Pelvic Inflammatory Disease (PID)

PID results from microorganisms ascending from the vagina and cervix into the uterus and fallopian tubes. The sexually transmitted infections Neisseria gonorrhoeae Gonorrhea Gonorrhea is caused by the bacterium 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 Chlamydia and Mycoplasmal Mucosal Infections Sexually transmitted urethritis, cervicitis, proctitis, and pharyngitis (that are not due to gonorrhea) are caused predominantly by chlamydiae and less frequently by mycoplasmas. Chlamydiae... read more are common causes of PID. 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 chlamydia.

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

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

Index of suspicion should be high, particularly in reproductive-age women and girls with risk factors, because clinical presentation is variable and even minimally symptomatic infection may have severe sequelae.

PID is suspected when women of reproductive age have lower abdominal pain or cervical or unexplained vaginal discharge, particularly with fever. PID is also considered when irregular vaginal bleeding, dyspareunia, or dysuria is unexplained.

A presumptive diagnosis of PID should be made and treatment initiated for sexually active young women and other women at risk for STIs if they are experiencing pelvic or lower abdominal pain, no cause for the illness other than PID can be identified, and if 1 or more of the following 3 minimum clinical criteria are present on pelvic examination:

In addition, on pelvic examination, a palpable adnexal mass suggests tubo-ovarian abscess.

If PID is suspected, NAAT (nucleic acid amplification test) of cervical specimens for N. gonorrhoeae and C. trachomatis (which is about 99% sensitive and specific) is done. If NAAT is unavailable, cultures are done. However, upper tract infection is possible even if tests for cervical infection are negative.

The white blood cell count may be elevated but is not helpful diagnostically. A pregnancy test should be performed in reproductive-age women.

If a patient cannot be adequately examined because of tenderness, imaging studies are done as soon as possible. Ultrasonography is the preferred first-line test. If ultrasound is not available or is inconclusive, other imaging modalities like CT scan may be performed to evaluate for abscess formation, including tubo-ovarian abscess.

Other indications for imaging are if an adnexal or pelvic mass is suspected clinically or if patients do not respond to antibiotics within 48 to 72 hours. In such cases, ultrasonography or CT scan is done as soon as possible to exclude tubo-ovarian abscess, pyosalpinx, and disorders unrelated to PID (eg, ectopic pregnancy Ectopic Pregnancy Ectopic pregnancy is the implantation of a pregnancy in a site other than the endometrial lining of the uterine cavity—ie, in the fallopian tube, uterine cornua, cervix, ovary, or abdominal... 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. Symptoms include severe pelvic pain, often with nausea and vomiting... read more ).

If the diagnosis is uncertain after ultrasonography or other imaging modalities, or if empiric treatment for PID fails, laparoscopy should be done; purulent peritoneal material noted during laparoscopy is the diagnostic gold standard.

When a PID diagnosis is suspected but cervical infection has not been confirmed or the patient does not meet all clinical criteria, empiric treatment of PID is given for several reasons:

Antibiotics are given empirically to cover N. gonorrhoeae, C. trachomatis, and vaginal flora, including anaerobes, and are modified based on laboratory test results.

Patients with cervicitis or clinically mild to moderate PID do not require hospitalization. Outpatient treatment regimens (see table ) usually also aim to eradicate bacterial vaginosis Treatment Bacterial vaginosis is a dysbiosis, a complex alteration of vaginal flora, in which lactobacilli decrease and anaerobic pathogens overgrow. Symptoms include a yellow-green or gray, thin, malodorous... 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 may 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 ) 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 caused by sexually... 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).