Gynecology Book

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Pelvic Inflammatory Disease

Aka: Pelvic Inflammatory Disease, PID
  1. Etiology
    1. Chlamydia trachomatis
    2. NeisseriaGonorrhea
    3. Mycoplasma hominis
    4. Facultative or anaerobic organisms
  2. Risk Factors
    1. Sexually Transmitted Disease (STD) history
    2. Prior history of Pelvic Inflammatory Disease
    3. Onset sexual intercourse at a young age
    4. High number of sexual partners
  3. Symptoms: Onset usually in first half of Menstrual Cycle
    1. Abdominal Pain (varying intensity)
    2. High fever
    3. Dyspareunia
    4. Prolonged Menses
  4. Exam
    1. Bimanual exam and speculum exam in all suspected cases
    2. See Diagnosis below for signs
  5. Diagnosis: 2002 CDC Criteria
    1. Major Criteria (Required)
      1. Uterine or Adnexal tenderness to palpation or
      2. Cervical motion tenderness
      3. No other apparent cause
    2. Minor Criteria (Supporting, but not required)
      1. Fever >101 F (38.3 C)
      2. Abnormal discharge per Cervix or vagina
      3. WBCs on Gram Stain or Saline of Cervix swab
      4. Gonorrhea or Chlamydia testing positive
      5. Increased Erythrocyte Sedimentation Rate or C-Reactive Protein
      6. PID findings on diagnostic study (see below)
    3. Most specific findings
      1. Endometrial Biopsy with histology suggestive of Endometritis
      2. Imaging (Transvaginal Ultrasound or MRI) with classic findings
  6. Differential Diagnosis
    1. See Acute Pelvic Pain
    2. See Acute Pelvic Pain Causes
    3. Ruptured Ovarian Cyst
      1. Sudden onset of mid-cycle pain
    4. Ectopic Pregnancy
      1. Unilateral pain
      2. Positive Pregnancy Test
      3. Afebrile
      4. White Blood Cell count normal
    5. Appendicitis
      1. Right Lower Quadrant Abdominal Pain
      2. More bowel Symptoms
    6. Urinary Tract Infection
      1. No Cervical Motion Tenderness or Vaginal Discharge
    7. Ovarian Torsion
      1. More localized pain
      2. Sudden onset
      3. Afebrile
      4. White Blood Cell count normal
  7. Labs
    1. General
      1. Do not delay treatment while waiting for labs
    2. Inflammatory markers (if all normal, rules-out PID)
      1. Complete Blood Count (CBC)
      2. Erythrocyte Sedimentation Rate or C-Reactive Protein
      3. Vaginal secretion exam (saline wet prep)
        1. Vaginal PMNs (Negative Predictive Value 95%)
    3. Other initial labs
      1. DNA probe for Gonorrhea and Chlamydia
        1. Cervical specimen recommended over urine specimen
      2. Blood Cultures
      3. Urine Pregnancy Test
      4. Rapid Plasma Reagin (RPR)
  8. Diagnostics
    1. Endometrial Biopsy: Endometritis
    2. Transvaginal pelvic ultrasound
      1. Pelvic free fluid in cul-de-sac
      2. Tubo-ovarian abscess may be present
      3. Doppler demonstrates tubal hyperemia
      4. Fallopian tube changes
        1. Thickened fallopian tube wall >5 mm
        2. Fluid filled fallopian tubes
        3. Incomplete septae in fallopian tube
          1. Cogwheel sign on tube cross-section view
    3. CT Pelvis
      1. Pelvic floor fascial, Adnexal inflammation
      2. Uterosacral ligament thickening
      3. Pelvic free fluid
    4. MRI Pelvis (Test Sensitivity: 95%, Specificity: 89%)
