Pelvic Inflammatory Disease (PID)

Snapshot

• A sexually active 17-year-old girl is brought to the emergency department due to lower abdominal pain of acute onset. She has no nausea or vomiting. Vital signs are significant for a temperature of 101.4°F (38.5°C). Bimanual pelvic exam shows cervical exudate and cervical motion tenderness. There is bilateral lower quadrant tenderness. Her β-HCG is within normal limits.

Introduction

• Clinical definition
  • pelvic inflammatory disease (PID) is an infection of the upper female genital tract that is often polymicrobial
    • may include
      • endometritis
      • salpingitis
      • tubo-ovarian abscess
      • pelvic peritonitis
• Epidemiology
  • incidence
    • US incidence
      • 750,000 cases annually
  • demographics
    • sexually active women
    • 15-29 years of age
  • location
    • upper female genital tract
  • risk factors
    • age < 25 years of age
    • risky sexual behavior
    • earlier age at first intercourse
    • increasing number of sex partners
• Pathophysiology
  • pathobiology
    • usually polymicrobia
    • likely microbes
      • Neisseria gonorrhoeae
      • Chlamydia trachomatis
      • anaerobes
      • gram-negative rods
      • Streptococcus agalactiae
      • Gardnerella vaginalis
      • Haeomphilus influenza
      • Cytomegalovirus
      • Mycoplasma genitalium
  • pathoanatomy
    • ascending infection of microbes from endocervix to upper genital tract
• Associated conditions
  • other sexually transmitted diseases (e.g., chlamydia, chancroid, herpes, etc.)
• Prognosis
  • may recur
  • prognostic variable
    • negative
      • salpingitis
• multiple recurrence

Presentation

• Symptoms
  • may be asymptomatic if subclinical
  • primary symptoms
    • lower abdominal or pelvic pain
    • chills
    • dyspareunia
    • dysuria
    • nausea or vomiting
• Physical exam
  • inspection
    • fever
    • abnormal cervical discharge or bleeding
    • cervical friability
    • abnormal vaginal odor
    • ecchymosis and swelling
    • diffuse tenderness
  • provocative tests
    • cervical motion tenderness
      • also known as “chandelier test”
    • adnexal tenderness
• uterine tenderness

Imaging

• Ultrasonography
  • indication
    • if diagnosis is uncertain with physical exam and clinical history
  • view
    • transvaginal
  • findings
    • thickened fluid-filled tubes
    • with or without free pelvic fluid
• with or without tubo-ovarian abscess

Studies

• Labs
  • may test positive for sexually transmitted diseases
    • Neisseria gonorrhoeae
    • Chlamydia trachomatis
• Diagnostic criteria
  • positive physical exam findings
    • uterine tenderness
    • adnexal tenderness
• cervical motion tenderness

Differential

• Ectopic pregnancy 
  • positive pregnancy test
• Appendicitis 
• PID typically presents with bilateral abdominal tenderness

Treatment

• Medical
  • cephalosporin plus doxycycline (outpatient)
    • indications
      • clinical findings of PID alone is often enough to indicate treatment of PID
      • uncomplicated PID
  • cefoxitin plus doxycycline
    • indications for intravenous medication or hospitalization
      • uncertain diagnosis
      • tubo-ovarian abscess
      • unstable patient
• failure to respond to outpatient treamtment within 72 hours

Complications

• Infertility
  • 15% after one episode of PID
• Ectopic pregnancy
  • 10x risk after PID
• Fitz-Hugh-Curtis syndrome 
  • clinical definition
    • infection of liver capsule with multiple peritoneal adhesions
  • incidence
    • 10% of women with PID