Pelvic Inflammatory Disease (PID)
Pelvic Inflammatory Disease (PID): Excerpt from The 5-Minute Pediatric Consult
Jonathan R. Pletcher, MDDaniel H. Reirden, MD
Pelvic Inflammatory Disease - BASICS
Pelvic Inflammatory Disease - description
- An ascending, polymicrobial infection of the female upper genital tract. It includes an array of inflammatory disorders, including endometritis, parametritis, salpingitis, oophoritis, tubo-ovarian abscess (TOA), peritonitis, and perihepatitis.
- Pelvic inflammatory disease (PID) is a clinical diagnosis.
- The Centers for Disease Control and Prevention (CDC) has established the minimal clinical criteria; if present and no other cause can be identified, empiric therapy for PID should be initiated in sexually active young women:
- Uterine or adnexal tenderness
- Cervical motion tenderness
- Additional criteria can be used to enhance the specificity of the diagnosis of PID in women with more severe clinical signs:
- Oral temperature >38°C (101°F)
- Abnormal cervical or vaginal mucopurulent discharge
- Presence of WBCs on a wet mount of vaginal secretions
- Elevated ESR
- Elevated C-reactive protein (CRP)
- Laboratory-documented evidence of infection with Neisseria gonorrhoeae or Chlamydia trachomatis
- Definitive criteria:
- Histopathologic evidence of endometritis on endometrial biopsy
- Transvaginal sonography or other imaging techniques showing thickened fluid-filled tubes with or without free pelvic fluid or TOA
- Laparoscopic abnormalities consistent with PID
Pelvic Inflammatory Disease - general prevention
- Primary prevention involves early education and aggressive screening for STIs.
- Abstinence should be advocated.
- For those individuals unable to commit to abstinence, consistent condom use should be advocated and facilitated.
- Regular screening for STIs and treatment of sexual partners should be encouraged and facilitated.
Pelvic Inflammatory Disease - epidemiology
- Clinical diagnosis of PID is imprecise.
- Positive predictive value of clinical diagnosis ranges from 65–90% compared to laparoscopy.
- No single history item, physical exam finding, or laboratory test is either completely sensitive or specific for the diagnosis.
Pelvic Inflammatory Disease - risk factors
- Adolescent women possess biologic factors that increase risk of PID:
- Increased cervical ectopy
- Decreased cervical immunity
- Risk also increases with:
- Failure to use condoms
- Sex during menses
- Number of lifetime partners
- Having new partners in the last 3 months
- History of STIs
- Presence of an intrauterine device (IUD)
- Lack of access to confidential health care
Pelvic Inflammatory Disease - pathophysiology
- PID begins as an infection of the cervix.
- Direct spread of bacteria to ascending structures, via migration, sperm transport, or refluxed menstrual blood
- Direct migration may be facilitated by menstrual flow, as there is loss of protective cervical mucus.
- Microbes invade epithelial cells, mucosa, and serosa, causing inflammation with subsequent scarring.
Pelvic Inflammatory Disease - etiology
Although a polymicrobial infection, cervical infection or vaginal bacterial overgrowth with the following organisms can lead to acute PID:
- N. gonorrhoeae cervicitis
- C. trachomatis cervicitis: Tends to be associated with less fever, pain, and systemic symptoms than PID due to gonococcus.
- Bacterial vaginosis: Bacteroides, Mobiluncus, and Peptostreptococcus species
Pelvic Inflammatory Disease - DIAGNOSIS
Pelvic Inflammatory Disease - signs & symptoms
Classic presentation of PID includes:
- Lower abdominal pain
- Dysparuenia
- Abnormal vaginal discharge
- Dysuria
- Irregular vaginal bleeding
- Fever
Pelvic Inflammatory Disease - history
Assessment begins with sensitive, private interview with a practitioner who can ensure confidentiality.
- Review of systems:
- Presentation may be silent, with relatively few or mild symptoms.
- Complete medical, gynecologic, menstrual, sexual, GI, and urinary histories:
- Associated symptoms may include dysmenorrhea, dyspareunia, vomiting, diarrhea, or constipation.
- Supportive historic data include recent menstruation, use of IUD or douche, inconsistent condom use, and multiple or new sexual partners.
Pelvic Inflammatory Disease - physical exam
- Perform a thorough abdominal exam, noting tenderness, rebound or guarding, and signs of perihepatic involvement.
