Pelvic Inflammatory Disease
Erin Shankel
Definition
A.Pelvic inflammatory disease (PID) is an inflammation caused by an infection of the upper genital tract. This inflammation can involve the uterine endometrium (endometritis), fallopian tubes (salpingitis), ovaries (oophoritis), broad ligament or uterine serosa (parametritis), and the pelvic vascular system or pelvic connective tissue.
Incidence
A.Annual incidence is estimated to be approximately one million cases in the United States. In women aged 15 to 24 years, the incidence is projected at 1% annually in the United States, with lifetime prevalence of approximately 4.4%.
B.PID is the leading cause of infertility in the world.
Pathogenesis
A.PID is caused by organisms that ascend from the vagina and cervix into the uterus. Menses facilitates gonococcal invasion of the upper genital tract as the luteal phase stimulates gonococcal growth and the cervical mucus barrier is removed. Infection and inflammation spread throughout the endometrium to the fallopian tubes. From there, it extends to the ovaries and peritoneal cavity.
B.The most common organisms cultured from patients with PID are Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma hominis, Ureaplasma urealyticum, Bacteroides, Peptostreptococcus, Escherichia coli, and some endogenous aerobes and anaerobes.
C.The incubation period varies with the infective organism.
Predisposing Factors
A.Age: Rates of PID are higher for women at younger ages. It is highest in the younger than 30-year-old age group (70% incidence younger than age 25). Teens are particularly susceptible because they have an immature immune system and larger zones of cervical ectopy with thinner cervical mucus.
B.Sexual activity: Women with multiple sexual partners are three times more likely to develop PID when compared to women with only one partner.
C.Intrauterine contraceptive device (IUC): IUCs can lead to an iatrogenic development of PID and can promote the spread of vaginal or cervical organisms into the uterus by means of the IUC string.
D.History of PID.
E.Menstruation: Supports the development and spread of PID. Women who are not currently menstruating have a decreased risk.
F.History of invasive procedures: These procedures may result in iatrogenic PID. PID is usually seen within 4 weeks of the procedure (dilatation and curettage [D&C], IUC insertion, hysterosalpingogram (HSG), and vacuum curettage abortion).
G.There is an increased incidence of PID in African Americans, non-White women, and women in lower socioeconomic groups.
H.Cigarette smoking.
I.Frequent vaginal douching.
Common Complaints
A.Lower abdominal pain.
B.Fever or chills.
C.Increased vaginal discharge.
D.Nausea and vomiting.
E.Low back pain.
Other Signs and Symptoms
A.Asymptomatic; vague and nonspecific symptoms.
B.Minimal to severe pelvic pain.
C.Right upper quadrant pain (25%).
D.Abnormal vaginal bleeding.
Subjective Data
A.Determine onset, duration, and course of presenting symptoms.
B.Review the character of vaginal discharge (if any); history of recent dysmenorrhea and/or dyspareunia; any intestinal or bladder symptoms.
C.Question the patient regarding sexual history: current number of sexual partners; current or most recent sexual activity; and contraceptive used (condoms, pills, diaphragm, IUC), and frequency of method used.
D.Question the patient as to whether her current sexual partner has experienced any symptoms.
E.What is the patient’s current menstrual pattern? Does she think she is pregnant? When did the pain begin in relation to her cycle?
F.Review prior pelvic or abdominal surgeries and procedures (hysterosalpingogram [HSG], abortion) and when they were done.
G.Review the history and quality of pain, how long, bilateral or unilateral, what makes it better, and what makes it worse (intercourse, Valsalva’s maneuver with bowel movement, activity).
Physical Examination
Lower abdominal or pelvic pain is the most common symptom of PID and typically is moderate to severe. However, many women may have subtle or mild symptoms that are not readily recognizable as PID, including abnormal bleeding, dyspareunia, or vaginal discharge.
A.Check temperature, pulse, respirations, blood pressure (BP), height, and weight to calculate body mass index (BMI).
B.Observe general overall appearance for discomfort before, during, and after exam. Watch patient ambulate. Patients with PID often shuffle their feet to avoid pain with movement.
C.Auscultate the abdomen for bowel sounds in all quadrants. Auscultation of the abdomen should precede any palpation or percussion due to the changes in intensity and frequency of sounds after manipulation.
D.Percuss the abdomen for organomegaly.
E.Palpate:
1.Palpate the groin for lymphadenopathy.
2.Palpate the abdomen for masses.
3.Palpate the levator ani muscle left and right, the urethra, and trigone of the bladder.
4.Perform rebound, involuntary guarding, and jar tests. The jar test is performed by intentionally hitting or jarring the examination table and watching for a pain response. Pelvic discomfort is exacerbated by the Valsalva’s maneuver, intercourse, or movement. Abdominal or pelvic pain with PID is usually bilateral. About 25% of patients complain of right upper quadrant pain; the pain usually occurs within 7 to 10 days of menses, remains continuously, and is most severe in the lower quadrants.
F.Pelvic examination:
1.Examine the vulva for Bartholin’s gland enlargement, fissures, condyloma, herpes, and pelvic relaxation.
2.Palpate: Milk
the urethra for discharge.
3.Speculum examination: Inspect for cervicitis and friability. Evaluate vaginal discharge and bleeding for color, amount, and odor.
