Pelvic Inflammatory Disease (PID)

• • Lower abdominal pain

  • Fever and chills

  • Menstrual disturbances

  • Purulent cervical discharge

  • Cervical and adnexal tenderness

Epidemiology

• • 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

Symptoms and Signs

• • 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)

Laboratory Findings

• • 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

Imaging Findings

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

• • 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

Rule Out

• • Ectopic pregnancy

  • Septic abortion

  • Torsed or hemorrhagic ovarian cyst

• • Thorough pelvic exam

  • Endocervical culture for N gonorrhoeae and C trachomatis

  • CBC

  • Basic chemistries

  • β-hCG

  • Transvaginal US

  • Endometrial biopsy

When to Admit

• • 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

When to Refer

• • 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

• • 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 ...