AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Pelvic inflammatory disease (PID) is an inflammatory disorder of the uterus, fallopian tubes, and adjacent pelvic structures. Risk factors for PID include young age at first intercourse, multiple sexual partners, intrauterine device (IUD) insertion, and tobacco smoking. A delay in diagnosis or treatment can result in long-term sequelae such as tubal infertility.

Pathophysiology

In PID, the upper female genital tract is infected by direct spread of microorganisms ascending from the vagina and cervix. The cervix produces mucus that usually protects against upward spread, but bacteria may penetrate the cervical mucus and cause widespread extension of infection.

Frequency

United States

PID affects 11% of women of reproductive age. Approximately 1 million women experience an episode of PID per year, and 20% of these women require hospitalization for treatment. The disease produces 2.5 million office visits and 125,000-150,000 hospitalizations yearly.

International

Public health efforts implemented in Scandinavia to decrease the prevalence of sexually transmitted diseases (STDs) have been quite effective.

Mortality/Morbidity

A delay in diagnosis or treatment can result in long-term reproductive sequelae, such as tubal infertility. Each repeat episode of PID doubles the risk for tubal factor infertility. Women with a history of PID have a 7- to 10-fold increased risk for ectopic pregnancy (tubal pregnancy) compared with women with no history of PID. Chronic pelvic pain can also follow PID and occurs in 25-75% of women.

Sex

PID is an infection of the female genital tract.

Age

PID may occur more frequently in adolescents (ie, 15-19 y), but it can occur in any patients who are sexually active. Age distributions vary with geographic location and etiology. Young age at first intercourse increases risk for PID.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Patients can present with a variety of symptoms, ranging from lower abdominal pain to dysuria. A direct correlation exists between the incidence of STDs and pelvic inflammatory disease (PID) in any given population.

• Pain is present in more than 90% of documented cases and is by far the most common presenting symptom.
• • Usually, pain is described as dull, aching, and constant; it begins a few days after the onset of the last menstrual period and tends to be accentuated by motion, exercise, or coitus.
  • Pain from PID usually lasts less than 7 days; if pain lasts longer than 3 weeks, the likelihood that PID is the correct diagnosis declines substantially.
• Abnormal vaginal discharge is present in approximately 75% of cases.
• Unanticipated vaginal bleeding coexists in about 40% of cases.
• Temperature higher than 38°C (30%), nausea, and vomiting manifest late in the clinical course of the disease.

Physical

The sensitivity of the pelvic examination is only 60%. The Centers for Disease Control and Prevention (CDC) recommends the following minimal clinical criteria for the diagnosis of PID in sexually active young women: uterine/adnexal tenderness or cervical motion tenderness.

Additional criteria may be used to enhance the specificity of the minimum criteria:

• Temperature higher than 101°F (38.3°C)
• Abnormal cervical or vaginal mucopurulent discharge
• Presence of white blood cells (WBCs) on saline microscopy of vaginal secretions
• Elevated erythrocyte sedimentation rate
• Elevated C-reactive protein level
• Laboratory documentation of cervical infection with Neisseria gonorrhoeae or Chlamydia trachomatis

Causes

The classic high-risk patient is a menstruating woman younger than 25 years who has multiple sex partners, does not use contraception, and lives in an area with a high prevalence of STD. PID is also more prevalent among unmarried women and individuals who are young at first intercourse. The IUD confers a relative risk of 2.0-3.0 for the first 4 months following insertion, but then it decreases to baseline thereafter. Women who are not sexually active have a very low incidence of upper genital tract infection, as do women who have undergone tubal sterilization.

• C trachomatis: C trachomatis, an intracellular bacterial pathogen, is the predominant STD organism causing PID. Clinically, infection with this obligate intracellular parasite may manifest as mucopurulent cervicitis.
• Cytomegalovirus (CMV): CMV has been found in the upper genital tracts of women with PID, suggesting a potential role of CMV in PID.
• Endogenous microflora: In iatrogenically induced infections, the endogenous microflora of the vagina predominate.
• Gardnerella vaginalis
• Haemophilus influenzae
• Enteric gram-negative organisms (Escherichia coli)
• Peptococcus species
• Streptococcus agalactiae
• Bacteroides fragilis: This can cause tubal and epithelial destruction.
• Pregnancy: PID is rare in pregnancy.
• N gonorrhoeae: In the United States, the role of N gonorrhoeae as the primary cause of PID has decreased.
• Mycoplasma genitalium: M genitalium has been isolated in the endometrium and fallopian tubes of women who have PID.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Rupture of an adnexal mass
Adnexal torsion
Perihepatic inflammation (Fitz-Hugh and Curtis syndrome)