G.Bimanual examination:
1.Check cervical motion tenderness (CMT); evaluate the size, contour, mobility, and tenderness of the uterus.
2.Palpate the adnexa for tenderness and masses. The pelvic area may feel hot. Classic PID presentation is lower abdominal and adnexal tenderness and CMT (chandelier sign).
H.Rectovaginal examination: Assess for adnexal thickening and masses.
Diagnostic Tests
A.Complete blood count (CBC) with differential; white blood cells (WBCs) greater than 10,500 cell/mm3.
B.Sedimentation rate or C-reactive protein.
C.Quantitative beta human chorionic gonadotropin (HCG).
D.Rapid plasma reagin (RPR) hepatitis B surface antigen, and HIV.
E.Cultures for gonorrhea (GC) and C. trachomatis (CT).
F.Transvaginal ultrasonography.
G.Laparoscopy, by referral.
Always test the patient for quantitative beta HCG even if the patient claims her menses are regular and she is using reliable contraception, because of the extreme risk of ectopic pregnancy. Cultures must always be done; lab work (such as HIV and RPR) may be done as indicated, depending on the patient’s history and presentation. Eliciting data in the health history about hysterectomy, previous appendectomy, abortions, and procedures such as HSG may provide exclusionary diagnoses.
H.Diagnostic criteria for clinical diagnosis of PID:
1.Maintain a high index of suspicion and err toward the side of overtreatment in favor of prevention of long-term sequelae associated with missed diagnoses. Empiric treatment should be started in sexually active women with pelvic/lower abdominal pain and no other discernable cause and any ONE of the following:
a.Uterine tenderness.
b.Adnexal tenderness.
c.CMT.
2.Additional criteria to support diagnosis:
a.Oral temperature greater than 101°F.
b.Abnormal cervical or vaginal discharge.
c.Elevated erythrocyte sedimentation rate (>15 mm/hr).
d.Elevated C-reactive protein.
e.Laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis.
f.Abundant WBCs on saline wet prep.
3.Highly specific criteria for diagnosing PID:
a.Ultrasound, Doppler, or MRI findings suggesting infection.
b.Laparoscopic abnormalities consistent with PID.
c.Endometrial biopsy showing endometriosis.
Differential Diagnoses
A.Gynecologic factors:
1.PID.
2.Ectopic pregnancy.
3.Pelvic endometriosis.
4.Dysmenorrhea.
5.Adenomyosis.
6.Functional ovarian cysts.
7.Endometrial polyps or fibroid.
8.Pelvic relaxation.
9.Anatomic abnormalities.
B.Gastrointestinal (GI) factors:
1.Acute appendicitis.
2.Irritable bowel syndrome (IBS).
3.Ulcerative colitis, Crohn’s disease (CD).
4.Diverticulitis.
5.Hernia.
C.Genitourinary factors:
1.Cystitis, urethritis interstitial cystitis (IC).
2.Ureteral obstruction.
3.Carcinoma of bladder.
D.Musculoskeletal factors:
1.Myofascial pain.
2.Pelvic floor myalgia.
3.Spinal injuries or degenerative disease.
E.Neurologic factor: Nerve entrapment syndrome.
Plan
A.General interventions
1.A low threshold is needed for diagnosis of PID because of the risk of damage to reproductive health. Early treatment with the use of antibiotics of an upper genital tract infection is imperative. Other causes of lower abdominal pain, such as IBS and endometriosis, are not likely to be impaired by empiric antibiotic therapy. The risk of ectopic pregnancy is 6 to 10 times greater in women with PID compared with uninfected women.
2.Antibiotic therapy should be instituted promptly, based on clinical diagnosis without awaiting culture results, to minimize the risk of progression of the infection and risk of transmission of the organisms to other sexual partners.
3.Evidence is insufficient to recommend intrauterine device (IUD) removal in women with PID. If it is left in place, follow-up is essential.
4.Ambulatory patients should be monitored closely and reevaluated within 3 days of initiating antibiotic therapy. A decrease in pelvic tenderness should be observed within 3 to 5 days of initiation of therapy; if not, additional evaluation is warranted.
B. 
See Section III: Patient Teaching Guide Pelvic Inflammatory Disease.
1.Male sexual partners (and all partners) of patients with PID must be examined, cultured when possible, and treated empirically for presumptive gonorrheal and chlamydial infection.
2.Women who do not use any contraception are at the greatest risk. Transmission of sexually transmitted infections (STIs) can be minimized with effective use of condoms.
C.Pharmaceutical therapy: The current (2015) Centers for Disease Control and Prevention (CDC) guidelines are listed in Table 17.7.
Follow-Up
A.Because of the high risk of reinfection, many clinicians recommend reevaluation in 4 to 6 weeks after completion of therapy. Patients with positive cultures for GC and CT should be recultured in 7 to 10 days after completing therapy. Test of cure
is necessary.
B.Hepatitis B immunization should be initiated in previously unvaccinated persons.
Consultation/Referral
Consult a gynecologist if the patient diagnosis is atypical, evidence for a presumptive diagnosis is present, or hospitalization is required. General criteria for hospitalization are the following:
A.Diagnosis is uncertain.
B.Pelvic or tubo-ovarian abscess is suspected.
C.IUC in situ.
D.The patient is pregnant.
E.The patient is an adolescent or is believed to be incapable of adhering to outpatient regimen.