II. Epidemiology

  1. Incidence: 750,000 cases per year in United States
  2. Age: Peaks between ages 15 to 29 years

III. Pathophysiology

  1. Intra-abdominal spread
    1. Cervix to endometrium and via salpinx to peritoneal cavity
  2. Lymphatic spread
    1. Example: IUD related infection
  3. Hematogenous spread (rare)
    1. Example: Tuberculosis

IV. Etiology

  1. Chlamydia trachomatis
  2. Neisseria Gonorrhea
  3. Mycoplasma hominis
  4. Mycoplasma genitalium (associated with treatment failures, not covered by all antibiotic regimens)
  5. Facultative or anaerobic organisms

V. Risk Factors

  1. Sexually Transmitted Disease (STD) history
    1. Chlamydia is asymptomatic in 80-90% of women
    2. Gonorrhea is asymptomatic in 10% of women
    3. Untreated Chlamydia or Gonorrhea is associated with a 10-20% risk of PID
  2. Age younger than 25 years
  3. Onset sexual intercourse at a young age (younger than 15 years old)
  4. Prior history of Pelvic Inflammatory Disease
  5. High number of sexual partners
  6. Non-barrier Contraception (e.g. IUD, Oral Contraceptives)

VI. Symptoms: Onset usually in first half of Menstrual Cycle

  1. Abdominal Pain or Pelvic Pain or cramping (varying intensity)
  2. Vaginal Discharge (new or abnormal)
  3. Fever or chills (fever may be high grade)
  4. Dyspareunia
  5. Dysuria
  6. Heavy or prolonged Menses or post-coital bleeding

VII. Exam

  1. Bimanual exam and speculum exam in all suspected cases
    1. Cervical motion tenderness
    2. Uterine tenderness
    3. Adnexal tenderness
  2. See Diagnosis below for signs
  3. Clinical diagnosis alone is accurate (when compared with imaging and laparoscopy)
    1. Test Sensitivity: 87%
    2. Test Specificity: 50%
    3. Positive Predictive Value: 65-90%

VIII. Diagnosis: 2002 CDC Criteria

  1. Major Criteria (Required)
    1. Uterine or Adnexal tenderness to palpation or
    2. Cervical motion tenderness
    3. No other apparent cause
  2. Minor Criteria (Supporting, but not required)
    1. Fever >101 F (38.3 C)
    2. Abnormal discharge per Cervix or vagina
    3. WBCs on Gram Stain or Saline of Cervix swab
    4. Gonorrhea or Chlamydia testing positive
    5. Increased Erythrocyte Sedimentation Rate or C-Reactive Protein
    6. PID findings on diagnostic study (see below)
  3. Most specific findings (not required and rarely indicated unless refractory to management or unclear diagnosis)
    1. Laparoscopy findings consistent with PID
    2. Endometrial Biopsy with histology suggestive of Endometritis
    3. Imaging (Transvaginal Ultrasound or MRI) with classic findings
      1. Thickened, fluid filled tubes
      2. Free pelvic fluid may be present
      3. Tubo-ovarian complex
      4. Tubal hyperemia on doppler Ultrasound

IX. Differential Diagnosis

  1. See Acute Pelvic Pain
  2. See Acute Pelvic Pain Causes
  3. Ruptured Ovarian Cyst
    1. Sudden onset of mid-cycle pain
  4. Ectopic Pregnancy
    1. Unilateral pain
    2. Positive Pregnancy Test
    3. Afebrile
    4. White Blood Cell Count normal
  5. Appendicitis
    1. Right Lower Quadrant Abdominal Pain
    2. More bowel Symptoms
  6. Urinary Tract Infection (including Pyelonephritis)
    1. No Cervical Motion Tenderness or Vaginal Discharge
  7. Ovarian Torsion
    1. More localized pain
    2. Sudden onset
    3. Afebrile
    4. White Blood Cell Count normal
  8. Other common causes
    1. Nephrolithiasis
    2. Inflammatory Bowel Disease

