Pelvic Inflammatory Disease

English and Spanish Patient handouts on PID: youngwomenshealth.org

Last updated 12/2013

Definition and Epidemiology

  • Infection of female upper genital tract including any of:
    • endometritis, salpingitis, oophoritis, tubo-ovarian abscess, pelvic peritonitis, or perihepatitis
    • Infection is usually sexually transmitted or acquired
    • May present as perihepatitis (Fitz-Hugh-Curtis syndrome) alone with no pelvic signs or symptoms
    • Risk of PID in sexually active 15-year-olds is 1:8
    • About 20% of 1 million annual cases in US are in adolescents

Pathogenesis

  • In sexually transmitted PID, the initial infection is on the cervix. The organisms then ascend through the uterus into the tubes and, at times, into the abdominal cavity
  • Presence of Bacterial Vaginosis and menstrual blood flow may facilitate ascension of these organisms 
  • Unreated Neisseria gonorrhea &Chlamydia trachomatis cervicitis have a 30% risk of PID in teens (10% in adults)
  • Mycoplasma genitalium common in GC/CT-negative cases
  • Invasion of anareobes and polymicrobial flora after initial cervical infection, e.g. Gardnerella vaginalis, Haemophilus influenzae, group B Streptococci, Bacteroides species

Adolescents at increased risk for PID

  • Increased risk for GC/CT (given high risk sex behaviors) and less likely to be screened for GC/CT
  • Low levels of local protective antibody due to lack of prior exposure
  • Cervical ectropion- STI pathogens readily adhere to exposed columnar epithelium
  • General Risk Factors
    • Prior PID diagnosis
    • Smoking and douching
    • Immuno-compromise
  • OCP use not a clear risk factor. No increased risk with IUD device beyond first few weeks post-insertion

History and Physical Exam Findings

  • History:
    • abdominal pain
    • spotting or bleeding
    • thick or foul smelling vaginal discharge
    • pain with coitus
    • fever, nausea, emesis
  • Exam: vital signs, abdominal exam, pelvic exam are key
    • typically bilateral lower abdominal or adnexal tenderness
    • cervical motion tenderness, though not-specific
    • purulent discharge from cervix
    • rebound tenderness if peritonitis
    • liver tenderness if perihepatitis
  • PID may present with perihepatitis, (Fitz-Hugh-Curtis) alone

Hospitalization Criteria

  • Age less than 15 years
  • Unable to follow or tolerate an outpatient therapy
  • Pregnancy
  • Previous episode of PID
  • Termination or other gyn procedure less than 2 weeks prior
  • Surgical emergencies cannot be excluded
  • Severe illness (nausea, vomiting, or high fever)
  • Did not respond clinically to oral antimicrobial therapy
  • Adnexal mass or tubo-ovarian abscess

INPATIENT MANAGEMENT  

  • Recommended Regimen: Cefoxitin 2 G IV Q6hrs PLUS
  • Doxycycline 100 mg oral with food Q12hrs
  • Alternative regimens in case of pregnancy or drug allergies or complications
  • can be found on page 66 of www.cdc.gov/mmwr/pdf/rr/rr5912.pdf
  • On admission: While maintaining confidentiality, consent and screen for HIV and RPR, begin STI and contraception counseling, and consult SW to ensure insurance/need for medication assistance/partner notification.
  • On hospital day 2 or about 48 hours post treatment: repeat bimanual exam.  If no improvement in tenderness consider transvaginal ultrasound. If peritoneal signs develop, consult Gyn and Surgery to consider surgical etiology.
  • Discharge criteria:
    • Improvement in abdominal/pelvic pain and tenderness and
    • resolution of fever and vomiting if present on admission
    • Filled RX for completion of total 14 days with oral doxycyline 100mg BID and, if tubo-ovarian abcess, with oral metronidazole 500mg BID also for 14 total days
    • If not using a contraceptive method currently, despite counseling, RX Emergency Contraception
    • Follow up appointment in 1 week with PCP AND consultation referral to Adolescent Medicine (discuss appointment details with attending on service and email PASSoutpatient with overbook request)
    • If patient is >19 years old and needs a new PCP, refer to Family Medicine for follow up.  Ensure 1 week follow up date.

