Pelvic Inflammatory Disease (PID)

PID results from microorganisms ascending from the vagina and cervix into the endometrium and fallopian tubes. Neisseria gonorrhoeae Gonorrhea Gonorrhea is caused by the bacteria Neisseria gonorrhoeae. It typically infects epithelia of the urethra, cervix, rectum, pharynx, or conjunctivae, causing irritation or pain and purulent... read more and Chlamydia trachomatis Chlamydial, Mycoplasmal, and Ureaplasmal Mucosal Infections Sexually transmitted urethritis, cervicitis, proctitis, and pharyngitis not due to gonorrhea are caused predominantly by chlamydiae and infrequently by mycoplasmas or Ureaplasma sp. Chlamydiae... read more are common causes of PID; they are transmitted sexually. Mycoplasma genitalium, which is also sexually transmitted, can also cause or contribute to PID. Incidence of sexually transmitted PID is decreasing; < 50% of patients with acute PID test positive for gonorrhea or chlamydial infection.

PID usually also involves other aerobic and anaerobic bacteria, including pathogens that are associated with bacterial vaginosis Bacterial Vaginosis (BV) Bacterial vaginosis is vaginitis due to a complex alteration of vaginal flora in which lactobacilli decrease and anaerobic pathogens overgrow. Symptoms include a gray, thin, fishy-smelling vaginal... read more . Vaginal microorganisms such as Haemophilus influenzae, Streptococcus agalactiae, and enteric gram-negative bacilli can be involved in PID, as can Ureaplasma sp. Vaginal inflammation and bacterial vaginosis help in the upward spread of vaginal microorganisms.

Pelvic inflammatory disease commonly causes lower abdominal pain, fever, cervical discharge, and abnormal uterine bleeding, particularly during or after menses.

Pelvic inflammatory disease is suspected when women of reproductive age, particularly those with risk factors, have lower abdominal pain or cervical or unexplained vaginal discharge. PID is considered when irregular vaginal bleeding, dyspareunia, or dysuria is unexplained. PID is more likely if lower abdominal, unilateral or bilateral adnexal, and cervical motion tenderness are present. A palpable adnexal mass suggests tubo-ovarian abscess. Because even minimally symptomatic infection may have severe sequelae, index of suspicion should be high.

If PID is suspected, PCR of cervical specimens for N. gonorrhoeae and C. trachomatis (which is about 99% sensitive and specific) and a pregnancy test are done. If PCR is unavailable, cultures are done. However, upper tract infection is possible even if cervical specimens are negative. At the point of care, cervical discharge is usually examined to confirm purulence; a Gram stain or saline wet mount is used, but these tests are neither sensitive nor specific.

If a patient cannot be adequately examined because of tenderness, ultrasonography is done as soon as possible.

The white blood cell count may be elevated but is not helpful diagnostically.

If the pregnancy test is positive, ectopic pregnancy Ectopic Pregnancy In ectopic pregnancy, implantation occurs in a site other than the endometrial lining of the uterine cavity—ie, in the fallopian tube, uterine cornua, cervix, ovary, or abdominal or pelvic cavity... read more , which can produce similar findings, should be considered.

Other common causes of pelvic pain Female Pelvic Pain Pelvic pain is discomfort in the lower abdomen and is a common complaint. It is considered separately from vaginal pain and from vulvar or perineal pain, which occurs in the external genitals... read more include endometriosis Endometriosis In endometriosis, functioning endometrial cells are implanted in the pelvis outside the uterine cavity. Symptoms depend on location of the implants. The classic triad of symptoms is dysmenorrhea... read more , adnexal torsion Adnexal Torsion Adnexal torsion is twisting of the ovary and sometimes the fallopian tube, interrupting the arterial supply and causing ischemia. Adnexal torsion is uncommon, occurring most often during reproductive... read more , ovarian cyst rupture Benign Ovarian Masses Benign ovarian masses include functional cysts and tumors; most are asymptomatic. Treatment varies depending on the patient's reproductive status. There are 2 types of functional cysts: Follicular... read more , and appendicitis Appendicitis Appendicitis is acute inflammation of the vermiform appendix, typically resulting in abdominal pain, anorexia, and abdominal tenderness. Diagnosis is clinical, often supplemented by CT or ultrasonography... read more . Differentiating features of these disorders are discussed elsewhere.

Fitz-Hugh-Curtis syndrome may mimic acute cholecystitis Acute Cholecystitis Acute cholecystitis is inflammation of the gallbladder that develops over hours, usually because a gallstone obstructs the cystic duct. Symptoms include right upper quadrant pain and tenderness... read more but can usually be differentiated by evidence of salpingitis during pelvic examination or, if necessary, with ultrasonography.

If an adnexal or pelvic mass is suspected clinically or if patients do not respond to antibiotics within 48 to 72 hours, ultrasonography is done as soon as possible to exclude tubo-ovarian abscess, pyosalpinx, and disorders unrelated to PID (eg, ectopic pregnancy Ectopic Pregnancy In ectopic pregnancy, implantation occurs in a site other than the endometrial lining of the uterine cavity—ie, in the fallopian tube, uterine cornua, cervix, ovary, or abdominal or pelvic cavity... read more , adnexal torsion Adnexal Torsion Adnexal torsion is twisting of the ovary and sometimes the fallopian tube, interrupting the arterial supply and causing ischemia. Adnexal torsion is uncommon, occurring most often during reproductive... read more ).

If the diagnosis is uncertain after ultrasonography, laparoscopy should be done; purulent peritoneal material noted during laparoscopy is the diagnostic gold standard.

Antibiotics are given empirically to cover N. gonorrhoeae and C. trachomatis and are modified based on laboratory test results. Empirical treatment is needed whenever the diagnosis is in question for several reasons:

Patients with cervicitis or clinically mild to moderate PID do not require hospitalization. Outpatient treatment regimens (see table Regimens for Treatment of Pelvic Inflammatory Disease Regimens for Treatment of Pelvic Inflammatory Disease* ) usually also aim to eradicate bacterial vaginosis Treatment Bacterial vaginosis is vaginitis due to a complex alteration of vaginal flora in which lactobacilli decrease and anaerobic pathogens overgrow. Symptoms include a gray, thin, fishy-smelling vaginal... read more , which often coexists.

Sex partners of patients with N. gonorrhoeae or C. trachomatis infection should be treated.

If patients do not improve after treatment that covers the usual pathogens, PID due to M. genitalium should be considered. Patients can be treated empirically with moxifloxacin 400 mg orally once a day for 7 to 14 days (eg, for 10 days).

Women with PID are usually hospitalized if any of the following are present:

In these cases, IV antibiotics (see table Regimens for Treatment of Pelvic Inflammatory Disease Regimens for Treatment of Pelvic Inflammatory Disease* ) are started as soon as cultures are obtained and are continued until patients have been afebrile for 24 hours.

Tubo-ovarian abscess may require more prolonged IV antibiotic treatment. Treatment with ultrasound- or CT-guided percutaneous or transvaginal drainage can be considered if response to antibiotics alone is incomplete ( 1 Treatment reference Pelvic inflammatory disease (PID) is a polymicrobial infection of the upper female genital tract: the cervix, uterus, fallopian tubes, and ovaries; abscess may occur. PID may be sexually transmitted... read more ). Laparoscopy or laparotomy is sometimes required for drainage. Suspicion of a ruptured tubo-ovarian abscess requires immediate laparotomy. In women of reproductive age, surgery should aim to preserve the pelvic organs (with the hope of preserving fertility).