X. Labs

  1. General
    1. Do not delay treatment while waiting for labs
  2. Inflammatory markers (if all normal, PID is very unlikely)
    1. Complete Blood Count (CBC)
    2. Erythrocyte Sedimentation Rate or C-Reactive Protein
    3. Vaginal secretion exam (saline wet prep)
      1. Vaginal PMNs (Negative Predictive Value 95%)
      2. Identifies Trichomonas vaginalis and Bacterial Vaginosis
  3. Sexually Transmitted Disease screening
    1. DNA probe PCR for Gonorrhea and Chlamydia
      1. Cervical specimen recommended over urine specimen
      2. Test Sensitivity and Test Specificity are high
    2. Rapid Plasma Reagin (RPR)
    3. Human Immunodeficiency Virus Test (HIV Test)
  4. Other initial labs
    1. Urine Pregnancy Test
    2. Blood Cultures

XI. Diagnostics

  1. Endometrial Biopsy: Endometritis
    1. Test Sensitivity: 74%
    2. Test Specificity: 84%
  2. Transvaginal pelvic Ultrasound
    1. Efficacy
      1. Test Sensitivity: 30%
      2. Test Specificity: 76%
    2. Pelvic free fluid in cul-de-sac
    3. Tubo-ovarian abscess may be present
    4. Doppler demonstrates tubal hyperemia
    5. Fallopian tube changes
      1. Thickened fallopian tube wall >5 mm
      2. Fluid filled fallopian tubes
      3. Incomplete septae in fallopian tube
        1. Cogwheel sign on tube cross-section view
  3. CT Pelvis
    1. Other imaging modalities are preferred for PID evaluation
    2. Pelvic floor fascial, Adnexal inflammation
    3. Uterosacral ligament thickening
    4. Pelvic free fluid
  4. MRI Pelvis
    1. Efficacy
      1. Test Sensitivity: 81-95%
      2. Test Specificity: 89-100%
    2. Tubo-ovarian abscess may be present
    3. Pelvic free fluid
    4. Fallopian tube changes
      1. Fluid filled fallopian tubes
      2. Ovaries have polycystic appearance
    5. References
      1. Tukeva (1999) Radiology 210:209-16 [PubMed]
  5. Laparoscopy
    1. Indicated for unclear diagnosis
    2. Pelvic Inflammatory Disease misdiagnosed 25% time

XII. Management: General

  1. Intrauterine Device (IUD) removal is controversial
    1. IUD increases PID for only first 3 weeks following insertion
      1. Risks are similar between the Copper-T IUD and the Mirena IUD
    2. Historically, IUD has been removed at time of PID diagnosis
    3. No evidence supports removal of IUD in PID
    4. Close follow-up is critical for those who developed PID with IUD in place
  2. Treat patient's sexual contacts within last 60 days
    1. Abstain from sexual intercourse until patient and partner have completed treatment
  3. Start empiric therapy if minimal criteria present
    1. Do not delay treatment
    2. Delay >3 days increases ectopic and Infertility risk
  4. Antibiotic should cover Gonorrhea and Chlamydia

XIII. Management: Special Populations

  1. HIV positive women
    1. May be treated with same antibiotics and guidelines as non-HIV patients
    2. More likely to be infected with Mycoplasma or Streptococcus than with Gonorrhea or Chlamydia
  2. Pregnant women
    1. PID is less common in pregnancy, but can occur in first trimester before formation of mucous plug
    2. Pregnant women with PID have greater risk of complications including Preterm Labor and mortality
    3. Admit and initiate parenteral antibiotics for initial PID treatment in pregnancy
    4. Treat with Cefoxitin and Azithromycin one gram

