Guidelines for Nurse Practitioners in Gynecologic Settings 2016
Care Plan – Pelvic Inflammatory Disease
N73.9 – Female pelvic inflammatory disease, unspecified
I. DEFINITION
PID comprises a spectrum of inflammatory disorders of the upper genital tract. This may include any combination of endometritis, salpingitis, tubo- ovarian abscess, and pelvic peritonitis.
II. ETIOLOGY
A. Causative organisms include
1. Neisseria gonorrhoeae
2. Streptococcus agalactiae
3. Peptostreptococcus, Peptococcus
4. Bacteroides
5. C. trachomatis
6. E. coli
7. Mycoplasma hominis
8. RNA virus of the family Orthomyxoviridae
9. U. urealyticum
10. Gardnerella vaginalis
11. Trichomonads
12. Staphylococcus
13. Pseudomonas
14. Diphtheroids
15. Cytomegalovirus (CMV)
16. Haemophilus agalactiae
17. Haemophilus influenzae
18. Mycoplasma hominis
19. Mycoplasma genitalium
III. HISTORY
A. What the patient may present with (wide variation in symptomatology, making diagnosis difficult)
1. Lower abdominal pain, usually bilateral
2. Chills, fever
3. Anorexia
4. Nausea
5. Vomiting
6. Increased vaginal discharge
7. Heavier-than-usual period; abnormal bleeding
8. Urinary symptoms: frequency, pain
9. May complain of right upper quadrant pain; also Fitz–Hugh– Curtis syndrome
10. Dyspareunia
11. Back pain
B. Additional information to be considered
1. Known exposure to STI
2. Previous STI
3. Previous diagnosis of PID
4. Previously diagnosed endometriosis
5. History of abdominal surgery
6. Chronic illness
7. Sexual activity (present and recent past)
8. Last menstrual period (LMP); birth control method; presence of an IUD or recent insertion; recent pregnancy, childbirth, or abortion
9. Medication allergy
10. Currently taking any medication
11. Recent pelvic surgery (i.e., therapeutic abortion or dilation and curettage)
12. Smoker or nonsmoker (smoking cigarettes has recently been implicated as a risk factor for PID)
13. History of douching
IV. PHYSICAL EXAMINATION
A. Vital signs
1. Temperature
2. Blood pressure
3. Pulse
4. Respiration
B. Abdominal examination
1. Bowel sounds: normal, hyperactive, sluggish, absent
2. Generalized lower abdominal tenderness
3. Guarding
4. Rebound tenderness
C. External genitalia
1. Lesions
2. Observe and palpate Skene’s and Bartholin’s glands
D. Vaginal examination (speculum)
1. Profuse vaginal discharge (may be purulent)
2. Examine cervix for
a. Erosion, ectropion
b. Friability
c. Discharge in os
E. Bimanual examination
1. Examine cervix for cervical motion tenderness
2. Examine uterus for tenderness
3. Examine adnexa for
a. Tenderness
b. Mass
4. Rectovaginal examination for tenderness; if present, describe location (e.g., cervix, uterus, adnexa)
V. LABORATORY EXAMINATION
A. Gonococcal culture
B. Chlamydia smear
C. Microorganisms comprising vaginal flora (e.g., anaerobes, G. vaginalis,
H. influenzae, enteric gram-negative rods, and S. agalactiae; CMV,
M. hominis, U. urealyticum, and M. genitalium have been associated with some cases of PID.
D. CBC/differential, C-reactive protein
E. Sedimentation rate
F. Urinary tract infection screen
G. Serology test for syphilis; HIV
H. Human chorionic gonadotropin (hCG) if history indicates: urine, serum
I. Transvaginal ultrasound
J. MRI—severe symptoms
K. Endometrial biopsy with histologic evidence of endometritis
L. Laparoscopic abnormalities consistent with PID
M. Culdocentesis (refer to a physician)
VI. CRITERIA FOR CLINICAL DIAGNOSIS
A. Criteria for ambulatory treatment
1. The three minimum criteria for diagnosis of PID are
a. History of uterine tenderness or
b. Cervical motion tenderness or
c. Adnexal tenderness (may be unilateral)
2. Additional criteria that will increase the specificity of diagnosis
a. Temperature of 101°F (38.3°C) or higher
b. WBCs on saline microscopy of vaginal secretions
c. Abnormal cervical or vaginal mucopurulent discharge
d. Elevated C-reactive protein
e. Culdocentesis yielding peritoneal fluid that contains bacteria; WBCs
f. Presence of adnexal mass noted on bimanual examination; tubo-ovarian abscess on sonography
