Pelvic Inflammatory Disease (PID) – Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Description

  • An acute infection of the upper genital tract in women caused by the ascent of sexually transmitted infections (STIs) from the vagina and endocervix to the uterus, fallopian tubes, ovaries, and contiguous structures.
  • Pelvic inflammatory disease (PID) is a broad term that encompasses a variety of upper genital tract infections, including endometritis, salpingitis, oophoritis, tubo-ovarian abscess, peritonitis, and perihepatitis.
  • Accurate diagnosis is challenging and incorrect in up to 1/3 of women.
  • System(s) affected: Reproductive
  • Synonym(s): Salpingitis; Salpingo-oophoritis; Adnexitis; Pyosalpinx; Tubo-ovarian abscess; Pelvic peritonitis; Upper genital tract infection

Epidemiology

  • Predominant age: 1/3 of patients are <20 years of age; 2/3 are <25 years of age.
  • Predominant sex: Female only

Incidence

In the US, 1 million women are treated each year.

Prevalence

100–200 per 100,000 women

Risk Factors

  • Sexually active and age <25 years
  • 1st sexual activity at young age
  • New/multiple sexual partners
  • Nonbarrier contraception (i.e., oral contraceptive pills)
  • Previous history of PID; 20–25% will have a recurrence.
  • History of Chlamydia trachomatis; 10–40% will develop PID.
  • History of gonococcal cervicitis; 10–20% will develop PID.

General Prevention

  • Educational programs about safer sex practices and STI prevention
  • Barrier contraceptives, especially condoms and spermicidal creams or sponges, provide protection, the extent of which is not well documented
  • Early medical care with occurrence of genital lesions or abnormal discharge
  • Intrauterine device (IUD) insertion is contraindicated in women with active (acute) cervical or pelvic infection.
  • Annual chlamydia screening of all sexually active women aged <25 years and of older women with risk factors (e.g., those who have a new sex partner or multiple sex partners
  • Routine STI screening in pregnancy
  • Evaluation and treatment of sexual partners after diagnosis with STI

Pathophysiology

  • The precise mechanism by which microorganisms ascend from the lower genital tract is not known. One possibility is that chlamydial or gonococcal endocervicitis disturbs the vaginal ecosystem, allowing ascent of the vaginal flora with or without the original pathogen. Thus, polymicrobial infection can occur without Neisseria gonorrhoeae or C. trachomatis infection.
  • 75% of cases occur within 7 days of menses, when the cervical mucous favors ascension of organisms.

Etiology

Multiple organisms act as etiologic agents in PID. Most cases are polymicrobial.

  • C. trachomatisN. gonorrhoeae and a wide variety of aerobic and anaerobic bacteria are recognized as etiologic agents.
  • The proportion of cases infected with chlamydia or gonorrhea varies widely depending on the population studied.
  • The most common organisms include H. influenzae, streptococcus pyogenes, Bacteroides, E. coli, Peptococcus, and Peptostreptococcus sp.
  • Bacterial vaginosis is more common among women with PID but does not confer and increased risk of PID.
  • Mycoplasmas also have been implicated, but their role is less clear.

Commonly Associated Conditions

  • If PID is suspected in a patient with a long-term indwelling IUD and a pelvic abscess is present, an Actinomyces infection requiring penicillin treatment may be present.
  • Rupture of an adnexal abscess is rare but life-threatening. Early surgical exploration is mandatory.
  • Chlamydial or gonococcal perihepatitis may occur with PID. This combination is called Fitz-Hugh-Curtis syndrome and is characterized by severe pleuritic right upper quadrant pain. FHC complicates 10% of PID.

Diagnosis

  • It is wiser to overtreat a lower tract genital infection than to miss an upper tract infection.
  • For the diagnosis of PID, the Centers for Disease Control and Prevention (CDC) recommend only a minimal diagnostic criterion of cervical motion, uterine or adnexal tenderness in the presence of lower abdominal pain.

History

  • PID diagnosis is elusive, and even asymptomatic patients are at risk for sequelae.
  • Fever (50%)
  • Nausea and vomiting
  • Lower abdominal pain, worse with coitus and jarring movements
  • New/abnormal vaginal discharge
  • Irregular bleeding occurs in ≥1/3 patients
  • Urinary discomfort
  • Proctitis

Physical Exam

  • Criteria for diagnosis:
    • Lower abdominal/suprapubic pain (+/- rebound)
    • Adnexal tenderness (unilateral or bilateral)
    • Cervical motion tenderness
  • Supports diagnosis:
    • Temperature ≥38.3°C
    • Cervical or vaginal mucopurulent discharge

