Pelvic inflammatory disease


Pelvic anatomy.
  • Pelvic Inflammatory Disease (PID) comprises spectrum of infections of the upper reproductive tract:
  • 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
  • Bilateral tubal ligation does not confer protection against risk[1]

Risk factors[2]

  • Age < 25
  • Age at first sexual intercourse < 20
  • Non-white ethnicity
  • Nulliparous
  • History of transmitted diseases, especially chlamydia
  • IUD within 21 days after insertion[3]

Clinical Features


Physical Exam

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


Differential Diagnosis

Pelvic Pain

Pelvic origin

Abdominal origin


PID with pyosalpinx on transvaginal ultrasound: bilateral adenexal cysts consistent with pyosalpinges (white arrows).
PID on CT with bilateral adnexal complex fluid-filled and thick-walled cysts typical for tubo-ovarian abcess formation and an associated ileus.


  • Urine pregnancy
  • Wet mount
  • Endocervical swab (for GC, Chlamydia)
  • CBC
  • Urine culture, analysis (to exclude UTI)
  • Pelvic ultrasound
    • Ultrasound sensitivity may be as low as 56% and specificity of 85% [4]
  • CT

CDC Empiric Diagnosis Criteria[5]

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


No sexual activity for 2 weeks;
Treat all partners who had sex with patient during previous 60 days prior to symptom onset

Outpatient Options

Alternative Outpatient Options



  • No change in treatment if IUD in place (may treat without removal)




  • 72hr follow up
  • Instruct patient to abstain from sex or adhere strictly to condom use until partner treatment and symptoms have abated
  • HIV+ is not an automatic criteria for admission, consider overall clinical impression

See Also


  1. Shepherd SM et al. Pelvic Inflammatory Disease Clinical Presentation. Jan 2017.
  2. Simms I et al. Risk factors associated with pelvic inflammatory disease. Sex Transm Infect. 2006 Dec; 82(6): 452–457.
  4. 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
  6. Hayes BD. Trick of the Trade: IV ceftriaxone for gonorrhea. October 9th, 2012 ALiEM. Accessed October 23, 2018.
  7. 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
  8. CDC PID Treatment
  9. 9.0 9.1 Savaris RF. et al. Comparing ceftriaxone plus azithromycin or doxycycline for pelvic inflammatory disease: a randomized controlled trial. Obstet Gynecol. 2007 Jul;110(1):53-60