Updated: 12/11/2019

Pelvic Inflammatory Disease (PID)

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Snapshot
  • A sexually active 14-year-old girl is brought to the emergency department because of acute bilateral lower quadrant abdominal pain. She has a history of multiple sexual partners. Her temperature is 102°F (38.9°C). Bimanual pelvic exam shows cervical exudate and tenderness on cervical motion. Her β-HCG is within normal limits. Sonogram shows thickened fallopian tubes with fluid in the posterior cul-de-sac.
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
      • right upper quadrant tenderness
        • perihepatic space may be involved
    • provocative tests
      • cervical motion tenderness
        • also known as “chandelier test”
      • adnexal tenderness
      • uterine tenderness
Imaging
  • Ultrasonography
    • indication
      • if diagnosis is uncertainty 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
 

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Questions (2)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.GN.13.49) A 20-year-old G0 woman presents with 4 days of fever and pelvic pain. The patient has had these symptoms before but not to this extent. Last night, she even experienced an episode of emesis from her discomfort. The patient is a yoga instructor, does not smoke or drink alcohol, is a vegan, and is sexually active with both men and women. Her temperature is 102°F (38.9°C), blood pressure is 124/84 mmHg, pulse is 110/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical examination reveals cervical motion tenderness, left adnexal fullness, and the finding in Figure A. Laboratory values are ordered as seen below.

Hemoglobin: 13 g/dL
Hematocrit: 39%
Leukocyte count: 19,500/mm^3 with normal differential
Platelet count: 297,000/mm^3

An ultrasound is performed as seen in Figure B. Which of the following is the most appropriate initial treatment for this patient?
Review Topic | Tested Concept

QID: 103412
FIGURES:
1

Cefoxitin and doxycycline

17%

(6/35)

2

Ceftriaxone and azithromycin

71%

(25/35)

3

Levofloxacin and metronidazole

0%

(0/35)

4

Metronidazole

3%

(1/35)

5

Surgical drainage

3%

(1/35)

L 3 E

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