Diagnostic Tests & Interpretation

Lab

Initial lab tests

  • Pregnancy test – must be performed to rule out ectopic pregnancy and complications of an intrauterine pregnancy
  • CBC: WBC count ≥10,500/mm3 – ≤50% PID presents with leukocytosis.
  • Chlamydia and Gonorrhea cultures
  • Urine analysis
  • Saline microscopy of vaginal fluid with increased WBC

Follow-Up & Special Considerations

  • Erythrocyte sedimentation rate (ESR) >15 mm/h
  • Elevated C-reactive protein
  • Consider HIV testing in patients with PID

Imaging

Not necessary for diagnosis, although supports diagnosis

Initial approach

Transvaginal ultrasound – may show thickened, fluid-filled tubes +/- free fluid or tubo-ovarian abscess (TOA)

Follow-Up & Special Considerations

TOA will not resolve immediately after treatment. Follow-up ultrasound can be followed as outpatient for resolution of adnexal abscess.

Diagnostic Procedures/Surgery

  • Culdocentesis with culture is rarely necessary.
  • Laparoscopy is best used for confirming as opposed to making the diagnosis of PID. Should be reserved for the following situations:
    • Ill patient with competing diagnosis (e.g., appendicitis)
    • Ill patient who has failed outpatient treatment
    • Any patient not improving after 72 hours of inpatient treatment
  • Endometrial biopsy

Pathological Findings

Endometrial biopsy reveals endometritis/plasma cells.

Differential Diagnosis

  • Appendicitis
  • Ectopic pregnancy
  • Ovarian torsion
  • Hemorrhagic or ruptured ovarian cyst
  • Endometriosis/dysmenorrhea
  • Inflammatory bowel disease
  • Diverticulitis
  • Pyelonephritis

Treatment

Outpatient treatment if appropriate. Criteria for hospitalization and parenteral treatment include:

  • Suspected tubo-ovarian abscess
  • Pregnancy (rare)
  • Temp >38°C
  • Inability to tolerate oral medications
  • Peritoneal signs
  • Failure to respond to oral antibiotics after 48 hours

Medication

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First Line

  • Several antibiotic regimens are highly effective, with no single regimen of choice, but coverage should include Chlamydia, gonorrhea, anaerobes, gram-negative rods, and streptococci. CDC regimens that follow are recommendations, and the specific antibiotics named are examples.
  • Parenteral regimen A:
    • Cefoxitin 2 g IV q6h or cefotetan 2 g IV q12h (or other cephalosporins, such as ceftizoxime, cefotaxime, and ceftriaxone) plus doxycycline 100 mg PO or IV q12h
    • Parenteral therapy × 24 h after clinical improvement; continue doxycycline after discharge for a total of 10–14 days.
  • Parenteral regimen B:
    • Clindamycin 900 mg IV q8h plus gentamicin loading dose IV or IM (2 mg/kg of body weight) followed by a maintenance dose (1.5 mg/kg) q8h
    • Parenteral therapy for 24 h after clinical improvement; continue doxycycline after discharge as above or clindamycin 450 mg PO q.i.d. for a total of 14 days.
  • Outpatient treatment regimen A:
    • Levofloxacin 500mg PO × 14 days OR Ofloxacin 400mg PO BID × 14 days +/-Metronidazole 500mg PO BID × 14 days
  • Outpatient treatment regimen B:
    • Cefoxitin 2 g IM plus Probenecid 1 g PO concurrently as a single dose OR Ceftriaxone 250 mg IM
    • Plus doxycycline 100 mg PO b.i.d. × 14 days
    • +/- metronidazole 500 mg PO b.i.d. × 14 days
  • On the basis of the recent emergence of fluoroquinolone-resistant gonococci, the CDC no longer recommends the use of these agents for the treatment of gonococcal infections and associated conditions such as PID.
  • Only cephalosporins are still recommended (1)[A].

Second Line

  • Many other antibiotic regimens have been proposed and used with success, for example, tobramycin in place of gentamicin or tetracycline in place of doxycycline (2).
  • In persons with documented severe allergic reactions to penicillins or cephalosporins, azithromycin or spectinomycin might be an option for therapy of uncomplicated gonococcal infections (1)[A].

Additional Treatment

General Measures

  • Patient should avoid sex until treatment is completed.
  • Refer sex partners for appropriate evaluation and treatment. Partners should be treated, irrespective of evaluation, with regimens effective againstChlamydia and gonorrhea.

Surgery/Other Procedures

  • Reserved for failures of medical treatment and for suspected ruptured adnexal abscess with resulting acute surgical abdomen
  • Conservative surgery preferred
  • Failure of medical therapy is associated with adnexal abscess, which may be amenable to transabdominal or transvaginal drainage under guidance by ultrasonography, CT scan, or laparoscopy.

