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Pelvic inflammatory disease (PID)
From WikEM
Contents
Background
- Pelvic Inflammatory Disease (PID) comprises spectrum of infections of the upper reproductive tract:
- Salpingitis, endometritis, myo/parametritis, and oophoritis
- Perihepatitis (Fitz-Hugh-Curtis) is caused by lymphatic spread
- Tubo-ovarian abscess is caused by direct extension
- It is the most common serious infection in women aged 16 to 25 years and begins as cervicitis (commonly due to GC or chlamydia) that may progress to polymicrobial infection.
- Initial lower tract infection may be asymptomatic
- Most common cause of death is rupture of a tubo-ovarian abscess
Clinical Features
History
- Pelvic Pain (90%)
- Vaginal discharge (75%)
- Vaginal and postcoital bleeding (>33%)
- Dysuria, fever, malaise, nausea and vomiting
Physical Exam
- Cervical motion tenderness
- Adnexal tenderness (Most sensitive finding - Sn ~95%)
- Mucopurulent cervicitis
- Absence should prompt consideration of another diagnosis
- RUQ Pain
- May indicate perihepatic inflammation (particularly if jaundice also present)
Differential Diagnosis
Pelvic Pain
Pelvic origin
- Urinary Tract Infection
- Ectopic
- Ovarian torsion
- Endometriosis
- PID
- Cervicitis
- Ectopic Pregnancy
- Ovarian Torsion
- Spontaneous abortion
- Septic abortion
- Myoma (degenerating)
- Ovarian cyst (rupture)
- Tubo-ovarian abscess
- Mittelschmerz
- Sexual assault/trauma
- Ovarian hyperstimulation syndrome
Abdominal origin
- Appendicitis
- Kidney stone
- Psoas abscess
- Mesenteric adenitis
- Incarcerated hernia
- Diverticulitis
- Pyelonephritis
Evaluation
Work-Up
- Urine pregnancy
- Wet mount
- Endocervical swab (for GC, Chlamydia)
- CBC
- ESR/CRP
- Urine culture, analysis (to exclude UTI)
Imaging
- Pelvic U/S
- Ultrasound sensitivity may be as low as 56% and specificity of 85% [1]
- CT
CDC Empiric Diagnosis Criteria[2]
- Woman at risk for STIs
- Pelvic or lower abdominal pain
- No cause for the illness other than PID can be identified
- At least one of the following on pelvic exam:
- CMT
- Uterine tenderness
- Adnexal tenderness.
- Additional criteria that make the diagnosis more likely:
Management
- Treat all partners who had sex with patient during previous 60 days prior to symptom onset
Outpatient Options
- Ceftriaxone 250mg IM x1 + doxycycline 100mg PO BID x14d +/- metronidazole 500mg PO BID x14d [3]
- Metronidazole based upon assessment of risk for anaerobes; consider in:
- Pelvic abscess
- Proven or suspected infection w/ Trichomonas or Bacterial Vaginosis
- History of gynecological instrumentation in the preceding 2-3wks
- Metronidazole based upon assessment of risk for anaerobes; consider in:
- Cefoxitin 2 g IM in a single dose and Probenecid, 1 g PO administered concurrently in a single dose[4] + Doxycycline 100 mg PO BID x 14 days +/- flagyl based on above criteria
Alternative Outpatient Options
- Ceftriaxone 250mg IM x1 + 1 g of azithromycin per week, x 2 weeks[5] +/- flagyl based on above criteria
- A single randomized controlled trial shows that azithromycin is superior to doxycycline even when compliance in taking doxycycline is excellent (98.2% vs 87.5%)[5]
Inpatient
- Cefoxitin 2gm IV q6hr OR cefotetan 2gm IV q12hr) + doxycycline PO or IV 100 mg q12hr OR
- Clindamycin 900mg IV q8h + gentamicin 2mg/kg QD OR
- Ampicillin-sulbactam 3gm IV q6hr + doxycycline 100mg IV/PO q12hr
IUD
- No change in treatment if IUD in place (may treat without removal)
Disposition
Admit
- Tubo-ovarian abscess
- Fitz-Hugh-Curtis
- Pregnancy
- Sepsis/Peritonitis
- Unable to tolerate PO
- Failed outpatient treatment
- HIV+
Discharge
- 72hr follow up
- Instruct patient to abstain from sex or adhere strictly to condom use until symptoms have abated
Complications
- Tubo-ovarian abscess
- Fitz-Hugh-Curtis
- Perihepatic inflammation seen only on CT, not US; LFTs are normal
- Responds to standard antibiotic regimen
- Infertility
- Ectopic pregnancy
- Chronic pelvic pain
See Also
References
- ↑ Lee DC, Swaminathan AK. Sensitivity of ultrasound for the diagnosis of tubo-ovarian abscess: a case report and literature review. J Emerg Med. 2011 Feb;40(2):170-5. doi: 10.1016 PMID 20466506
- ↑ http://www.cdc.gov/std/tg2015/pid.htm
- ↑ Ness RB et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol 2002;186:929–37
- ↑ CDC PID Treatment http://www.cdc.gov/std/treatment/2010/pid.htm
- ↑ 5.0 5.1 Savaris RF. et al. Comparing ceftriaxone plus azithromycin or doxycycline for pelvic inflammatory disease: a randomized controlled trial. Obstet Gynecol. 2007 Jul;110(1):53-60