      1. Tubo-ovarian abscess may be present
      2. Pelvic free fluid
      3. Fallopian tube changes
        1. Fluid filled fallopian tubes
        2. Ovaries have polycystic appearance
      4. References
        1. Tukeva (1999) Radiology 210:209-16
    5. Laparoscopy
      1. Indicated for unclear diagnosis
      2. Pelvic Inflammatory Disease misdiagnosed 25% time
  9. Management: General
    1. Remove Intrauterine Device (IUD)
    2. Treat patient's sexual contacts within last 60 days
    3. Start empiric therapy if minimal criteria present
    4. Do not delay treatment
      1. Delay >3 days increases ectopic and Infertility risk
    5. Antibiotic should cover Gonorrhea and Chlamydia
    6. Fluoroquinole resistant Gonorrhea is increasing
      1. Do not use Fluoroquinolones in high risk groups
      2. Cohorts at risk for resistance
        1. Homosexual men and any female sexual contacts
        2. Endemic areas
          1. Asia: China, Japan, Korea, Philippines, Vietnam
          2. Other: England, Wales, Australia
          3. US: California
  10. Management Outpatient
    1. Step 1: Initial Treatment at Diagnosis (with step 2)
      1. Cefoxitin 2g IM and Probenecid 1g PO or
      2. Ceftriaxone 250 mg IM for 1 dose or
      3. Other third generation Cephalosporin (e.g Cefotaxime)
    2. Step 2: Outpatient 14 day antibiotic course
      1. Select general antibiotic coverage
        1. Ofloxacin 400 mg PO bid for 14 days (95% cure) or
        2. Levofloxacin 500 mg PO daily for 14 days or
        3. Doxycycline 100 mg PO bid for 14 days (75% cure)
      2. Add anaerobic coverage (consider)
        1. Clindamycin 450 mg PO qid for 14 days or
        2. Metronidazole 500 mg PO bid for 14 days
    3. References
      1. Ross (2001) BMJ 322:251-2
  11. Management Inpatient
    1. Hospitalization Indications
      1. Toxic appearance
      2. Unable to take oral fluids
      3. Unclear diagnosis
        1. Appendicitis
        2. Ectopic Pregnancy
        3. Ovarian torsion
      4. Pelvic abscess
      5. Pregnancy
      6. HIV positive
      7. Adolescents
      8. Outpatient treatment failure
      9. Unreliable patient
    2. Inpatient treatment Regimens
      1. General
        1. Treat for at least 48 hours IV
      2. Regimen A (preferred)
        1. Cefoxitin 2g IV q6h OR Cefotetan 2g IV q12h and
        2. Doxycycline 100 mg PO or IV q12h
      3. Regimen B
        1. Clindamycin 900 mg IV q8h and
        2. Gentamicin 2 mg/kg IV load, then 1.5 mg/kg IV q8h
          1. Alternative: Conversion to single daily dosing
      4. Regimen C
        1. Ofloxacin 400 mg IV q12h or Levoquin 500 IV qd and
        2. Consider adding Metronidazole 500 IV q8 hours
      5. Regimen D
        1. Unasyn 3g IV q6 hours and
        2. Doxycycline 100 mg PO or IV q12 hours
      6. Discharge Regimen (after IV antibiotics above)
        1. See Outpatient Management Step 2 above
  12. Prevention
    1. Screen all sexually active women <25 for Chlamydia
  13. Complications
    1. Infertility (20%)
    2. Chronic Pelvic Pain (18%)
    3. Tubal Pregnancy (9%)
  14. References
    1. (2002) MMWR Recomm Rep 51(RR-6):1-78
    2. Crossman (2006) Am Fam Physician 73(5):859-64
    3. Miller (2003) Am Fam Physician 67(9):1915-22