g. Elevated sedimentation rate greater than 15 mm/hr
h. Positive gonococcal culture from cervix
i. Positive Chlamydia smear from cervix
B. Criteria for hospitalization
1. Surgical emergencies such as appendicitis cannot be excluded.
2. The patient is pregnant.
3. The patient does not respond clinically to oral antimicrobial therapy.
4. The patient is unable to follow or tolerate an outpatient oral regimen.
5. The patient has severe illness, nausea, and vomiting or high fever.
6. The patient has a tubo-ovarian abscess.
7. The patient is immunodeficient (i.e., has HIV infection with low counts; is taking immunosuppressant therapy) or has another disease.
VII. DIFFERENTIAL DIAGNOSIS
A. Septic abortion
B. Ectopic gestation
C. Ovarian cyst
D. Ruptured ovarian cyst
E. Cystitis
F. Pyelonephritis
G. Peptic ulcer disease
H. Hepatitis
I. Appendicitis
J. Adhesions
K. Endometriosis/endometritis
L. Diverticular disease
M. Pelvic neoplasms
N. Irritable bowel syndrome
O. Ovarian torsion
P. Inflammatory bowel disease
VIII. TREATMENT
Centers for Disease Control and Prevention (CDC) recommendations (2014) for uncomplicated PID (mild to moderately severe acute PID)
A. Medication
1. Ceftriaxone 250 mg im in a single dose plus doxycycline 100 mg orally twice a day for 14 days with or without metronidazole 500 mg orally twice a day for 14 days or
2. Cefoxitin 2 g im and probenecid 1 g orally concurrently in a single dose plus doxycycline 100 mg orally twice a day for 14 days with or without metronidazole 500 mg orally twice a day for 14 days or
3. Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime plus doxycycline 100 mg orally twice a day for
14 days with or without metronidazole 500 mg orally twice a day for 14 days)*
4. Pregnant women: Hospitalize and treat with parenteral antibiotics per CDC guidelines for hospitalization
* Because of the limitations in coverage of anaerobes by the recommended third- generation cephalosporins and until it is known that extended anaerobic cover- age is not important for treatment of acute PID, the addition of metronidazole to treatment regimens with third-generation cephalosporins should be considered (CDC, FO2014).
5. Refer to CDC guidelines (2014) if patient meets hospitalization criteria
B. General measures
1. Bed rest
2. Increased fluid intake
3. General diet
4. Stress the importance of partner being examined and treated
5. Stress the use of condoms to prevent reinfection or future infections
6. No douching
C. Management of sex partners
1. Examine and treat if sexual contact with patient during 60 days prior to onset of symptoms
IX. COMPLICATIONS
A. Sterility
B. Generalized sepsis
C. Chronic pelvic pain
D. Tubal pregnancy
E. Surgical interventions
F. Dyspareunia
G. Tubo-ovarian abscess
H. Fitz–Hugh–Curtis syndrome: perihepatitis
X. CONSULTATION/REFERRAL
A. If failure to improve within 3 days (48–72 hours) after starting the aforementioned treatment
B. For hospitalization
C. For culdocentesis or diagnostic laparoscopy if indicated
XI. FOLLOW-UP
A. Reevaluate within 72 hours or sooner if symptoms worsen or do not improve. Patients should demonstrate substantial clinical improve- ment within 3 days.
B. After completion of medication course (no sooner than 7 days)
1. Bimanual
2. Cultures if indicated (i.e., positive lab results prior to treatment); some specialists recommend rescreening for gonorrhea and
C. trachomatis regardless of prior culture results 4 to 6 weeks after completion of therapy.
C. Male sex partners of women with PID should be examined and treated if sexual contact was 60 days or less preceding symptom onset.
See Bibliographies.
Website: www.cdc.gov/std/treatment/2014/2014-std-guidelines-peer-reviewers- 08-20-2014.pdf