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Additional criteria may be used to increase the specificity of the diagnosis as listed below.
• Vaginal wet mount - Increased amount of white cells
• Erythrocyte sedimentation rate (ESR) - Elevated, nonspecific
• C-reactive protein (CRP) - Elevated, nonspecific
• CBC count - Elevated white blood cell count
• Gonorrhea cultures - Generally used to confirm diagnosis (frequently negative in later stages)
• Chlamydial cultures - Generally used to confirm diagnosis (large variability in recovery from cervix [5-56%])

Imaging Studies

• Transvaginal sonography may not be useful in the diagnosis of PID. It has poor sensitivity (81%) and specificity (78%) with mild or atypical PID. It can be used to document an adnexal mass or demonstrate fluid-filled fallopian tubes.
• Although the specificity (95%) and sensitivity (95%) of MRI is relatively high, it is costly and rarely indicated in acute PID. If used in the management of PID, MRI can demonstrate thickened fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex.

Procedures

Culdocentesis: With the advent of transvaginal sonography, culdocentesis is rarely performed. In the absence of current technology, insertion of an 18-gauge spinal needle attached to a syringe can be performed. The needle is inserted transvaginally into the cul-de-sac, yielding either purulent fluid or bloody fluid from the peritoneum.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

• Most patients are now managed as outpatients, but physicians should consider hospitalization for patients with the following conditions, although no clear data suggest that these patients benefit from hospitalization:

• Uncertain diagnosis
• Pelvic abscess on ultrasound
  
  
• Pregnancy
  
  
• Failure to respond to outpatient management
  
  
• Inability to tolerate outpatient PO regimen
  
  
• Severe illness or nausea and vomiting precluding outpatient treatment
  
  
• Immunodeficiency (eg, HIV with low CD4 count, using immunosuppressive medications)
  
  
• Failure to improve clinically after 72 hours with outpatient therapy
   
• Inpatient treatment includes the following
  
  
  • Regimen A: Administer cefoxitin 2 g IV q6h or cefotetan 2 g IV q12h plus doxycycline 100 mg PO/IV q12h. Cefotetan is no longer distributed in the United States. Continue this regimen for 24 hours after the patient remains clinically improved, and then start doxycycline 100 mg PO bid for a total of 14 days. Administer doxycycline PO when possible because of pain associated with infusion. Bioavailability is similar with PO and IV administrations. If tubo-ovarian abscess is present, use clindamycin or metronidazole with doxycycline for more effective anaerobic coverage.
    
  • Regimen B: Administer clindamycin 900 mg IV q8h plus gentamicin 2 mg/kg loading dose IV followed by a maintenance dose of 1.5 mg/kg q8h. IV therapy may be discontinued 24 hours after the patient improves clinically, and PO therapy of 100 mg bid of doxycycline should be continued for a total of 14 days of therapy. If tubo-ovarian abscess is present, use clindamycin or metronidazole with doxycycline for more effective anaerobic coverage.
• Outpatient treatment
• • Regimen A: Administer ceftriaxone 250 mg IM once as a single dose plus doxycycline 100 mg PO bid for 14 days, with or without metronidazole 500 mg PO bid for 14 days. Metronidazole can be added if there is evidence or suspicion for vaginitis or gynecologic instrumentation in the past 2-3 weeks.
  • Regimen B: Administer cefoxitin 2 g IM once as a single dose and probenecid 1 g PO concurrently in a single dose or other single dose parenteral third-generation cephalosporin (ceftizoxime or cefotaxime) plus doxycycline 100 mg PO bid for 14 days with or without metronidazole 500 mg PO bid for 14 days. Metronidazole can be added if there is evidence or suspicion for vaginitis or gynecological instrumentation in the past 2 to 3 weeks.
• In April 2007, the Centers for Disease Control and Prevention (CDC) updated treatment guidelines for gonococcal infection and associated conditions. Fluoroquinolone antibiotics are no longer recommended to treat gonorrhea in the United States. The recommendation was based on analysis of new data from the CDC's Gonococcal Isolate Surveillance Project (GISP). The data from GISP showed the proportion of fluoroquinolone-resistant gonorrhea (QRNG) cases in heterosexual men reached 6.7%, an 11-fold increase from 0.6% in 2001. The data were published in the April 13, 2007 issue of the Morbidity and Mortality Weekly Report. This limits treatment of gonorrhea to drugs in the cephalosporin class (eg, ceftriaxone 125 mg IM once as a single dose). Fluoroquinolones may be an alternative treatment option for disseminated gonococcal infection if antimicrobial susceptibility can be documented. For more information, see the CDC's Antibiotic-Resistant Gonorrhea Web site; CDC Updated Gonococcal treatment recommendations (April 2007); or Medscape Medical News on CDC Issues New Treatment Recommendations for Gonorrhea.