Pelvic Inflammatory Disease (C0242172)

Definition (NCI) Pelvic inflammatory disease (PID) is an acute or chronic inflammation in the pelvic cavity. It is most commonly caused by sexually transmitted diseases, including chlamydia and gonorrhea that have ascended into the uterus, fallopian tubes, or ovaries as a result of intercourse or childbirth, or of surgical procedures, including insertion of IUDs or abortion. PID may be either symptomatic or asymptomatic. It may cause infertility and it may raise the risk of ectopic pregnancy. PID is a disease associated with HIV infection.
Definition (NCI) A disorder characterized by an infectious process involving the pelvic cavity.
Definition (NCI) Any pelvic infection involving the upper female genital tract beyond the cervix.
Definition (MEDLINEPLUS)

Pelvic inflammatory disease (PID) is an infection and inflammation of the female reproductive organs. It can scar the tubes that carry eggs from the ovary to the uterus which can lead to infertility, ectopic pregnancy, pelvic pain and other problems. PID is the most common preventable cause of infertility in the United States. Gonorrhea and chlamydia are the most common causes, but other bacteria can also cause PID.

You are at risk if you

  • Are sexually active and younger than 25
  • Have more than one sex partner
  • Douche

Some women have no symptoms. Others have pain in the lower abdomen, fever, smelly vaginal discharge, irregular bleeding or pain during intercourse. Antibiotics can cure PID. Early treatment is important – waiting too long increases the risk of infertility.