In-Patient Considerations

Initial Stabilization

Manage fever, infection, and pelvic pain.

Admission Criteria

Hospitalization recommended in the following:

  • Uncertain diagnosis
  • Surgical emergencies (e.g., appendicitis)
  • Suspected pelvic abscess
  • Pregnancy
  • Adolescent patient with uncertain compliance with therapy
  • Severe illness
  • Intolerance to outpatient regimen
  • Failure to respond to outpatient therapy
  • Inability to arrange clinical follow-up within 72 h of starting antibiotics

IV Fluids

Maintenance

Ongoing Care

Follow-Up Recommendations

Patient Monitoring

  • Close observation of clinical status, particularly for fever, symptoms, level of peritonitis, WBCs
  • Follow adnexal abscess size and position with US.

Patient Education

  • Abstinence from any type of sexual contact until treatment of patient/partner (if necessary) is complete
  • Consistent and correct condom use should be enforced.
  • Hepatitis B and human papilloma virus (HPV) vaccines should be given to patients who meet criteria.
  • Continue annual STI screening.

Prognosis

  • Wide variation with good prognosis if early, effective therapy is instituted and further infection is avoided
  • Poor prognosis related to late therapy and continued unsafe lifestyle

Complications

  • A tubo-ovarian abscess will develop in ∼7–16% of patients (3).
  • Recurrent infection occurs in 20–25% of patients.
  • Risk of ectopic pregnancy is increased 7- to 10-fold for ∼8% of women who have had PID.
  • Tubal infertility occurs in 15%, 35%, and 55% of women after 1, 2, and 3 episodes of PID, respectively (4).
  • Chronic pelvic pain in 20% is related to adhesion formation, chronic salpingitis, or recurrent infection.

References

1. Haggerty CL, Ness RB. Newest approaches to treatment of pelvic inflammatory disease: a review of recent randomized clinical trials. Clin Infect Dis.2007;44:953–60.

2. Sexually transmitted disease treatment guidelines, 2006. MMWR. 2006;55(RR-11).

3. Lareau SM, Beigi RH. Pelvic Inflammatory Disease and Tubo-ovarian Abscess. Infect Dis Clin North Am. 2008;22:693–708.

4. Pellati D, Mylonakis I, Bertoloni G, et al. Genital tract infections and infertility. Eur J Obstet Gynecol Reprod Biol. 2008.

Additional Reading

Haggerty CL, Ness RB. Diagnosis and treatment of pelvic inflammatory disease. Womens Health (Lond Engl). 2008;4:383–97.

Risser JM, Risser WL. Purulent vaginal and cervical discharge in the diagnosis of pelvic inflammatory disease. Int J STD AIDS. 2009;20:73–6.

Tarr ME, et al. Sexually transmitted infections in adolescent women. Clin Ob Gyn. 2008;51(2):306–18.

See Also (Topic, Algorithm, Electronic Media Element)

Algorithm: Pelvic Girdle Pain

Codes

ICD9

  • 614.0 Acute salpingitis and oophoritis
  • 614.1 Chronic salpingitis and oophoritis
  • 614.2 Salpingitis and oophoritis not specified as acute, subacute, or chronic
  • 614.3 Acute parametritis and pelvic cellulitis
  • 614.4 Chronic or unspecified parametritis and pelvic cellulitis
  • 614.5 Acute or unspecified pelvic peritonitis, female
  • 614.6 Pelvic peritoneal adhesions, female (postoperative) (postinfection)
  • 614.7 Other chronic pelvic peritonitis, female
  • 614.8 Other specified inflammatory disease of female pelvic organs and tissues
  • 614.9 Unspecified inflammatory disease of female pelvic organs and tissues

Snomed

  • 198130006 female pelvic inflammatory disease (disorder)
  • 266581008 acute salpingo-oophoritis (disorder)
  • 198142001 chronic salpingo-oophoritis (disorder)
  • 198154001 acute parametritis and pelvic cellulitis (disorder)
  • 198159006 chronic parametritis and pelvic cellulitis (disorder)
  • 67602004 acute peritonitis (disorder)
  • 87510000 chronic peritonitis (disorder)

Clinical Pearls

  • History of lower abdominal pain, cervical motion tenderness, and adnexal tenderness is sufficient for a diagnosis of PID in an at-risk woman.
  • Most often PID starts with gonorrhea or Chlamydia, but it can be polymicrobial.
  • Complications include hydrosalpinx, adhesions, pelvic pain, and 10× increased risk or ectopic pregnancy.
  • PID is a common cause of infertility.

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