Surgical Care

The advantage of laparoscopy is that it allows direct visualization of the pelvis and provides a more accurate and bacteriologic diagnosis if cultures are obtained. However, laparoscopy is not always available in acute PID. In addition, this procedure is costly and requires general anesthesia. It should be used if the diagnosis is in doubt. However, if operative laparoscopy is used early in the course of the disease, copious irrigation and separation of thin adhesions by blunt dissection may prevent later sequelae.

Consultations

• Obstetrician
• Gynecologist

Diet

Patients should take nothing by mouth (NPO) if the diagnosis is uncertain or if the patient is scheduled for surgery.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

See Medical Care for treatment regimens.

Drug Category: Antibiotics

Therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting.

Drug Category: Uricosuric agents

Reduce clearance of some types of antibiotics, increasing their plasma levels.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Most patients clinically respond within 48-72 hours after medical therapy. If the patient continues to have fever, chills, uterine tenderness, adnexal tenderness, and cervical motion tenderness, consider other possible causes and a diagnostic laparoscopy.

Further Outpatient Care

• Perform a follow-up examination 48-72 hours after prescribing outpatient therapy to ensure clinical improvement. If the patient continues to have fevers, chills, uterine tenderness, adnexal tenderness, and cervical motion tenderness, consider hospitalization.
• Male sex partners of women with PID should be examined and treated if they have had sexual contact with the patient during the 60 days preceding the onset of symptoms in the patient.

In/Out Patient Meds

See Medical Care.

Deterrence/Prevention

• Randomized controlled trials suggest that preventing chlamydial infection reduces the incidence of PID. Other methods of preventing PID and STD include reducing the number of sexual partners, avoiding unsafe sexual practices, and using condoms with spermicide. Use of mechanical barriers with spermicide also decreases the risk of acquiring STDs.
• Notification of the female sex partners of men infected with C trachomatis is recommended.

Complications

• Tubo-ovarian abscess is one of the major complications of acute PID, and it occurs in up to 15-30% of women requiring hospitalization for treatment of PID.

Prognosis

• Therapy using antibiotics alone is successful in 33-75% of cases. If surgical therapy is warranted, the current trend in therapy is conservation of reproductive potential with simple drainage, adhesiolysis, and copious irrigation or unilateral adnexectomy, if possible. Further surgical therapy is needed in 15-20% of cases so managed.
• Chronic pelvic pain occurs in approximately 25% of patients with a history of PID. This pain is thought to be related to cyclic menstrual changes, but it also may be the result of adhesions or hydrosalpinx.
• Impaired fertility is a major concern in women with a history of PID. The rate of infertility increases with the number of episodes of infection.
• The risk of ectopic pregnancy is increased in women with a history of PID. Ectopic pregnancy is a direct result of damage to the fallopian tube.

Patient Education

• Asking women about high-risk sexual behavior is important.
• Encourage screening tests for those at risk.
• Ensure that male sex partners are evaluated and treated.
• Counsel women about safe sex practices.
• For excellent patient education resources, visit eMedicine's Women's Health Center, Sexually Transmitted Diseases Center, and Pregnancy and Reproduction Center. Also, see eMedicine's patient education articles Pelvic Inflammatory Disease, Ectopic Pregnancy, Birth Control Overview, Birth Control FAQs, and Female Sexual Problems.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

A frequent cause of litigation is failure to diagnose. The physician should always clearly document the patient's symptoms, as well as the physical examination and results of laboratory and radiological studies. Documenting the diagnosis, treatment plan, and disposition of the case is equally important. If the patient is referred to other services for consultation, a copy of the consulting physician's note should be attached to the medical record.