National Women's Health Information Center
Definition (NCI) A condition in which the female reproductive organs are inflamed. It may affect the uterus, fallopian tubes, ovaries, and certain ligaments. Pelvic inflammatory disease is usually caused by a bacterial infection. It may cause infertility and an increased risk of an ectopic pregnancy (pregnancy in the fallopian tubes).
Definition (CSP) spectrum of inflammation involving the female upper genital tract and the supporting tissues; is usually caused by an ascending infection of organisms from the endocervix that may be confined to the uterus, fallopian tubes, ovaries, the supporting ligaments, or may involve several of the above uterine appendages; such inflammation can lead to functional impairment and infertility.
Definition (MSH) A spectrum of inflammation involving the female upper genital tract and the supporting tissues. It is usually caused by an ascending infection of organisms from the endocervix. Infection may be confined to the uterus (ENDOMETRITIS), the FALLOPIAN TUBES; (SALPINGITIS); the ovaries (OOPHORITIS), the supporting ligaments (PARAMETRITIS), or may involve several of the above uterine appendages. Such inflammation can lead to functional impairment and infertility.
Concepts Disease or Syndrome (T047)
MSH D000292
ICD9 614.9, 614-616.99
ICD10 N70-N77.9, N73.9, N70-N77
SnomedCT 155986001, 198131005, 37518008, 155967009, 198570007, 198244005, 266584000, 198130006, 198178006, 155968004, 266648001, 155974004, 266651008
English P.I.D., Disease, Pelvic Inflammatory, Diseases, Pelvic Inflammatory, Inflammatory Disease, Pelvic, Inflammatory Diseases, Pelvic, Pelvic Inflammatory Diseases, DISEASE PELVIC INFLAMMATORY, INFLAMMATION PELVIC, PELVIC INFLAMMATION, Disease, Inflammatory Pelvic, Diseases, Inflammatory Pelvic, Inflammatory Pelvic Disease, Inflammatory Pelvic Diseases, Inflammatory disease of female pelvic organs and tissues, NOS, Pelvic Disease, Inflammatory, Pelvic Diseases, Inflammatory, Female pelvic inflam disease, Female pelvic inflam.dis.NOS, Female pelvic inflammatory disease NOS, Female pelvic inflammatory diseases NOS, Inflammatory diseases of female pelvic organs, Inflammtry dis/fem pelv org, [X]Inflammatory diseases of female pelvic organs, [X]Inflammtry dis/fem pelv org, Female pelvic inflammatory disease, unspecified, INFLAMMATORY DISEASES OF THE FEMALE GENITAL ORGANS AND TISSUES, PELVIC INFLAMM DIS, INFLAMM PELVIC DIS, PELVIC DIS INFLAMM, INFLAMM DIS PELVIC, pelvic inflammatory disease, pelvic inflammatory disease (diagnosis), 7-71 INFLAMMATORY DISEASES OF THE FEMALE GENITAL ORGANS AND TISSUES, pid, Female pelvic inflammatory disease NOS (disorder), Inflammatory disease of female pelvic organs AND/OR tissues (disorder), PID - pelvic inflammatory dis, Disease pelvic inflammatory, Pelvic inflammatory disease NOS, PID Pelvic inflammatory disease, Inflammation pelvic, Pelvic inflammation, [X]Inflammatory diseases of female pelvic organs (disorder), Pelvic Infection, Fem pelv inflam dis NOS, Female pelvic inflammatory diseases NOS (disorder), Pelvic inflammatory disease (PID), PID, PELVIC INFLAMMATORY DISEASE, PELVIC INFLAMMATORY DISEASE, DISEASE (PID), PELVIC INFLAMMATORY, INFLAMMATORY DISEASE (PID), PELVIC, PELVIC INFLAMMATORY DISEASE, (PID), Pelvic infection, Pelvic Inflammatory Disease [Disease/Finding], pelvic inflammation, pelvic inflammatory diseases, Disease;pelvic inflammatory, Infection;pelvic inflammatory, inflammatory pelvic disease, pelvic inflammatory disease (PID), Inflammatory diseases of female pelvic organs (N70-N77), PID, Pelvic inflammatory disease, Female pelvic inflammation, Female pelvic inflammatory disease, PID - pelvic inflammatory disease, Female pelvic inflammatory disease (disorder), Inflammatory disease of female pelvic organs AND/OR tissues, inflammation; pelvic, pelvic inflammatory disease; female, Female pelvic infection, Inflam. dis.- pelvic, Inflammatory disease of female pelvic organs AND/OR tissues [Ambiguous], Pelvic inflam. disease NOS, Pelvic Inflammatory Disease, Unspecified inflammatory disease of female pelvic organs and tissues, INFLAMMATORY DISEASE OF FEMALE PELVIC ORGANS, pelvic inflammatory infection
