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Pelvic Inflammatory Disease
Pelvic inflammatory disease (PID) is an acute infection of the upper genital tract in women, involving any or all of the uterus, oviducts, and ovaries. PID is a community acquired infection initiated by a sexually transmitted agent.
Clinical evaluation
Lower abdominal pain is the cardinal presenting symptom in women with PID, although the character of the pain may be quite subtle. The onset of pain during or shortly after menses is particularly suggestive. The abdominal pain is usually bilateral and rarely of more than two weeks' duration.
Abnormal uterine bleeding occurs in one-third or more of patients with PID. New vaginal discharge, urethritis, proctitis, fever, and chills can be associated signs.
Risk factors for PID:
- Age less than 35 years
- Nonbarrier contraception
- New, multiple, or symptomatic sexual partners
- Previous episode of PID
- Oral contraception
Physical examination
Only one-half of patients with PID have fever. Abdominal examination reveals diffuse tenderness greatest in the lower quadrants, which may or may not be symmetrical. Rebound tenderness and decreased bowel sounds are common. Tenderness in the right upper quadrant does not exclude PID, because approximately 10 percent of these patients
have perihepatitis (Fitz-Hugh Curtis syndrome).
Purulent endocervical discharge and/or acute cervical motion and adnexal tenderness by
bimanual examination is strongly suggestive of PID. Rectovaginal examination should reveal the uterine adnexal tenderness.
Diagnosis
Diagnostic criteria and guidelines.
The index of suspicion for the clinical diagnosis of PID should be high, especially in adolescent women.
The CDC has recommended minimum criteria required for empiric treatment of PID. These major determinants include lower abdominal tenderness, adnexal tenderness, and cervical motion tenderness.
Minor determinants (ie, signs that may increase the suspicion of PID) include:
- Fever (oral temperature >101°F; >38.3°C)
- Vaginal discharge
- Documented STD
- Erythrocyte sedimentation rate (ESR)
- C-reactive protein
- Systemic signs
- Dyspareunia
Empiric treatment for pelvic inflammatory disease is recommended when:
- The examination suggests PID
- Demographics (risk factors) are consistent with PID
- Pregnancy test is negative
Laboratory Evaluation for Pelvic Inflammatory Disease
- Pregnancy test
- Microscopic exam of vaginal discharge in saline
- Complete blood counts
- Tests for chlamydia and gonococcus
- Urinalysis
- Fecal occult blood test
- C-reactive protein(optional)
Diagnostic testing
Laboratory testing
for patients suspected of having PID always begins with a pregnancy test to rule out ectopic pregnancy and complications of an intrauterine pregnancy. A urinalysis and a stool for occult blood should be obtained because abnormalities
in either reduce the probability of PID.
Blood counts have limited value. Fewer than onehalf of PID patients exhibit leukocytosis.
Gram stain and microscopic examination of vaginal discharge may provide useful information. If a cervical Gram stain is positive for Gram-negative intracellular diplococci, the probability of PID greatly increases; if negative, it is of little use.
Increased white blood cells (WBC) in vaginal fluid may be the most sensitive single laboratory test for PID (78 percent for >3 WBC per high power field. However, the specificity is only 39 percent.
Recommended laboratory tests:
1. Pregnancy test
2. Microscopic exam of vaginal discharge in saline
3. Complete blood counts
4. Tests for chlamydia and gonococcus
5. Urinalysis
6. Fecal occult blood test
7. C-reactive protein(optional)
Ultrasound imaging is reserved for acutely ill patients with PID in whom a pelvic abscess is a consideration.
Health care providers should maintain a low threshold for the diagnosis of PID, and sexually active young women with lower abdominal, adnexal, and cervical motion tenderness should receive empiric treatment. The specificity of these clinical criteria can be enhanced by the presence of fever, abnormal cervical/vaginal discharge, elevated ESR and/or serum C-reactive protein, and the demonstration of cervical gonorrhea or
chlamydia infection.
If clinical findings (epidemiologic, symptomatic, and physical examination) suggest PID empiric treatment should be initiated.
Differential Diagnosis of Pelvic Inflammatory Disease
- Appendicitis
- Ectopic pregnancy
- Hemorrhagic ovarian cyst
- Ovarian torsion
- Endometriosis
- Urinary tract Infection
- Irritable bowel syndrome
- Somatization
- Gastroenteritis
- Cholecystitis
- Nephrolithiasis
Treatment of pelvic inflammatory disease
The two most important initiators of PID, Neisseria gonorrhoeae and Chlamydia trachomatis, must be treated, but coverage should also be provided for groups A and B streptococci, Gram negative enteric bacilli (Escherichia coli, Klebsiella spp., and Proteus spp.), and anaerobes.
Additional evaluation:
- Serology for the human immunodeficiency virus (HIV)
- Papanicolaou smear
- Hepatitis B surface antigen determination and initiation of the vaccine series for patients who are antigen negative and unvaccinated.
- Hepatitis C virus serology
- Serologic tests for syphilis
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