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Pelvic Inflammatory Disease
Aka: Pelvic Inflammatory Disease, PID
- Epidemiology
- Incidence: 750,000 cases per year in United States
- Age: Peaks between ages 15 to 29 years
- Pathophysiology
- Intra-abdominal spread
- Cervix to endometrium and via salpinx to peritoneal cavity
- Lymphatic spread
- Example: IUD related infection
- Hematogenous spread (rare)
- Example: Tuberculosis
- Etiology
- Chlamydia trachomatis
- NeisseriaGonorrhea
- Mycoplasma hominis
- Mycoplasma genitalium (associated with treatment failures, not currently covered by antibiotic regimens)
- Facultative or anaerobic organisms
- Risk Factors
- Sexually Transmitted Disease (STD) history
- Chlamydia is asymptomatic in 80-90% of women
- Gonorrhea is asymptomatic in 10% of women
- Untreated Chlamydia or Gonorrhea is associated with a 10-20% risk of PID
- Age younger than 25 years
- Onset sexual intercourse at a young age (younger than 15 years old)
- Prior history of Pelvic Inflammatory Disease
- High number of sexual partners
- Non-barrier Contraception (e.g. IUD, Oral Contraceptives)
- Symptoms: Onset usually in first half of Menstrual Cycle
- Abdominal Pain or Pelvic Pain or cramping (varying intensity)
- Vaginal Discharge (new or abnormal)
- Fever or chills (fever may be high grade)
- Dyspareunia
- Dysuria
- Heavy or prolonged Menses or post-coital bleeding
- Exam
- Bimanual exam and speculum exam in all suspected cases
- Cervical motion tenderness
- Uterine tenderness
- Adnexal tenderness
- See Diagnosis below for signs
- Clinical diagnosis alone is accurate (when compared with imaging and laparoscopy)
- Test Sensitivity: 87%
- Test Specificity: 50%
- Positive Predictive Value: 65-90%
- Diagnosis: 2002 CDC Criteria
- Major Criteria (Required)
- Uterine or Adnexal tenderness to palpation or
- Cervical motion tenderness
- No other apparent cause
- Minor Criteria (Supporting, but not required)
- Fever >101 F (38.3 C)
- Abnormal discharge per Cervix or vagina
- WBCs on Gram Stain or Saline of Cervix swab
- Gonorrhea or Chlamydia testing positive
- Increased Erythrocyte Sedimentation Rate or C-Reactive Protein
- PID findings on diagnostic study (see below)
- Most specific findings (not required and rarely indicated unless refractory to management or unclear diagnosis)
- Laparoscopy findings consistent with PID
- Endometrial Biopsy with histology suggestive of Endometritis
- Imaging (Transvaginal Ultrasound or MRI) with classic findings
- Thickened, fluid filled tubes
- Free pelvic fluid may be present
- Tubo-ovarian complex
- Tubal hyperemia on doppler Ultrasound
- Differential Diagnosis
- See Acute Pelvic Pain
- See Acute Pelvic Pain Causes
- Ruptured Ovarian Cyst
- Sudden onset of mid-cycle pain
- Ectopic Pregnancy
- Unilateral pain
- Positive Pregnancy Test
- Afebrile
- White Blood Cell Count normal
- Appendicitis
- Right Lower Quadrant Abdominal Pain
- More bowel Symptoms
- Urinary Tract Infection (including Pyelonephritis)
- No Cervical Motion Tenderness or Vaginal Discharge
- Ovarian Torsion
- More localized pain
- Sudden onset
- Afebrile
- White Blood Cell Count normal
- Other common causes
- Nephrolithiasis
- Inflammatory Bowel Disease
- Labs
- General
- Do not delay treatment while waiting for labs
- Inflammatory markers (if all normal, PID is very unlikely)
- Complete Blood Count (CBC)
- Erythrocyte Sedimentation Rate or C-Reactive Protein
- Vaginal secretion exam (saline wet prep)
- Vaginal PMNs (Negative Predictive Value 95%)
- Identifies Trichomonas vaginalis and Bacterial Vaginosis
- Sexually Transmitted Disease screening
- DNA probe PCR for Gonorrhea and Chlamydia
- Cervical specimen recommended over urine specimen
- Test Sensitivity and Test Specificity are high
- Rapid Plasma Reagin (RPR)
- Human Immunodeficiency Virus Test (HIV Test)
- Other initial labs
- Urine Pregnancy Test
- Blood Cultures
- Diagnostics
- Endometrial Biopsy: Endometritis
- Test Sensitivity: 74%
- Test Specificity: 84%
- Transvaginal pelvic Ultrasound
- Efficacy
- Test Sensitivity: 30%
- Test Specificity: 76%
- Pelvic free fluid in cul-de-sac
- Tubo-ovarian abscess may be present
- Doppler demonstrates tubal hyperemia
- Fallopian tube changes
- Thickened fallopian tube wall >5 mm
- Fluid filled fallopian tubes
- Incomplete septae in fallopian tube
- Cogwheel sign on tube cross-section view
- CT Pelvis
- Other imaging modalities are preferred for PID evaluation
- Pelvic floor fascial, Adnexal inflammation
- Uterosacral ligament thickening
- Pelvic free fluid
- MRI Pelvis
- Efficacy
- Test Sensitivity: 81-95%
- Test Specificity: 89-100%
- Tubo-ovarian abscess may be present
- Pelvic free fluid
- Fallopian tube changes
- Fluid filled fallopian tubes