Special Concerns

Women with HIV infection who have PID have similar symptoms when compared to women who do not have HIV. However, women with HIV infection are more likely to have a tubo-ovarian abscess but effectively respond to standard parenteral and oral antibiotics.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Aledort JE, Hook EW, Weinstein MC, Goldie SJ. The cost effectiveness of gonorrhea screening in urban emergency departments. Sex Transm Dis. Jul 2005;32(7):425-36. [Medline].
• CDC, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. Aug 4 2006;55(RR-11):1-94. [Medline]. [Full Text].
• CDC. Update to CDC's sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR Morb Mortal Wkly Rep. Apr 13 2007;56(14):332-6. [Medline].
• Cohen CR, Sinei S, Reilly M, et al. Effect of human immunodeficiency virus type 1 infection upon acute salpingitis: a laparoscopic study. J Infect Dis. Nov 1998;178(5):1352-8. [Medline].
• Coonrod D, Collier AC, Ashley R, et al. Association between cytomegalovirus seroconversion and upper genital tract infection among women attending a sexually transmitted disease clinic: a prospective study. J Infect Dis. May 1998;177(5):1188-93. [Medline].
• Hillis SD, Owens LM, Marchbanks PA, et al. Recurrent chlamydial infections increase the risks of hospitalization for ectopic pregnancy and pelvic inflammatory disease. Am J Obstet Gynecol. Jan 1997;176(1 Pt 1):103-7. [Medline].
• Howell MR, Kassler WJ, Haddix A. Partner notification to prevent pelvic inflammatory disease in women. Cost-effectiveness of two strategies. Sex Transm Dis. May 1997;24(5):287-92. [Medline].
• Howell MR, Quinn TC, Brathwaite W, et al. Screening women for chlamydia trachomatis in family planning clinics: the cost-effectiveness of DNA amplification assays. Sex Transm Dis. Feb 1998;25(2):108-17. [Medline].
• Irwin KL, Moorman AC, O''Sullivan MJ, et al. Influence of human immunodeficiency virus infection on pelvic inflammatory disease. Obstet Gynecol. Apr 2000;95(4):525-34. [Medline].
• Jamieson DJ, Duerr A, Macasaet MA, et al. Risk factors for a complicated clinical course among women hospitalized with pelvic inflammatory disease. Infect Dis Obstet Gynecol. 2000;8(2):88-93. [Medline].
• Peipert JF, Ness RB, Soper DE. Association of lower genital tract inflammation with objective evidence of endometritis. Infect Dis Obstet Gynecol. 2000;8(2):83-7. [Medline].
• Peipert JF, Sweet RL, Walker CK, Bass D. Evaluation of ofloxacin in the treatment of laparoscopically documented acute pelvic inflammatory disease (salpingitis). Infect Dis Obstet Gynecol. 1999;7(3):138-44. [Medline].
• Rock JA, Thompson JD. Telinde's Operative Gynecology. 1997. 8^th ed. Philadelphia, Pa: Lippincott Williams & Wilkins Publishers; 657-684.
• Ross JD. Is Mycoplasma genitalium a cause of pelvic inflammatory disease?. Infect Dis Clin North Am. Jun 2005;19(2):407-13. [Medline].
• Scholes D, Stergachis A, Heidrich FE, et al. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. N Engl J Med. May 23 1996;334(21):1362-6. [Medline].
• Sorbye IK, Jerve F, Staff AC. Reduction in hospitalized women with pelvic inflammatory disease in Oslo over the past decade. Acta Obstet Gynecol Scand. Mar 2005;84(3):290-6. [Medline].
• Tukeva TA, Aronen HJ, Karjalainen PT, et al. MR imaging in pelvic inflammatory disease: comparison with laparoscopy and US. Radiology. Jan 1999;210(1):209-16. [Medline].
• Wiesenfeld HC, Sweet RL, Ness RB, et al. Comparison of acute and subclinical pelvic inflammatory disease. Sex Transm Dis. Jul 2005;32(7):400-5. [Medline].

Article Last Updated: Dec 3, 2007