Introduction

Essentials of Diagnosis

 
• Lower abdominal, adnexal, or cervical motion tenderness.  
• Absence of a competing diagnosis.

General Considerations

Pelvic inflammatory disease is a polymicrobial infection of the upper genital tract associated with the sexually transmitted organisms N gonorrhoeae and C trachomatis as well as endogenous organisms, including anaerobes, H influenzae, enteric gram-negative rods, and streptococci. It is most common in young, nulliparous, sexually active women with multiple partners. Other risk markers include nonwhite race, douching, and smoking. The use of oral contraceptives or barrier methods of contraception may provide significant protection.

Tuberculous salpingitis is rare in the United States but more common in developing countries; it is characterized by pelvic pain and irregular pelvic masses not responsive to antibiotic therapy. It is not sexually transmitted.

Clinical Findings

A. Symptoms and Signs
Patients with pelvic inflammatory disease may have lower abdominal pain, chills and fever, menstrual disturbances, purulent cervical discharge, and cervical and adnexal tenderness. Right upper quadrant pain (Fitz-Hugh and Curtis syndrome) may indicate an associated perihepatitis. However, diagnosis of PID is complicated by the fact that many women may have subtle or mild symptoms, not readily recognized as PID.

B. Minimum Diagnostic Criteria
Women with uterine adnexal or cervical motion tenderness should be considered to have PID and be treated with antibiotics unless there is a competing diagnosis such as ectopic pregnancy or appendicitis.

C. Additional Criteria
The following criteria may be used to enhance the specificity of the diagnosis: (1) oral temperature > 38.3 °C, (2) abnormal cervical or vaginal discharge with white cells on saline microscopy, (3) elevated erythrocyte sedimentation rate, (4) elevated C-reactive protein, and (5) laboratory documentation of cervical infection with N gonorrhoeae or C trachomatis. Endocervical culture should be performed routinely, but treatment should not be delayed while awaiting results.

D. Definitive Criteria
In selected cases where the diagnosis based on clinical or laboratory evidence is uncertain, the following criteria may be used: (1) histopathologic evidence of endometritis on endometrial biopsy, (2) transvaginal sonography or MRI showing thickened fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex, and (3) laparoscopic abnormalities consistent with PID.

Differential Diagnosis

Appendicitis, ectopic pregnancy, septic abortion, hemorrhagic or ruptured ovarian cysts or tumors, twisted ovarian cyst, degeneration of a myoma, and acute enteritis must be considered. Pelvic inflammatory disease is more likely to occur when there is a history of pelvic inflammatory disease, recent sexual contact, recent onset of menses, or an IUD in place or if the partner has a sexually transmitted disease. Acute pelvic inflammatory disease is highly unlikely when recent intercourse has not taken place or an IUD is not being used. A sensitive serum pregnancy test should be obtained to rule out ectopic pregnancy. Culdocentesis will differentiate hemoperitoneum (ruptured ectopic pregnancy or hemorrhagic cyst) from pelvic sepsis (salpingitis, ruptured pelvic abscess, or ruptured appendix). Pelvic and vaginal ultrasound are helpful in the differential diagnosis of ectopic pregnancy of over 6 weeks. Laparoscopy is often utilized to diagnose pelvic inflammatory disease, and it is imperative if the diagnosis is not certain or if the patient has not responded to antibiotic therapy after 48 hours. The appendix should be visualized at laparoscopy to rule out appendicitis. Cultures obtained at the time of laparoscopy are often specific and helpful.

Treatment

A. Hospitalization
Patients with acute pelvic inflammatory disease should be admitted for intravenous antibiotic therapy if (1) surgical emergencies such as appendicitis cannot be ruled out, (2) the patient has a tubo-ovarian abscess, (3) the patient is pregnant, (4) the patient is unable to follow or tolerate an outpatient regimen, (5) the patient has failed to respond clinically to outpatient therapy, or (6) the patient has severe illness, nausea and vomiting, or high fever. In the past, many experts recommended that all patients with PID be hospitalized for bed rest and supervised treatment with parenteral antibiotics. However, a recent large, randomized clinical trial suggests that in women with mild to moderate pelvic inflammatory disease there is no difference between inpatient and outpatient therapy in short-term clinical outcomes or in long-term reproductive outcomes. Patients with tubo-ovarian abscesses should have direct inpatient observation for at least 24 hours prior to switching to outpatient parenteral therapy.

B. Antibiotics
Early treatment with appropriate antibiotics effective against N gonorrhoeae, C trachomatis, and the endogenous organisms listed above is essential to prevent long-term sequelae. The sexual partner should be examined and treated appropriately.

Two inpatient regimens have been shown to be effective in the treatment of acute pelvic inflammatory disease: (1) Cefoxitin, 2 g intravenously every 6 hours, or cefotetan, 2 g every 12 hours, plus doxycycline, 100 mg intravenously or orally every 12 hours. This regimen is continued for at least 24 hours after the patient shows significant clinical improvement. Doxycycline, 100 mg twice daily, should be continued to complete a total of 14 days therapy. If a tubo-ovarian abscess is present, it is advisable to add oral clindamycin or metronidazole to the doxycycline to provide more effective anaerobic coverage. (2) Clindamycin, 900 mg intravenously every 8 hours, plus gentamicin intravenously in a loading dose of 2 mg/kg followed by 1.5 mg/kg every 8 hours. This regimen is continued for at least 24 hours after the patient shows significant clinical improvement and is followed by either clindamycin, 450 mg four times daily, or doxycycline, 100 mg twice daily, to complete a total of 14 days of therapy.

Limited data exist on other parenteral regimens. Two regimens providing broad-spectrum coverage have been investigated in at least one clinical trial: (1) ofloxacin, 400 mg intravenously every 12 hours, or levofloxacin, 500 mg intravenously once daily, plus metronidazole, 500 mg intravenously every 8 hours; and (2) ampicillin-sulbactam, 3 g intravenously every 6 hours, plus doxycycline, 100 mg intravenously or orally every 12 hours.

Two outpatient regimens are recommended: (1) ofloxacin, 400 mg orally twice daily for 14 days, or levofloxacin, 500 mg orally once daily for 14 days, plus metronidazole, 500 mg orally twice daily, for 14 days; and (2) either a single dose of cefoxitin, 2 g intramuscularly, with probenecid, 1 g orally, or ceftriaxone, 250 mg intramuscularly, plus doxycycline, 100 mg orally twice daily, for 14 days, with or without metronidazole, 500 mg orally twice daily for 14 days.

C. Surgical Measures
Tubo-ovarian abscesses may require surgical excision or transcutaneous or transvaginal aspiration. Unless rupture is suspected, institute high-dose antibiotic therapy in the hospital, and monitor therapy with ultrasound. In 70% of cases, antibiotics are effective; in 30%, there is inadequate response in 48-72 hours, and intervention is required. Unilateral adnexectomy is acceptable for unilateral abscess. Hysterectomy and bilateral salpingo-oophorectomy may be necessary for overwhelming infection or in cases of chronic disease with intractable pelvic pain.

Prognosis

In spite of treatment, one-fourth of women with acute disease develop long-term sequelae, including repeated episodes of infection, chronic pelvic pain, dyspareunia, ectopic pregnancy, or infertility. The risk of infertility increases with repeated episodes of salpingitis: it is estimated at 10% after the first episode, 25% after a second episode, and 50% after a third episode.

Preferences:
Ness RB et al: Effectiveness of outpatient strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol 2002;186:929.

Sexually transmitted disease treatment guidelines 2002. Centers for Disease Control and Prevention. MMWR Recomm Rep 2002;51(RR-6):1.