- Pelvic examination: Document the following:
- Presence of external or vaginal lesions
- Origin, quality, and quantity of discharge (e.g., “copious, mucopurulent cervical discharge,” or “scant, thin vaginal discharge”)
- Signs of cervical inflammation (e.g., erythema, friability)
- Cervical motion tenderness
- Adnexal tenderness and/or fullness
- Blot away discharge to better assess the source of new fluid accumulation
Pelvic Inflammatory Disease - tests
Caution:
- Most bacteriologic studies are technique dependent and require trained clinicians.
- All home pregnancy tests should be repeated.
Pelvic Inflammatory Disease - lab
- Urine β-human chorionic gonadotropin (β-hCG):
- It is essential to know if the patient is pregnant, regardless of sexual history.
- Complete blood count with differential
- ESR or CRP
- Wet prep of discharge for trichomonads, hyphae, clue cells, presence of WBCs (>10 WBC/high-power field is suggestive of infection)
- Gram stain of cervical discharge:
- Testing for N. gonorrhoeae and C. trachomatis
- Culture is technique dependent, yielding 80% sensitivity.
- Antigen detection tests (e.g., direct fluorescent antibody [DFA], enzyme-linked immunosorbent assay [ELISA]) have lower sensitivities.
- Genetic amplification (polymerase chain reaction [PCR]) requires a single specimen for both organisms, has a 24-hour turnaround time, and has 90–95% sensitivity.
- Syphilis serology (e.g., rapid plasma reagin [RPR] testing) and HIV testing with appropriate counseling and follow-up
Pelvic Inflammatory Disease - imaging
Pelvic ultrasound:
- Rule out TOA or other pelvic pathology.
- Note: Pelvic ultrasound requires a full urinary bladder, unlike transvaginal ultrasound.
Pelvic Inflammatory Disease - diag proced-surgery
Laparoscopy: Not routinely used, but considered the gold standard for diagnosis
Pelvic Inflammatory Disease - differencial diagnosis
- Infection:
- Cervicitis
- Vulvovaginal candidiasis
- Trichomoniasis
- Bacterial vaginosis
- TOA
- Pyelonephritis or cystitis
- Appendicitis
- Appendiceal abscess
- Tuberculosis
- Viral or bacterial enteritis
- Acute cholecystitis
- Mesenteric lymphadenitis
- Pelvic thrombophlebitis
- Gynecologic:
- Dysmenorrhea
- Pregnancy: Intrauterine or ectopic
- Ovarian cyst or torsion
- Chronic pelvic pain
- Endometriosis
- Teratoma or other mass
- Miscellaneous:
- Foreign body or pelvic trauma
- Functional pain
Pelvic Inflammatory Disease - TREATMENT
Pelvic Inflammatory Disease - general measures
- The goal of treatment is to eliminate infection and to reduce or prevent the likelihood of long-term negative outcomes.
- A patient may be treated as an outpatient or an inpatient based on a clinician’s judgment as to the severity of the disease and the patient’s ability to follow through with medical care.
- Hospitalization is recommended in the following cases:
- Surgical emergency (e.g., appendicitis) can not be ruled out.
- Patient is pregnant.
- Suspected TOA
- Patient has failed outpatient treatment.
- Patient is clinically ill or is at high risk for sequelae.
- When choosing outpatient treatment:
- Repeat bimanual exam within 72 hours of initiating therapy.
- Patient must be willing to take the medications and follow-up.
- Patient should be given a full course of doxycycline (or other oral medications) and tolerate the 1st dose under supervision.
- All patients with PID should receive intensive education about STI prevention and partner treatment.
Pelvic Inflammatory Disease - medication
- Inpatient management:
- CDC regimen A:
- Cefotetan 2 g IV q12h or cefoxitin 2 g IV q6h
- Plus, doxycycline 100 mg PO b.i.d. for 14 days
- Regimen A should be continued for at least 24 hours after clinical improvement, and is followed by the completion of a 14-day course of doxycycline 100 mg PO b.i.d.
- CDC regimen B:
- Clindamycin 900 mg IV q8h
- Plus, gentamicin loading dose 2 mg/kg IV or IM, followed by maintenance dose 1.5 mg/kg q8h
- Regimen B should be continued for at least 24 hours after clinical improvement, and is followed by completion of a 14-day course of either doxycycline or clindamycin 450 mg PO b.i.d.
