Pelvic inflammatory disease

Background
Pelvic anatomy.
  • Pelvic Inflammatory Disease (PID) comprises spectrum of infections of the upper reproductive tract:
  • It is the most common serious infection in women aged 16 to 25 years and begins as cervicitis (commonly due to GC or chlamydia) that may progress to polymicrobial infection.
    • Initial lower tract infection may be asymptomatic
    • Most common cause of death is rupture of a tubo-ovarian abscess
    • Can be caused by organisms such as M. genitalium which is very difficult to isolate and will not be picked up on routine testing
  • Bilateral tubal ligation does not confer protection against risk[1]

Risk factors[2]
  • Age < 25
  • Age at first sexual intercourse < 20
  • Non-white ethnicity
  • Nulliparous
  • History of transmitted diseases, especially chlamydia
  • IUD within 21 days after insertion[3]

Clinical Features

History

Physical Exam
  • Cervical motion tenderness
  • Adnexal tenderness (Most sensitive finding - Sn ~95%)
  • Mucopurulent cervicitis
    • Absence should prompt consideration of another diagnosis
  • RUQ Pain
    • May indicate perihepatic inflammation (particularly if jaundice also present)


Complications

Differential Diagnosis

Pelvic Pain

Pelvic origin

Abdominal origin

Evaluation
PID with pyosalpinx on transvaginal ultrasound: bilateral adenexal cysts consistent with pyosalpinges (white arrows).
PID on CT with bilateral adnexal complex fluid-filled and thick-walled cysts typical for tubo-ovarian abcess formation and an associated ileus.

Workup
  • Urine pregnancy
  • Wet mount
  • Endocervical swab (for GC, Chlamydia)
  • CBC
  • ESR/CRP
  • Urine culture, analysis (to exclude UTI)
  • Pelvic ultrasound
    • Ultrasound sensitivity may be as low as 56% and specificity of 85% [4]
  • CT

CDC Empiric Diagnosis Criteria[5]
  • Woman at risk for STIs
  • Pelvic or lower abdominal pain
  • No cause for the illness other than PID can be identified
  • At least one of the following on pelvic exam:
    • CMT
    • Uterine tenderness
    • Adnexal tenderness.
  • Additional criteria that make the diagnosis more likely:
    • Oral temperature >101° F (>38.3° C)
    • Abnormal cervical or vaginal mucopurulent discharge
    • Presence of abundant numbers of WBC on saline microscopy of vaginal fluid
    • Elevated ESR
    • Elevated CRP
    • Laboratory documentation of cervical infection with GC or chlamydia

Management
No sexual activity for 2 weeks;
Treat all partners who had sex with patient during previous 60 days prior to symptom onset

Outpatient Options
  • Ceftriaxone 250mg IM (or IV)[6] x1 + doxycycline 100mg PO BID x14d +/- metronidazole 500mg PO BID x14d [7]
    • Metronidazole based upon assessment of risk for anaerobes; consider in:
      • Pelvic abscess
      • Proven or suspected infection w/ Trichomonas or Bacterial Vaginosis
      • History of gynecological instrumentation in the preceding 2-3wks
  • Cefoxitin 2 g IM in a single dose and Probenecid, 1 g PO administered concurrently in a single dose[8] + Doxycycline 100 mg PO BID x 14 days +/- flagyl based on above criteria

Alternative Outpatient Options

Inpatient

IUD
  • No change in treatment if IUD in place (may treat without removal)


Due to inability to test for all causative pathogens and the potential for serious complications such as infertility, the CDC has made this a purposefully vague condition with a low threshold for empiric treatment

Disposition

Admit

Discharge
  • 72hr follow up
  • Instruct patient to abstain from sex or adhere strictly to condom use until partner treatment and symptoms have abated
  • HIV+ is not an automatic criteria for admission, consider overall clinical impression

See Also

References
  1. Shepherd SM et al. Pelvic Inflammatory Disease Clinical Presentation. Jan 2017. https://emedicine.medscape.com/article/256448-clinical#b1.
  2. Simms I et al. Risk factors associated with pelvic inflammatory disease. Sex Transm Infect. 2006 Dec; 82(6): 452–457.
  3. https://www.cdc.gov/std/tg2015/pid.htm
  4. Lee DC, Swaminathan AK. Sensitivity of ultrasound for the diagnosis of tubo-ovarian abscess: a case report and literature review. J Emerg Med. 2011 Feb;40(2):170-5. doi: 10.1016 PMID 20466506
  5. http://www.cdc.gov/std/tg2015/pid.htm
  6. Hayes BD. Trick of the Trade: IV ceftriaxone for gonorrhea. October 9th, 2012 ALiEM. https://www.aliem.com/2012/10/trick-of-trade-iv-ceftriaxone-for/. Accessed October 23, 2018.
  7. Ness RB et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol 2002;186:929–37
  8. CDC PID Treatment http://www.cdc.gov/std/treatment/2010/pid.htm
  9. Savaris RF. et al. Comparing ceftriaxone plus azithromycin or doxycycline for pelvic inflammatory disease: a randomized controlled trial. Obstet Gynecol. 2007 Jul;110(1):53-60
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