers include nonwhite race, frequent douching, and smoking

    • The use of oral contraceptives or barrier methods of contraception are protective

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Symptoms and Signs

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  • • Lower abdominal pain

    • Cervical motion tenderness

    • Adnexal discomfort

    • Temperature > 38.3 °C

    • Purulent cervical discharge

    • Menstrual disturbances

    • Right upper quadrant pain (perihepatitis seen in Fitz-Hugh and Curtis syndromes)

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Laboratory Findings

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  • • Elevated ESR or C-reactive protein

    • Cervical infection with N gonorrhoeae or C trachomatis

    • Histopathologic evidence of endometritis on endometrial biopsy

    • β-hCG negative

    • Urine microscopic exam will frequently show a few RBCs and WBCs but is culture negative

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Imaging Findings

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  • • Transvaginal US demonstrates fluid-filled tubes often with free pelvic fluid in the cul-de-sac and tubo-ovarian complex

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  • • Acute appendicitis

    • Ectopic pregnancy

    • Septic abortion

    • Hemorrhagic ovarian cysts or tumors

    • Ruptured ovarian cysts or tumors

    • Torsed ovarian cyst or tumor

    • Myoma degeneration

    • Acute enteritis

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Rule Out

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  • • Ectopic pregnancy

    • Septic abortion

    • Torsed or hemorrhagic ovarian cyst

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  • • Thorough pelvic exam

    • Endocervical culture for N gonorrhoeae and C trachomatis

    • CBC

    • Basic chemistries

    • β-hCG

    • Transvaginal US

    • Endometrial biopsy

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When to Admit

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  • • Patient clinically toxic

    • When surgical emergencies such as acute appendicitis cannot be ruled out

    • Presence of tubo-ovarian abscess

    • Patient is pregnant

    • Unable to follow or tolerate outpatient antibiotic regimen

    • Failure to clinically respond to outpatient oral antibiotic therapy

    • Patient is immunodeficient

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When to Refer

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  • • Patient clinically toxic

    • When surgical emergencies such as acute appendicitis cannot be ruled out

    • Presence of tubo-ovarian abscess

    • Patient is pregnant

    • Patient is immunodeficient

    • Failure to respond to conservative IV antibiotic therapy

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  • • Early antibiotic therapy against N gonorrhoeae, C trachomatis, and enteric organisms is essential to prevent long-term sequelae

    • Sexual partner should be examined and treated appropriately

    • Outpatient antibiotic therapy is acceptable for uncomplicated cases

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