- Alternative parenteral regimens include the following:
- Ofloxacin 400 mg IV q12h or levofloxacin 500 mg IV daily
- With or without metronidazole 500 mg IV q8h, or
- Ampicillin/sulbactam 3 g IV q6h
- Plus, doxycycline 100 mg PO q12h
- Regimen A versus regimen B: Choice based on availability and the drug allergy history of the patient. Data to support the use of alternative regimens are limited.
- Outpatient management:
- Regimen A:
- Ofloxacin 400 mg PO daily for 14 days or levofloxacin 500 mg PO daily for 14 days; approved for patients older than 16 years
- With or without metronidazole 500 mg PO b.i.d. for 14 days
- Concern about quinolone-resistant N. gonorrhoeae has led to the recommendation that this regimen not be used in those individuals who have recent foreign travel or for infections acquired in California or Hawaii. This would also apply to the patient’s partner.
- Regimen B:
- Ceftriaxone 250 mg IM once or cefoxitin 2 g IM with probenecid 1 g PO once or other parenteral 3rd-generation cephalosporin
- Plus doxycycline 100 mg PO b.i.d. for 14 days
- With or without metronidazole 500 mg PO b.i.d. for 14 days
- Regimen A versus regimen B: Choice based on availability, cost, and patient history of drug allergy
Pelvic Inflammatory Disease - FOLLOW UP
- For inpatients, substantial clinical improvement should occur within 3 days if the patient has been properly diagnosed and treated.
- Outpatients should have significant improvement after 72 hours of treatment.
- Test-of-cure examination and laboratory testing should be considered for all patients 6–8 weeks after diagnosis.
Pelvic Inflammatory Disease - prognosis
- Excellent if adequate treatment obtained early and acute complications absent
- One episode of PID increases the risk of future ectopic pregnancy 10-fold.
- Long-term sequelae are present in 25% of affected women, with a higher likelihood in adolescents owing to later presentation, delay in diagnosis, and inadequate treatment.
Pelvic Inflammatory Disease - complications
- Chronic pelvic pain or dyspareunia (≤18%)
- Ectopic pregnancy
- Infertility:
- 1 episode is associated with a 13–21% risk of infertility, 2 episodes with a 35% risk, and 3 or more episodes with a 55–75% risk.
- TOA
- Fitz-Hugh–Curtis syndrome (perihepatitis resulting from tracking of pus along the paracolic gutters)
Pelvic Inflammatory Disease - bibliography
- Banikarim C, Chacko MR. Pelvic inflammatory disease in adolescents. Adolesc Med. 2004;15:273–285.
- Centers for Disease Control and Prevention. Sexually transmitted diseases and treatment guidelines, 2006. MMWR Morb Mortal Wkly Rep. 2006;55(RR-11):56–61. (Available at http://www.cdc.gov/std/treatment/default.htm)
- Hollier LM, Workowski K. Treatment of sexually transmitted diseases in women. Obst Gynecol Clin North Am. 2003;30:751–775.
Pelvic Inflammatory Disease - CODES
Pelvic Inflammatory Disease - icd9
614.9 Pelvic inflammatory disease
Pelvic Inflammatory Disease - FAQ
- Q: A patient states that she is not sexually active. Should I continue to consider PID?
- A: Yes. Because of the risk and severity of sequelae, PID should always be considered.
- Q: A patient does not meet the criteria for PID; however, it is still the most likely diagnosis. Should I start therapy while other studies are pending?
- A: Yes, appropriate therapy for PID may be initiated while other workups are in progress. Delay in therapy results in increased risk of sequelae from PID.
- Q: An adolescent patient with PID has inquired about fertility. What should I tell her?
- A: Many clinicians would argue that an episode of PID could serve as a wake-up call to teenagers, inspiring them to abstain or comply with barrier contraception. However, a young woman who is told that she may have impaired fertility might try testing it through unprotected sex.
- Q: Does the absence of cervical motion tenderness exclude the diagnosis of PID?
- A: No, cervical motion tenderness is only one of the 2 clinical signs that may be present in PID.
Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
More About Pelvic Inflammatory Disease
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Review other book chapters online related to Pelvic Inflammatory Disease:
Medical Books Excerpts
- Dysmenorrhea
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- Dysmenorrhea
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Vaginal Discharge
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Chronic Pelvic Pain
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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