CLINICAL ACTIONS:

Pelvic inflammatory disease (PID) is an inflammatory disorder of the upper female genital tract that includes endometritis, salpingitis, tubo-ovarian abscess and pelvic peritonitis. Symptoms may be obvious (high fever, severe lower abdominal pain, peritoneal signs), subtle (abnormal bleeding, vaginal discharge, dyspareunia) or absent.

Assume PID in a patient with lower abdominal/pelvic pain if

• Sexually active and/or at risk: adolescents, women attending STD clinics, those in communities with high rates of gonorrhea or chlamydia
• One or more of the following on pelvic exam:
  • Cervical motion tenderness (CMT)
  • Uterine tenderness
  • Adnexal tenderness
• Other causes (ectopic pregnancy, ovarian cyst, appendicitis, functional pain) are unlikely

Additional criteria to support the diagnosis of PID

• Oral temperature >101°F (>38.3°C)
• Abnormal cervical mucopurulent discharge or cervical friability
• Abundant WBCs on saline microscopy of vaginal fluid
• Elevated erythrocyte sedimentation rate (ESR)
• Elevated C-reactive protein (CRP)
• Positive gonorrhea/chlamydia trachomatis culture

Most specific criteria for diagnosing PID

• Endometrial biopsy for evidence of endometritis
• Transvaginal ultrasound or MRI demonstrating thickened fluid filled fallopian tubes, or tubo-ovarian collection, or tubal hyperemia
• Laparoscopic findings consistent with PID
  • The CDC cautions that laparoscopy “is not easily justifiable when symptoms are mild or vague. Moreover, laparoscopy will not detect endometritis and might not detect subtle inflammation of the fallopian tubes.”

SYNOPSIS:

Pelvic inflammatory disease comprises a spectrum of disorders ranging from asymptomatic to debilitating. Acute PID may be difficult to diagnose because of the wide variation in symptoms and signs. The diagnosis of PID is usually based on clinical findings noted above.

KEY POINTS:

• Wet Prep (saline preparation of vaginal fluid)
  • Most women with PID have either mucopurulent cervical discharge or evidence of WBCs on a microscopic evaluation
  • If the cervical discharge appears normal and no WBCs are observed on the wet prep of vaginal fluid, the diagnosis of PID is unlikely
    • Consider alternative causes of pain
    • A wet prep of vaginal fluid also can detect the presence of concomitant infections (e.g., BV and trichomoniasis)
• PID is usually, but not always, seen in the presence of gonorrhea or chlamydia trachomatis infections
  • Typical vaginal flora, cytomegalovirus, mycoplasma may be associated with PID
• Many episodes of PID go unrecognized with potential long-term sequelae of infertility or chronic pain
• Healthcare providers should maintain a low threshold for the diagnosis of PID
  • It is better to overtreat than to undertreat
• All women diagnosed with PID should be tested for HIV as well as gonorrhea and chlamydia
• Treatment should not be delayed until test results are available if there is a clinical suspicion of PID

Learn More – Primary Sources:

CDC 2021 PID Treatment Guidelines

Related ObG Topics:

Pelvic Inflammatory Disease – CDC Treatment Guidelines

Gonorrhea: CDC Diagnosis and Treatment Guidelines

Gonorrhea Treatment Pearls

Chlamydia: CDC Recommendations for Diagnosis and Treatment