Pelvic inflammatory disease

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 (commonly due to 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, nausea and vomiting

Physical Exam

• Cervical motion tenderness
• Adnexal tenderness (Most sensitive finding - Sn ~95%)
• Mucopurulent cervicitis
  • Absence should prompt consideration of another dx
• RUQ Pain
  • May indicate perihepatic inflammation (particularly if jaundice also present)

Differential Diagnosis

Acute Pelvic Pain

Differential diagnosis of 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
  • Cervicitis
  • Endometritis
  • Bartholin gland abscess
  • Pelvic inflammatory disease (PID)
  • Tubo-ovarian abscess
• Vulvovaginitis
  • Bacterial Vaginosis
  • Candida Vaginitis
  • Trichomonas
  • Contact Vulvovaginitis
  • Atrophic vaginitis
• 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

• Cystitis
• Pyelonephritis
• Urethritis (e.g. N. gonorrhoeae/Chlamydia)
• Urolithiasis

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%
• 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:
  • Oral temperature >101° F (>38.3° C)
  • Abnormal cervical or vaginal mucopurulent discharge
  • Pesence of abundant numbers of WBC on saline microscopy of vaginal fluid
  • Elevated ESR
  • Elevated CRP
  • Laboratory documentation of cervical infection with GC or chlamydia

Management

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) x1 + doxycycline 100mg PO BID x14d + metronidazole 500mg PO BID x14d
  • Metronidazole
    • Recommended for empiric treatment of PID by the CDC
    • Recommended empirically by European guidelines
• Cefoxitin 2 g IM in a single dose and Probenecid, 1 g PO administered concurrently in a single dose + Doxycycline 100 mg PO BID x 14 days + metronidazole

Inpatient Antibiotic Options

• Recommended: 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 outpatient treatment
• HIV+

Discharge

• 72hr follow up
• Instruct patient to abstain from sex or adhere strictly to condom use until symptoms 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

• Sexually Transmitted Diseases (STD)
• Pelvic pain