XIV. Management Outpatient

  1. Step 1: Initial Treatment at Diagnosis (with step 2)
    1. Cefoxitin 2g IM and Probenecid 1g PO or
    2. Ceftriaxone 250 mg IM for 1 dose or
    3. Other third generation Cephalosporin (e.g Cefotaxime, Ceftizoxime)
  2. Step 2: Outpatient 14 day antibiotic course
    1. Select general antibiotic coverage
      1. Doxycycline 100 mg PO bid for 14 days (75% cure, preferred agent) or
      2. Azithromycin 1 gram orally once weekly for 2 weeks (alternative option, not CDC guideline)
        1. Savaris (2007) Obstet Gynecol 110:53–60 [PubMed]
    2. Consider adding anaerobic coverage
      1. Metronidazole 500 mg orally twice daily for 14 days or
      2. Clindamycin 450 mg PO four times daily for 14 days
    3. Agents to avoid
      1. Fluoroquinolones (e.g. Ofloxacin 400 bid or Levofloxacin 500 daily) are no longer recommended
      2. Cohorts at highest risk for Fluoroquinolone resistance
        1. Homosexual men and any female sexual contacts
        2. Endemic areas
          1. Asia: China, Japan, Korea, Philippines, Vietnam
          2. Other: England, Wales, Australia
          3. US: California
  3. References
    1. Workowski (2010) MMWR Recomm Rep 59(RR-12): 1-110 [PubMed]

XV. Management Inpatient

  1. Hospitalization Indications
    1. Severe illness
      1. Toxic appearance
      2. High fever
    2. Unable to take oral fluids or oral medications
    3. Unclear diagnosis
      1. Appendicitis
      2. Ectopic Pregnancy
      3. Ovarian Torsion
    4. Pelvic abscess (tubo-ovarian abscess)
      1. Requires at least 24 hours of parenteral therapy inpatient
    5. Pregnancy
    6. HIV positive
    7. Adolescents
    8. Outpatient treatment failure
    9. Unreliable patient
  2. Inpatient treatment Regimens
    1. General
      1. Treat for at least 48 hours IV
    2. Regimen A (preferred)
      1. Cefoxitin 2g IV q6h OR Cefotetan 2g IV q12h and
      2. Doxycycline 100 mg PO or IV q12h
    3. Regimen B
      1. Clindamycin 900 mg IV q8h and
      2. Gentamicin 2 mg/kg IV load, then 1.5 mg/kg IV q8h
        1. Alternative: Conversion to single daily dosing (at 3-5 mg/kg)
    4. Alternative
      1. Unasyn 3g IV q6 hours and
      2. Doxycycline 100 mg PO or IV q12 hours
    5. Other options that are not recommended (listed for historical reasons)
      1. Regimen C
        1. Ofloxacin 400 mg IV q12h or Levoquin 500 IV qd and
        2. Consider adding Metronidazole 500 IV q8 hours
    6. Discharge Regimen (after IV antibiotics above)
      1. See Outpatient Management Step 2 above
      2. Discontinue 24 hours after clinical improvement and complete therapy with oral antibiotics
        1. Doxycycline 100 mg orally twice daily for 14 days or
        2. Clindamycin 450 mg PO qid for 14 days
  3. References
    1. Workowski (2010) MMWR Recomm Rep 59(RR-12): 1-110 [PubMed]

XVI. Course

  1. Expect clinical symptom improvement within first 72 hours of treatment
  2. Lack of improvement after 72 hours requires additional evaluation
    1. Consider inpatient parenteral therapy
    2. Broaden antibiotic coverage
    3. Consider Ultrasound to assess for tubo-ovarian abscess

XVII. Prevention

  1. Screen all sexually active women age <25 years for Chlamydia
  2. Re-screen for STD 6 months after PID episode (Gonorrhea and Chlamydia)
  3. Encourage barrier Contraception (Condom use)

