Author: Collette Wyte, MD, FACEP, Professor Clinical Emergency Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan
Last Update: 2015
PID is an acute clinical syndrome that frequently originates as a cervical infection with Neisseria gonorrheaand/or Chlamydia trachomatis, and becomes polymicrobial as it ascends into the uterus, fallopian tubes and ovaries. Although the incidence and hospitalization rate for PID have shown a decline in the past decade, PID remains a common serious infection in reproductive-aged women in the United States. 4.2% of women in the U.S. have been treated for PID in their lifetime.
Initial Actions and Primary Survey
When a woman of reproductive age presents with vaginal discharge or pelvic pain, a pelvic exam and pregnancy test should always be performed. If the patient is pregnant, other causes of pelvic pain such as ectopic pregnancy should be considered since PID is less likely in pregnancy. If PID does occur in pregnancy, it is most common in the first 12 weeks of pregnancy.
Women typically present with bilateral lower abdominal pain, purulent vaginal discharge, or less frequently with abnormal vaginal bleeding. Symptoms begin shortly after the start of the menstrual cycle, when there are fewer defenses by the cervical mucosal barrier to ascending infections. Patients may also present with fever, nausea, vomiting and general malaise, but this is variable and may range from minimally symptomatic to toxic appearing. PID associated with gonococcal infections is typically more rapid in onset and is associated with more toxic symptoms than nongonnoccal PID.
Prior history of sexually transmitted diseases (STDs), multiple sexual partners, intrauterine device (IUD) contraception use, adolescence (75% of PID cases occur between the ages of 15-25), sexual intercourse at an early age, and recent instrumentation of the uterine cavity are all risk factors that warrant a heightened suspicion for PID.
The most common physical exam findings are bilateral adnexal tenderness and purulent cervical discharge. Cervical motion, uterine, and lower abdominal tenderness may also be present. Unilateral adnexal tenderness or fullness may suggest the presence of a tuboovarian abscess, while right upper quadrant tenderness may suggest Fitz-Hugh-Curtis syndrome where the infection extends to cause a perihepatitis with inflammation of the liver capsule and ‘violin string’ scar tissue formation.
How do I make the diagnosis?
In a patient with a negative pregnancy test and elevated WBC, in the setting of fever, bilateral adnexal tenderness, and a mucopurulent cervical discharge, the diagnosis of PID is certain. PCR positive for N gonorrhea or C trachomatis is pathognomonic for PID in the appropriate clinical setting, but is not usually available while formulating the treatment plan in the emergency department. Up to one-third of women with PID do not have Neisseria or Chlamydia isolated, emphasizing the polymicrobial nature of this disease.
Because of the potential complications of untreated PID and the prevalence of infection, the Center for Disease Control (CDC) has recommended initiating empiric therapy for all patients who meet minimal clinical criteria for PID. This minimum criterion includes history of lower abdominal or pelvic pain coupled with adnexal, uterine or cervical motion tenderness on exam, in a patient at risk for STDs with no other discernible cause for the illness identified.
The complications of PID include chronic pelvic pain, dyspareunia, infertility, ectopic pregnancy, TOA and Fitz-Hugh-Curtis syndrome. Women with a previous episode of PID are 12-15 % more likely to have an ectopic pregnancy. Tuboovarian abscess is a walled-off abscess that originates in the infected fallopian tube and extends to involve the ovary. Women with TOA appear ill, and will often have severe unilateral adnexal tenderness and fullness on bimanual pelvic examination. Fitz-Hugh-Curtis syndrome is a perihepatitis that occurs in 8-10% of patients with PID. These patients appear septic as well, and often present with right upper quadrant or referred right shoulder pain. Elevated liver function studies confirm the diagnosis.
Once the CDC minimal criteria is met, women should be treated with antibiotics that cover the multiple organisms potentially responsible for this disease , including N gonorrhea, C trachomatis, Escherichia coli, and multiple anaerobic bacteria such as peptococcus, peptostreptococcus and bacteroides. The particular agent used will be determined by the toxicity of the patient.
Inpatient treatment should be started in the Emergency Department. The recommended regimen includes:
- Cefoxitin 2 grams IV q 6 hours with Doxycycline 100 mg PO or IV q 12 hours OR
- Cefotetan 2 grams IV q 12 hours with Doxycycline 100 mg PO or IV q 12 hours.
- If the patient is allergic to cephalosporins, they may be treated with Clindamycin 900 mg IV q 8 hours with Gentamycin.
- Alternatively they may be treated with Unasyn 3 grams IV q 6 hours with Doxycycline 100 mg PO or IV q 12 hours. Doxycycline should always be given orally when possible, because it is caustic to vessels.
The recommended regimen for outpatient therapy is Ceftriaxone 250 mg IM OR Cefoxitin 2 grams IM and Probenecid 1 gram PO. Doxycycline 100 mg BID for 14 days must also be prescribed. The addition of Metronidazole 500 mg BID for 14 days should be considered in women with more severe infection or history of uterine instrumentation within the preceding 3 weeks.
Indications for admission include suspected TOA or Fitz-Hugh-Curtis syndrome, patients with intractable vomiting, septic patients, those with peritonitis, prepubertal children, women with an indwelling intrauterine device (IUD) and although rare, pregnant patients. The nulliparous patient should be strongly considered for admission to preserve fertility, as well as women with co-morbidities such as diabetes or AIDs, who often have a protracted course. Women with an IUD should have the IUD removed after the initiation of antibiotics.
Discharged patients should be advised to avoid sexual contact, to refer their partners for treatment, and to follow up in 72 hours, unless their symptoms worsen requiring earlier follow up. Patients should also be referred for further STD testing including HIV, hepatitis, and syphilis.
Pearls and Pitfalls
- PID is a polymicrobial infection despite being most commonly associated with Chlamydia and gonorrhea.
- Women of reproductive age who present with pelvic pain require a pregnancy test. In the pregnant patient, PID is less likely (particularly after the first 12 weeks), and other causes such as ectopic pregnancy need to be excluded.
- Consider TOA or alternative diagnosis if patient does not improve with antibiotics.
- Patients with minimal CDC criteria should be treated for PID if no other discernible cause for their illness is identified, to reduce complications associated with untreated PID
- Pelvic ultrasound should be obtained in patients with unilateral tenderness or mass, or if the diagnosis is unclear.
- Partners of the patient should be seen and treated.
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