- Ovaries have polycystic appearance
- References
- Tukeva (1999) Radiology 210:209-16 [PubMed]
- Laparoscopy
- Indicated for unclear diagnosis
- Pelvic Inflammatory Disease misdiagnosed 25% time
- Management: General
- Intrauterine Device (IUD) removal is controversial
- IUD increases PID for only first 3 weeks following insertion
- Risks are similar between the Copper-T IUD and the Mirena IUD
- Historically, IUD has been removed at time of PID diagnosis
- No evidence supports removal of IUD in PID
- Close follow-up is critical for those who developed PID with IUD in place
- Treat patient's sexual contacts within last 60 days
- Abstain from sexual intercourse until patient and partner have completed treatment
- Start empiric therapy if minimal criteria present
- Do not delay treatment
- Delay >3 days increases ectopic and Infertility risk
- Antibiotic should cover Gonorrhea and Chlamydia
- Management: Special Populations
- HIV positive women
- May be treated with same antibiotics and guidelines as non-HIV patients
- More likely to be infected with Mycoplasma or Streptococcus than with Gonorrhea or Chlamydia
- Pregnant women
- PID is less common in pregnancy, but can occur in first trimester before formation of mucous plug
- Pregnant women with PID have greater risk of complications including Preterm Labor
- Admit and initiate parenteral antibiotics for initial PID treatment in pregnancy
- Management Outpatient
- Step 1: Initial Treatment at Diagnosis (with step 2)
- Cefoxitin 2g IM and Probenecid 1g PO or
- Ceftriaxone 250 mg IM for 1 dose or
- Other third generation Cephalosporin (e.g Cefotaxime, Ceftizoxime)
- Step 2: Outpatient 14 day antibiotic course
- Select general antibiotic coverage
- Doxycycline 100 mg PO bid for 14 days (75% cure, preferred agent) or
- Azithromycin 1 gram orally once weekly for 2 weeks (alternative option, not CDC guideline)
- Savaris (2007) Obstet Gynecol 110:53–60 [PubMed]
- Consider adding anaerobic coverage
- Metronidazole 500 mg orally twice daily for 14 days or
- Clindamycin 450 mg PO four times daily for 14 days
- Agents to avoid
- Fluoroquinolones (e.g. Ofloxacin 400 bid or Levofloxacin 500 daily) are no longer recommended
- Cohorts at highest risk for Fluoroquinolone resistance
- Homosexual men and any female sexual contacts
- Endemic areas
- Asia: China, Japan, Korea, Philippines, Vietnam
- Other: England, Wales, Australia
- US: California
- References
- Workowski (2010) MMWR Recomm Rep 59(RR-12): 1-110 [PubMed]
- Management Inpatient
- Hospitalization Indications
- Severe illness
- Toxic appearance
- High fever
- Unable to take oral fluids or oral medications
- Unclear diagnosis
- Appendicitis
- Ectopic Pregnancy
- Ovarian Torsion
- Pelvic abscess (tubo-ovarian abscess)
- Requires at least 24 hours of parenteral therapy inpatient
- Pregnancy
- HIV positive
- Adolescents
- Outpatient treatment failure
- Unreliable patient
- Inpatient treatment Regimens
- General
- Treat for at least 48 hours IV
- Regimen A (preferred)
- Cefoxitin 2g IV q6h OR Cefotetan 2g IV q12h and
- Doxycycline 100 mg PO or IV q12h
- Regimen B
- Clindamycin 900 mg IV q8h and
- Gentamicin 2 mg/kg IV load, then 1.5 mg/kg IV q8h
- Alternative: Conversion to single daily dosing (at 3-5 mg/kg)
- Alternative
- Unasyn 3g IV q6 hours and
- Doxycycline 100 mg PO or IV q12 hours
- Other options that are not recommended (listed for historical reasons)
- Regimen C
- Ofloxacin 400 mg IV q12h or Levoquin 500 IV qd and
- Consider adding Metronidazole 500 IV q8 hours
- Discharge Regimen (after IV antibiotics above)
- See Outpatient Management Step 2 above
- Discontinue 24 hours after clinical improvement and complete therapy with oral antibiotics
- Doxycycline 100 mg orally twice daily for 14 days or
- Clindamycin 450 mg PO qid for 14 days
- References
- Workowski (2010) MMWR Recomm Rep 59(RR-12): 1-110 [PubMed]
- Course
- Expect clinical symptom improvement within first 72 hours of treatment
- Lack of improvement after 72 hours requires additional evaluation
- Consider inpatient parenteral therapy
- Broaden antibiotic coverage
- Consider Ultrasound to assess for tubo-ovarian abscess
- Prevention
- Screen all sexually active women age <25 years for Chlamydia
- Re-screen for STD 6 months after PID episode (Gonorrhea and Chlamydia)
- Encourage barrier Contraception (Condom use)
- Complications
- Infertility associated with tubal scarring (20%)
- Chronic Pelvic Pain (18%)
- Tubal Pregnancy (9%)
- References
- (2002) MMWR Recomm Rep 51(RR-6):1-78 [PubMed]
- Crossman (2006) Am Fam Physician 73(5):859-64 [PubMed]
- Gradison (2012) Am Fam Physician 85(8): 791-6 [PubMed]
- Miller (2003) Am Fam Physician 67(9):1915-22 [PubMed]
- Workowski (2010) MMWR Recomm Rep 59(RR-12): 1-110 [PubMed]