XVIII. Complications

  1. Infertility associated with tubal scarring (20%)
  2. Chronic Pelvic Pain (18%)
  3. Tubal Pregnancy (9%)

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Ontology: Pelvic Inflammatory Disease (C0242172)

Definition (MSHCZE) Spektrum zánětlivých procesů u žen v oblasti horního genitálního traktu a souvisejících tkáních. To je obvykle způsobeno postupující infekcí v organismu z oblasti endocervixu výše. Infekce může být omezena na dělohu (ENDOMETRITIDA), VEJCOVODY (SALPINGITIDA), vaječníky (OOFORITIDA), podpůrné ligamenty (PARAMETRITIDA) nebo může napadnout více uvedených orgánů. Takový zánět může vést k funkčnímu poškození těchto orgánů a k neplodnosti.
Definition (MEDLINEPLUS)

Pelvic inflammatory disease (PID) is an infection and inflammation of the uterus, ovaries, and other female reproductive organs. It causes scarring in these organs. This can lead to infertility, ectopic pregnancy, pelvic pain, abscesses, and other serious problems. PID is the most common preventable cause of infertility in the United States.

Gonorrhea and chlamydia, two sexually transmitted diseases, are the most common causes of PID. Other bacteria can also cause it. You are at greater risk if you

  • Are sexually active and younger than 25
  • Have more than one sex partner
  • Douche

Some women have no symptoms. Others have pain in the lower abdomen, fever, smelly vaginal discharge, irregular bleeding, and pain during intercourse or urination. Doctors diagnose PID with a physical exam, lab tests, and imaging tests. Antibiotics can cure PID. Early treatment is important. Waiting too long increases the risk of infertility.