Diagnostic Criteria

  • Minimum criteria: Pelvic or lower abdominal pain AND either cervical motion tendernessOR uterine tenderness OR adnexal tenderness.
    • Adnexal tenderness most sensitive (95%) but not specific (4%)
  • Additional criteria enhances specificity of diagnosis: oral temp > 38.3, cervical mucopurulent discharge, abundant WBC on wet mount, elevated ESR or CRP,  positive GC/CT:
    • If no cervical discharge or WBC on wet prep, PID is unlikely, with a NPV of 95%.
    • Elevated CRP very highly (80-90%) sensitive and specific.
  • Definitive criteria: endometerial biopsy with histiopathic evidence of endometritis, transvaginal U/S or MRI showing thickenedfluid-filled fallopian tubes or tubal hyperemia, or laproscopy findings consistent with PID

Differential Diagnosis
Differential diagnosis important due to low specificity of diagnostic criteria

  • GI:   appendicitis, cholecystitis, hepatitis, constipation, diverticulitis, gastroenteritis, inflammatory bowel disease, irritable bowel syndrome
  • GYN:  ovarian cyst, endometriosis, dysmenorrhea, ectopic pregnancy, mittelschmerz, ruptured follicle, septic or threatened abortion, tubo-ovarian abscess
  • GU:   cystitis, pyelonephritis, urethritis, nephrolithiasis

Complications and Consequences

  • Tubo-ovarian abscess, presents later in menstrual cycle > 18d
  • Infertility (about 10% after first, 20-30% after second episode, and 40-70% after third PID episode)
  • Ectopic pregnancy (3-10x risk)
  • Chronic pelvic pain (24% patients have pelvic pain 6 months after hospitalization for PID and after two PID episodes 2.8 odds chronic pelvic pain at 2-5 years)
  • Increased risk of future PID (2-3x risk)

Counseling

  • PID treatment is protected under NYS confidentiality for minors. Be careful to maintain patient’s confidentiality
  • No sex until treatment course is completed
  • Any partners from 60 days prior to patient’s symptoms should be treated for both GC and CT exposure, regardless of patient or partners test results for GC/CT; give patient a letter to give to partner’s health care provider
  • STI protection and reproductive health care counseling

Evaluation

  • Confidential history noting abdominal or pelvic pain, spotting/bleeding/vaginal discharge, pain with coitus, fever, nausea, emesis, last menstrual period
  • Pelvic examination (speculum and bimanual) noting mucopurulent discharge from os, friable cervix, tenderness or mass
  • Abdominal exam noting masses and rebound tenderness
  • Labs and Diagnostics: pH and wet prep of cervical discharge, Endocervical NAAT for GC/CT, CBC with differential, CRP and ESR, Urine dipstick or Urinalysis, Urine Culture, Urine B-hCG, HIV test (if unprotected sex since last test OR last test unknown or > 1 year ago) and RPR
  • Also Consider:
    • Pelvic Ultrasound if: pelvic mass or adnexal tenderness with either high fever, elevated WBC, elevated CRP or ESR.
    • Serum BHcG, Type and Cross if: suspect ectopic pregnancy
    • Gynecologic consult if tubo-ovarian abscess > 8cm, pregnancy, other urgent gynecologic diagnosis
    • Surgery consult if suspect appendicitis or other surgical diagnoses

ED/OUTPATIENT MANAGEMENT  

  • Recommended Regimen: Ceftriaxone 250 mg IM PLUS Doxycycline 100 mg orally BIDfor 14 days WITH OR WITHOUT Metronidazole 500 mg orally BID for 14 days 
  • Alternative regimens in case of pregnancy or drug allergies or complications can be found on page 66 of www.cdc.gov/mmwr/pdf/rr/rr5912.pdf
  • While maintaining confidentiality, consent and screen for HIV and RPR, begin STI and contraception counseling, SW consult to ensure insurance status/need for medication assistance/partner notification.
  • Follow up 48 hours post treatment with PCP (if he/she provides gyn care) or adolescent medicine consultant (page or call adolescent medicine fellow (718-920-2180): repeat bimanual exam.  If no improvement in symptoms or exam consider TV Ultrasound and hospitalize for failure of outpatient treatment
  • Follow up 10 days post treatment: Ensure completion of treatment and resolution of symptoms. Ensure partner notification and treatment. Refer to Adolescent Medicine (718-741-2450) for STI and contraception counseling.