Pelvic inflammatory disease
Background
- Pelvic Inflammatory Disease (PID) comprises spectrum of infections of the upper reproductive tract:
- Salpingitis, endometritis, myo/parametritis, oophoritis
- Perihepatitis (Fitz-Hugh-Curtis) is caused by lymphatic spread
- Tubo-ovarain abscess is caused by direct extension
- Salpingitis, endometritis, myo/parametritis, oophoritis
- Most common serious infection in women aged 16 to 25 years
- Most common cause of death is rupture of a tubo-ovarian abscess
- Begins as cervicitis w/ GC or chlamydia that may progress to polymicrobial infection
- Initial lower tract infection may be asymptomatic
Diagnosis
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)
Work-Up
- Urine pregnancy
- Wet mount
- GC/Chlam swab
- CBC
- ESR/CRP
- UA
Imaging
- Pelvic US
- Ultrasound sensitivity may be as low as 56% and specificity of 85% [1]
- CT
DDX
- Cervicitis
- Ectopic Pregnancy
- Endometriosis
- Ovarian Cyst
- Ovarian Torsion
- Spontaneous abortion
- Septic abortion
- Cholecystitis
- Gastroenteritis
- Appendicitis
- Diverticulitis
- Pyelonephritis
- Renal Colic
CDC Treatment 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
- Tx all partners who had sex w/ pt during previous 60d prior to onset of sx
Outpatient
- Ceftriaxone 250mg IM x1 + doxycycline 100mg PO BID x14d +/- metronidazole 500mg PO BID x14d
- Metronidazole based upon assessment of risk for anaerobes; consider in:
- Pelvic abscess
- Proven or suspected infection w/ Trichomonas or Bacterial Vaginosis
- History of gynecological instrumentation in the preceding 2-3wks
- Metronidazole based upon assessment of risk for anaerobes; consider in:
Inpatient
- Cefoxitin 2gm IV q6hr OR cefotetan 2gm IV q12hr) + doxycycline PO or IV 100 mg q12hr OR
- Clindamycin 900mg IV q8h + genamicin 2mg/kg QD OR
- Ampicillin/sulbactam 3gm IV q6hr + doxycycline 100mg IV/PO q12hr
Disposition
Admit:
- Tubo-ovarian abscess
- Fitz-Hugh-Curtis
- Pregnancy
- Sepsis/peritonitis
- Unable to tolerate PO
- Failed outpt Rx
- 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 abx regimen
- Infertility
- Ectopic Pregnancy
- Chronic pelvic pain
See Also
Source
CDC 2010, Tintinalli
- ↑ 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