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Pelvic Inflammatory Disease (PID)

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Topic updated on 02/21/17 3:50pm

Snapshot
  • A sexually active 17-year-old girl is brought to the emergency department because of acute onset of lower abdominal pain. She has no nausea or vomiting. On physical exam, she is found with a high fever. Bimanual pelvic exam shows cervical exudate and cervical motion tenderness. There is bilateral lower quadrant tenderness. Her β-HCG is within normal limits.
Introduction
  • Clinical definition of disease
    • pelvic inflammatory disease (PID) is an infection of the upper female genital tract that is often polymicrobial
    • may include
      • endometritis
      • salpingitis
      • tubo-ovarian abscess
      • pelvic peritonitis
  • Epidemiology
    • incidence
      • US incidence
        • 750,000 cases annually
    • demographics
      • sexually active women
      • ages 15-29
    • location
      • upper female genital tract
    • risk factors
      • age < 25 years
      • risky sexual behavior
      • earlier age at first intercourse
      • increasing number of sex partners
  • Pathophysiology
    • mechanism of injury (trauma)
      • this is the mechanism of injury (valgus force on knee)
    • pathophysiology
      • this is the physiology (hormone feedback loop)
    • pathobiology
      • usually polymicrobia
      • likely microbes
        • Neisseria gonorrhoeae
        • Chlamydia trachomatis
        • Anaerobes
        • Gram-negative rods
        • Streptococcus agalactiae
        • Gardnerella vaginalis
        • Haeomphilus influenza
        • CMV
        • Mycoplasma genitalium
    • pathoanatomy
      • ascending infection of microbes from endocervix to upper genital tract
  • Associated conditions
    • other sexually transmitted diseases (e.g., chlamydia, chancroid, herpes, etc.)
  • Prognosis
    • may recur
    • prognostic variable
      • negative
        • salpingitis
        • multiple recurrence
Presentation
  • Symptoms
    • may be asymptomatic if subclinical
    • primary symptoms
      • lower abdominal or pelvic pain
      • chills
      • dyspareunia
      • dysuria
      • nausea or vomiting
    • defining characteristics
  • Physical exam
    • inspection
      • fever
      • abnormal cervical discharge or bleeding
      • cervical friability
      • abnormal vaginal odor
      • ecchymosis & swelling
      • diffuse tenderness
    • provocative tests
      • cervical motion tenderness
        • aka “chandelier test”
      • adnexal tenderness
      • uterine tenderness

Imaging
  • Ultrasonography
    • indications
      • if diagnosis is uncertainty with physical exam and clinical history
    • view
      • transvaginal
    • findings
      • thickened fluid-filled tubes
      • with or without free pelvic fluid
      • with or without tubo-ovarian abscess
Studies
  • Labs
    • may test positive for sexually transmitted diseases
      • Neisseria gonorrhoeae
      • Chlamydia trachomatis
  • Diagnostic criteria
    • positive physical exam findings
      • uterine tenderness
      • adnexal tenderness
      • cervical motion tenderness
Differential
  • Ectopic pregnancy
    • positive pregnancy test
  • Appendicitis
    • PID typically presents with bilateral abdominal tenderness
Treatment
  • Medical
    • cephalosporin plus doxycycline (outpatient)
      • indications
        • clinical findings of PID alone is often enough to indicate treatment of PID
        • uncomplicated PID
    • cefoxitin plus doxycycline
      • indications for IV medication or hospitalization
        • uncertain diagnosis
        • tubo-ovarian abscess
        • unstable patient
        • failure to respond to outpatient treamtment within 72 hours
Complications
  • Infertility
    • odds ratio 3.6-5.5
  • Ectopic pregnancy
    • odds ratio 2.5
  • Fitz-Hugh-Curtis syndrome
    • clinical definition
      • infection of liver capsule with multiple peritoneal adhesions
    • incidence
      • 10% of women with PID


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