Dutch ontsteking bekken, niet-gespecificeerde ontstekingsziekte van de vrouwelijke bekkenorganen en -weefsels, bekkenontstekingsziekte NAO, ontstekingsziekte bekken, PID Pelvic inflammatory disease, bekkenontsteking, Ontstekingen kleine bekken/PID, Ontsteking kleine bekken/ PID, bekkenontsteking; vrouw, ontsteking; bekken, Ontstekingsprocessen in vrouwelijk bekken, niet gespecificeerd, bekkenontstekingsziekte, Adnexitis, PID, Pelvic inflammatory disease
French Pelvi-péritonite, Inflammation pelvienne SAI, PID, Maladie inflammatoire pelvienne (MIP), Maladie inflammatoire non précisée des organes et tissus pelviens chez la gemme, Inflammation pelvienne, Atteinte inflammatoire pelvienne, AIP (Atteinte inflammatoire pelvienne), MIP (Maladie inflammatoire pelvienne), Syndrome inflammatoire pelvien, INFLAMMATION PELVIENNE, Maladie pelvienne inflammatoire, Maladie inflammatoire pelvienne, Inflammation du pelvis
German Beckenentzuendung NNB, Entzuendung des Beckens, PID, PID Beckenentzuendung, unspezifische Entzuendungen der Organe und Gewebe des weiblichen Beckens, BECKENENTZUENDUNG, Entzuendliche Krankheit im weiblichen Becken, nicht naeher bezeichnet, Entzuendung im kleinen Becken, Beckenentzuendung, Entzündliche Erkrankung des Beckens
Italian Infiammazione pelvica, Malattia infiammatoria non specificata degli organi e dei tessuti pelvici femminili, Malattia infiammatoria pelvica NAS, Malattia infiammatoria della pelvi, Malattia infiammatoria pelvica
Portuguese Inflamação pélvica, Doença inflamatória pélvica, Doença inflamatória pélvica NE, DIP, Doença inflamatória NE dos órgãos e tecidos pélvicos femininos, Doenca inflamatoria pelvica, INFLAMACAO PELVICA, Doença pélvica inflamatória, Doença Inflamatória da Pelve, Doença Inflamatória Pélvica, Doença Pélvica Inflamatória
Spanish Enfermedad inflamatoria no especificada de los órganos y tejidos pélvicos femeninos, Inflamación pélvica, Enfermedad inlamatoria pélvica, Enfermedad inflamatoria de la pelvis NEOM, Enfermedad inflamatoria pélvica EIP, Pyosalpinx, Inflam. dis.- pelvic, Pelvic inflammatory disease NOS, Pelvic inflam. disease NOS, Chronic pelvic inflammatory disease, Female pelvic infection, Pelvic inflammatory disease, PID - pelvic inflammatory disease, Female pelvic inflammatory disease, Female pelvic inflammatory diseases NOS, Pelvic inflam disease,chronic, PID, Enfermedad inflamatoria pelvica, PELVIS, INFLAMACION, [X]enfermedades inflamatorias de órganos pélvicos femeninos (trastorno), [X]enfermedades inflamatorias de órganos pélvicos femeninos, Female pelvic inflammatory disease NOS, EIP, EPI, enfermedad inflamatoria de los órganos Y/O tejidos pelvianos, enfermedad inflamatoria de los órganos Y/O tejidos pélvicos (concepto no activo), enfermedad inflamatoria de los órganos Y/O tejidos pélvicos, enfermedad inflamatoria pelviana, enfermedad inflamatoria pélvica en la mujer (trastorno), enfermedad inflamatoria pélvica en la mujer, enfermedad inflamatoria pélvica femenina, SAI (trastorno), enfermedad inflamatoria pélvica femenina, SAI, enfermedad inflamatoria pélvica femenina, enfermedad inflamatoria pélvica, enfermedad pélvica inflamatoria, enfermedades inflamatorias pélvicas femeninas, SAI (trastorno), enfermedades inflamatorias pélvicas femeninas, SAI, inflamación pélvica femenina, Enfermedad inflamatoria pélvica, Enfermedad Inflamatoria Pelvica, Enfermedad Inflamatoria Pélvica
Japanese 骨盤内炎症性疾患ＮＯＳ, 骨盤内炎症, ｺﾂﾊﾞﾝﾅｲｴﾝｼｮｳｾｲｼｯｶﾝ, ｺﾂﾊﾞﾝﾅｲｴﾝｼｮｳ, ｺﾂﾊﾞﾝﾅｲｴﾝｼｮｳｾｲｼｯｶﾝNOS, 骨盤内炎症性疾患, 子宮付属器炎, 付属器炎
Czech pánev - zánětlivé nemoci, Pánevní zánětlivé onemocnění, Pánevní zánětlivé onemocnění NOS, Zánět v pánvi, Zánětlivé onemocnění orgánů malé pánve, Pánevní zánět, Blíže neurčené zánětlivé onemocnění ženských pánevních orgánů a tkání
Finnish Sisäsynnytintulehdus, PID/SISASYNNYTTIMIEN TULEHDUS
Russian TAZOVYKH ORGANOV VOSPALITEL'NYE BOLEZNI, ADNEKSIT, АДНЕКСИТ, ТАЗОВЫХ ОРГАНОВ ВОСПАЛИТЕЛЬНЫЕ БОЛЕЗНИ
Swedish INFLAMMATION I BACKENORG, Bäckeninflammation
Norwegian UNDERLIVSINF/PELVIC INFL DISEASE
Danish Underlivsbetaendelse
Hungarian gyulladasos nogyogy. betegsegek, Kismedencei gyulladás, kismedencei gyulladásos betegség k.m.n., PID, PID (kismedencei gyulladásos betegség), pelvikus gyulladás, kismedencei gyulladásos betegség, pelvikus gyulladásos betegség, Női kismedencei szervek és szövetek nem meghatározott gyulladásos betegsége
Korean 상세불명의 여성 골반의 염증성 질환
Croatian UPALNE BOLESTI ZDJELICE, ZDJELICA, UPALNA BOLEST
Basque PELBISEKO ERITASUN HAUNDIGARRIA
Hebrew daleket haagan PID
Polish Choroba zapalna miednicy
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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