Pelvic inflammatory disease
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Background
Pelvic Inflammatory Disease (PID) comprises spectrum of infections of the upper reproductive tract:
- Salpingitis, endometritis, myo/parametritis, and oophoritis
- Perihepatitis (Fitz-Hugh-Curtis) is caused by lymphatic spread
- Tubo-ovarian abscess is caused by direct extension
It is the most common serious infection in women aged 16 to 25 years and begins as cervicitis with GC or chlamydia that may progress to polymicrobial infection.
- Initial lower tract infection may be asymptomatic
- Most common cause of death is rupture of a tubo-ovarian abscess
Clinical Features
History
- Pelvic Pain (90%)
- Vaginal discharge (75%)
- Vaginal and postcoital bleeding (>33%)
- Dysuria, fever, malaise, N/V
Physical Exam
- CMT
- Adnexal tenderness
- Most sensitive finding (Sn ~95%)
- Mucopurulent cervicitis
- Absence should raise consideration of another dx
- RUQ Pain
- May indicate perihepatic inflammation (particularly w/ jaundice)
Differential Diagnosis
Acute Pelvic Pain
Gynecologic/Obstetric
- Normal variants
- Nabothian cysts: Epithelial cells within mucous glans that appear as yellow inclusions on the cervix
- Cervial Ectropion: Edothelial cells on the exterior of the cervix
- Parous cervix: The is no longer round but may have multiple shapes after birth
- Pregnancy-related
- Ectopic Pregnancy
- Spontaneous abortion, threatened or incomplete
- Septic abortion
- Acute Infections
- Vulvovaginitis
- Adnexal Disorders
- Hemorrhage/rupture of ovarian cyst
- Ovarian torsion
- Twisted paraovarian cyst
- Other
- Myoma (degenerating)
- Genitourinary trauma
- Ovarian hyperstimulation syndrome
- Sexual assault
- Recurrent
- Mittelschmerz
- Primary/Secondary Dysmenorrhea
- Pelvic Congestion Syndrome
- Endometriosis
Genitourinary
Gastrointestinal
- Gastroenteritis
- Appendicitis
- Bowel obstruction
- Perirectal abscess
- Diverticulitis
- Inflammatory bowel disease
- Irritable bowel syndrome
- Mesenteric adenitis
Musculoskeletal
- Abdominal wall hematoma
- Psoas hematoma, psoas abscess
- Hernia
Vascular
- Pelvic thrombophlebitis
- Abdominal aortic aneurysm
- Ischemic bowel (Mesenteric Ischemia)
Diagnosis
Work-Up
- Urine pregnancy
- Wet mount
- Endocervical swab (for GC, Chlamydia)
- CBC
- ESR/CRP
- Urine culture, analysis (to exclude UTI)
Imaging
- Pelvic U/S
- Ultrasound sensitivity may be as low as 56% and specificity of 85% [2]
- CT
CDC Empiric Diagnosis Criteria
- Woman at risk for STIs
- Pelvic or lower abdominal pain
- No cause for the illness other than PID can be identified
- At least one of the following on pelvic exam:
- CMT
- Uterine tenderness
- Adnexal tenderness.
- Additional criteria that make the dx more likely:
Treatment
Antibiotics
- No sexual activity for 2 weeks;
- Treat all partners who had sex with patient during previous 60 days prior to symptom onset
Outpatient Antibiotic Options
- Ceftriaxone 500mg IM (1g if >150kg)[3][4] x1 + doxycycline 100mg PO BID x14d + metronidazole 500mg PO BID x14d [5][6]
- Cefoxitin 2 g IM in a single dose and Probenecid, 1 g PO administered concurrently in a single dose[9] + Doxycycline 100 mg PO BID x 14 days + metronidazole
Inpatient Antibiotic Options
- Recommended[10]: Ceftriaxone 1gm IV q24hr OR Cefoxitin 2gm IV q6hr OR cefotetan 2gm IV q12hr) + doxycycline PO or IV 100 mg q12hr + Metronidazole 500mg IV or PO Q12hr OR
- Clindamycin 900mg IV q8h + gentamicin 2mg/kg loading -> 1.5 mg/kg q8hr IV OR
- Ampicillin-sulbactam 3gm IV q6hr + doxycycline 100mg IV/PO q12hr
IUD
- No change in treatment if IUD in place (may treat without removal)
Disposition
Admit
- Tubo-ovarian abscess
- Fitz-Hugh-Curtis
- Pregnancy
- Sepsis/peritonitis
- Unable to tolerate PO
- Failed outpt treatment
- HIV+
Discharge
- 72hr f/u
- Instruct pt to abstain from sex or adhere strictly to condom use until sx have abated
Complications
- Tubo-Ovarian Abscess
- Fitz-Hugh-Curtis
- Perihepatic inflammation seen only on CT, not US; LFTs are normal
- Responds to standard antibiotic regimen
- Infertility
- Ectopic Pregnancy
- Chronic pelvic pain
See Also
References
- ↑ Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
- ↑ Lee DC, Swaminathan AK. Sensitivity of ultrasound for the diagnosis of tubo-ovarian abscess: a case report and literature review. J Emerg Med. 2011 Feb;40(2):170-5. doi: 10.1016 PMID 20466506
- ↑ Hayes BD. Trick of the Trade: IV ceftriaxone for gonorrhea. October 9th, 2012 ALiEM. https://www.aliem.com/2012/10/trick-of-trade-iv-ceftriaxone-for/. Accessed October 23, 2018.
- ↑ Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm
- ↑ Ness RB et al. Effectiveness of inpatient and outpatient treatment 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;186:929–37
- ↑ Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
- ↑ Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
- ↑ Ross J, Guaschino S, Cusini M, Jensen J, 2017 European guideline for the management of pelvic inflammatory disease. Int J STD AIDS. 2018 Feb;29(2):108-114. doi: 10.1177/0956462417744099. Epub 2017 Dec 4.
- ↑ CDC PID Treatment http://www.cdc.gov/std/treatment/2010/pid.htm
- ↑ Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon