Pelvic inflammatory disease

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Background

  • Upper genital tract infection in women that involves infection of any combination of endometrium, fallopian tubes, and peritoneum

Microbiology

Epidemiology

  • About 10-15% of women have at least one episode

Clinical Manifestations

  • Pelvic or abdominal pain is the main complaint
  • May be febrile and have adnexal, uterine, or cervical motion tenderness
  • May present with tubo-ovarian abscess
  • Minimum diagnostic criteria for treatment include lower abdominal pain, adnexal tenderness, and cervical motion tenderness
  • Additional supportive criteria include
    • Fever >38.3ºC
    • Presence of leukocytes on saline microscopy of vaginal secretions
    • Elevated ESR or CRP
    • Diagnosed gonorrhea or chlamydia

Complications

Differential Diagnosis

Investigations

  • No combination of routine investigations (including swabs and ultrasound) can be used to completely rule out PID
  • Laboratory investigations
    • β-hCG to rule out ectopic pregnancy
    • Endocarvical swabs for gonorrhea and chlamydia, and possibly HSV
    • Vaginal swabs for culture, pH, whiff testing, wet preps, and Gram stain
  • Radiography
    • Ultrasound can be helpful, especially for tuboovarian abscess
    • Ideally done as transvaginal ultrasound

Diagnosis

  • Definitive diagnosis is rarely obtained; more commonly, the disease is treated based on clinical findings
  • Definitive diagnostic criteria include:
    • Endometrial biopsy with evidence of endometritis
    • Transvaginal ultrasound showing thickened fluid-filled tubes, with or without free pelvic fluid or tubo-ovarian complex
    • Laparoscopy showing findings of PID, including fallopian tube erythema or mucopurulent exudates

Management

  • All patients must have a β-hCG to rule out pregnancy
  • Criteria for hospitalization include:
    • Possible surgical emergency
    • Pregnancy
    • No response to oral antibiotics
    • Unable to tolerate oral antibiotics
    • Severe illness, nausea and vomiting, or high fever
    • Presence of tubo-ovarian abscess
    • Pediatric patients
  • There are many possible regimens
  • If an intrauterine device is in situ, remove it only after at least 2 doses of antibiotics have been given
  • Pain should start to improve within 48 to 72 hours of antibiotics; if it does not, then consider further investigations
  • Rule out other sexually-transmitted infections, including HIV and syphilis
  • Immunize against hepatitis B and HPV if indicated
  • Partners should be screened and treated

Further Reading