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.) 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 Screening tests may include HIV syphilis hepatitis B pap smear hepatitis C (if patient has history of intravenous drug use) Differential Ectopic pregnancy positive pregnancy test Appendicitis PID typically presents with bilateral abdominal tenderness Treatment Medical ceftriaxone plus doxycycline (outpatient) indications clinical findings of PID alone is often enough to indicate treatment of PID uncomplicated PID urethritis cefoxitin plus doxycycline indications for intravenous medication or hospitalization uncertain diagnosis tubo-ovarian abscess failure to respond to outpatient treamtment within 72 hours clindamycin plus gentamicin most potent option for unstable patients and treatment-resistant infections e.g., tubo-ovarian abscess with hemodynamic instability 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 Prognosis May recur Prognostic variable negative salpingitis multiple recurrence