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Updated: Nov 30 2021

Pelvic Inflammatory Disease (PID)

3.9

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(7)

  • 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
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