NIH: National Institute of Allergy and Infectious Diseases

Definition (NCI_FDA) Any pelvic infection involving the upper female genital tract beyond the cervix.
Definition (NCI) Pelvic inflammatory disease (PID) is an acute or chronic inflammation in the pelvic cavity. It is most commonly caused by sexually transmitted diseases, including chlamydia and gonorrhea that have ascended into the uterus, fallopian tubes, or ovaries as a result of intercourse or childbirth, or of surgical procedures, including insertion of IUDs or abortion. PID may be either symptomatic or asymptomatic. It may cause infertility and it may raise the risk of ectopic pregnancy. PID is a disease associated with HIV infection.
Definition (NCI_NCI-GLOSS) A condition in which the female reproductive organs are inflamed. It may affect the uterus, fallopian tubes, ovaries, and certain ligaments. Pelvic inflammatory disease is usually caused by a bacterial infection. It may cause infertility and an increased risk of an ectopic pregnancy (pregnancy in the fallopian tubes).
Definition (NCI_CTCAE) A disorder characterized by an infectious process involving the pelvic cavity.
Definition (CSP) spectrum of inflammation involving the female upper genital tract and the supporting tissues; is usually caused by an ascending infection of organisms from the endocervix that may be confined to the uterus, fallopian tubes, ovaries, the supporting ligaments, or may involve several of the above uterine appendages; such inflammation can lead to functional impairment and infertility.
Definition (MSH) A spectrum of inflammation involving the female upper genital tract and the supporting tissues. It is usually caused by an ascending infection of organisms from the endocervix. Infection may be confined to the uterus (ENDOMETRITIS), the FALLOPIAN TUBES; (SALPINGITIS); the ovaries (OOPHORITIS), the supporting ligaments (PARAMETRITIS), or may involve several of the above uterine appendages. Such inflammation can lead to functional impairment and infertility.
Concepts Disease or Syndrome (T047)
MSH D000292
ICD9 614.9, 614-616.99
ICD10 N70-N77.9 , N73.9, N70-N77
SnomedCT 198130006, 198244005, 155974004, 155967009, 266584000, 266648001, 155968004, 198570007, 266651008, 198178006, 155986001, 37518008, 198131005
English Disease, Pelvic Inflammatory, Diseases, Pelvic Inflammatory, Inflammatory Disease, Pelvic, Inflammatory Diseases, Pelvic, Pelvic Inflammatory Diseases, PELVIC INFLAMMATION, Disease, Inflammatory Pelvic, Diseases, Inflammatory Pelvic, Inflammatory Pelvic Disease, Inflammatory Pelvic Diseases, Pelvic Disease, Inflammatory, Pelvic Diseases, Inflammatory, Female pelvic inflam disease, Female pelvic inflam.dis.NOS, Female pelvic inflammatory disease NOS, Female pelvic inflammatory diseases NOS, Inflammatory diseases of female pelvic organs, Inflammtry dis/fem pelv org, [X]Inflammatory diseases of female pelvic organs, [X]Inflammtry dis/fem pelv org, Female pelvic inflammatory disease, unspecified, PELVIC INFLAMM DIS, INFLAMM PELVIC DIS, PELVIC DIS INFLAMM, INFLAMM DIS PELVIC, pelvic inflammatory disease, pelvic inflammatory disease (diagnosis), PID, PID - pelvic inflammatory dis, Disease pelvic inflammatory, Pelvic inflammatory disease NOS, PID Pelvic inflammatory disease, Inflammation pelvic, Pelvic inflammation, Pelvic Infection, Fem pelv inflam dis NOS, Pelvic inflammatory disease (PID), Pelvic Inflammatory Disease [Disease/Finding], pelvic inflammation, pelvic inflammatory diseases, Disease;pelvic inflammatory, Infection;pelvic inflammatory, inflammatory pelvic disease, pelvic inflammatory disease (PID), pid, Inflammatory diseases of female pelvic organs (N70-N77), Female pelvic inflammatory disease NOS (disorder), Pelvic inflam. disease NOS, [X]Inflammatory diseases of female pelvic organs (disorder), Female pelvic infection, Inflammatory disease of female pelvic organs AND/OR tissues (disorder), Inflam. dis.- pelvic, Female pelvic inflammatory diseases NOS (disorder), DISEASE (PID), PELVIC INFLAMMATORY, PELVIC INFLAMMATORY DISEASE, (PID), PELVIC INFLAMMATORY DISEASE, Pelvic infection, PID, PELVIC INFLAMMATORY DISEASE, INFLAMMATORY DISEASE (PID), PELVIC, Pelvic inflammatory disease, Female pelvic inflammation, Female pelvic inflammatory disease, PID - pelvic inflammatory disease, Female pelvic inflammatory disease (disorder), Inflammatory disease of female pelvic organs AND/OR tissues, inflammation; pelvic, pelvic inflammatory disease; female, Inflammatory disease of female pelvic organs and tissues, NOS, Inflammatory disease of female pelvic organs AND/OR tissues [Ambiguous], Pelvic Inflammatory Disease, Unspecified inflammatory disease of female pelvic organs and tissues, INFLAMMATORY DISEASE OF FEMALE PELVIC ORGANS, pelvic inflammatory infection
Dutch ontsteking bekken, niet-gespecificeerde ontstekingsziekte van de vrouwelijke bekkenorganen en -weefsels, bekkenontstekingsziekte NAO, ontstekingsziekte bekken, PID Pelvic inflammatory disease, bekkenontsteking, Ontsteking kleine bekken/ PID, bekkenontsteking; vrouw, ontsteking; bekken, Ontstekingsprocessen in vrouwelijk bekken, niet gespecificeerd, bekkenontstekingsziekte, Adnexitis, PID, Pelvic inflammatory disease
French Pelvi-péritonite, Inflammation pelvienne SAI, Maladie inflammatoire pelvienne (MIP), Maladie inflammatoire non précisée des organes et tissus pelviens chez la gemme, Inflammation pelvienne, Atteinte inflammatoire pelvienne, AIP (Atteinte inflammatoire pelvienne), MIP (Maladie inflammatoire pelvienne), Syndrome inflammatoire pelvien, INFLAMMATION PELVIENNE, PID, Maladie pelvienne inflammatoire, Maladie inflammatoire pelvienne, Inflammation du pelvis
German Beckenentzuendung NNB, Entzuendung des Beckens, PID Beckenentzuendung, unspezifische Entzuendungen der Organe und Gewebe des weiblichen Beckens, BECKENENTZUENDUNG, Entzuendliche Krankheit im weiblichen Becken, nicht naeher bezeichnet, PID, Beckenentzuendung, Entzündliche Erkrankung des Beckens
Italian Infiammazione pelvica, Malattia infiammatoria non specificata degli organi e dei tessuti pelvici femminili, Malattia infiammatoria pelvica NAS, Malattia infiammatoria pelvica
Portuguese Inflamação pélvica, Doença inflamatória pélvica, Doença inflamatória pélvica NE, Doença inflamatória NE dos órgãos e tecidos pélvicos femininos, INFLAMACAO PELVICA, DIP, Doença Inflamatória da Pelve, Doença Pélvica Inflamatória, Doença pélvica inflamatória, Doença Inflamatória Pélvica
Spanish Enfermedad inflamatoria no especificada de los órganos y tejidos pélvicos femeninos, Inflamación pélvica, Enfermedad inlamatoria pélvica, Enfermedad inflamatoria de la pelvis NEOM, Enfermedad inflamatoria pélvica EIP, PELVIS, INFLAMACION, enfermedad inflamatoria pélvica femenina, SAI (trastorno), enfermedad inflamatoria pélvica, [X]enfermedades inflamatorias de órganos pélvicos femeninos, enfermedad inflamatoria pélvica femenina, SAI, enfermedad inflamatoria de los órganos Y/O tejidos pélvicos (concepto no activo), enfermedad pélvica inflamatoria, [X]enfermedades inflamatorias de órganos pélvicos femeninos (trastorno), enfermedad inflamatoria pelviana, enfermedad inflamatoria de los órganos Y/O tejidos pelvianos, enfermedades inflamatorias pélvicas femeninas, SAI (trastorno), EPI, enfermedades inflamatorias pélvicas femeninas, SAI, Female pelvic inflammatory disease NOS, enfermedad inflamatoria de los órganos Y/O tejidos pélvicos, EIP, enfermedad inflamatoria pélvica en la mujer (trastorno), enfermedad inflamatoria pélvica en la mujer, enfermedad inflamatoria pélvica femenina, inflamación pélvica femenina, Enfermedad inflamatoria pélvica, Enfermedad Inflamatoria Pélvica
Japanese 骨盤内炎症性疾患NOS, 骨盤内炎症, コツバンナイエンショウセイシッカン, コツバンナイエンショウ, コツバンナイエンショウセイシッカンNOS, 骨盤内炎症性疾患, 子宮付属器炎, 付属器炎
Finnish Sisäsynnytintulehdus
Czech Pánevní zánětlivé onemocnění, Pánevní zánětlivé onemocnění NOS, Zánět v pánvi, Zánětlivé onemocnění orgánů malé pánve, Pánevní zánět, Blíže neurčené zánětlivé onemocnění ženských pánevních orgánů a tkání, pánev - zánětlivé nemoci, pánevní zánět, pánevní zánětlivá onemocnění
Korean 상세불명의 여성 골반의 염증성 질환
Swedish Bäckeninflammation
Polish Choroba zapalna miednicy
Hungarian Kismedencei gyulladás, kismedencei gyulladásos betegség k.m.n., PID (kismedencei gyulladásos betegség), pelvikus gyulladás, kismedencei gyulladásos betegség, pelvikus gyulladásos betegség, Női kismedencei szervek és szövetek nem meghatározott gyulladásos betegsége, PID
Norwegian Bekkenbetennelse, Bekkeninflammasjon, Pelvioperitonitt