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Pelvic Inflammatory DiseaseAka: PID
- Etiology
- Chlamydia trachomatis
- Neisseria Gonorrhea
- Mycoplasma hominis
- Facultative or anaerobic organisms
- Risk Factors
- Sexually Transmitted Disease (STD) history
- Prior history of Pelvic Inflammatory Disease
- Onset sexual intercourse at a young age
- High number of sexual partners
- Symptoms: Onset usually in first half of Menstrual Cycle
- Abdominal Pain (varying intensity)
- High fever
- Dyspareunia
- Prolonged Menses
- Exam
- Bimanual exam and speculum exam in all suspected cases
- See Diagnosis below for signs
- Diagnosis: 2002 CDC Criteria
- Major Criteria (Required)
- Uterine or adnexal tenderness to palpation or
- Cervical motion tenderness
- No other apparent cause
- Minor Criteria (Supporting, but not required)
- Fever >101 F (38.3 C)
- Abnormal discharge per cervix or vagina
- WBCs on Gram Stain or Saline of cervix swab
- Gonorrhea or Chlamydia testing positive
- Increased sedimentation rate or C-Reactive Protein
- PID findings on diagnostic study (see below)
- Diagnosis: Historic Criteria (prior to 2002 CDC)
- All Major Criteria
- Abdominal tenderness and rebound Abdominal Pain
- Cervical motion tenderness
- Adnexal tenderness
- And one or more minor criteria (no longer required)
- Temperature over 38 C
- White Blood Cell count > 10,000
- Pus in cul-de-sac
- Pelvic abscess or inflammatory complex
- Cervical Mucus findings
- Gram Stain: Gram Positive diplococci
- Intracellular parasites
- Differential Diagnosis
- Ruptured Ovarian Cyst
- Sudden onset of mid-cycle pain
- Ectopic Pregnancy
- Unilateral pain
- Positive Pregnancy Test
- Afebrile
- White Blood Cell count normal
- Appendicitis
- Right Lower Quadrant Abdominal Pain
- More bowel Symptoms
- Urinary Tract Infection
- No Cervical Motion Tenderness or Vaginal Discharge
- Ovarian Torsion
- More localized pain
- Sudden onset
- Afebrile
- White Blood Cell count normal
- Labs
- General
- Do not delay treatment while waiting for labs
- Inflammatory markers (if all normal, rules-out PID)
- Complete Blood Count (CBC)
- Erythrocyte Sedimentation Rate or C-Reactive Protein
- Vaginal secretion exam (saline wet prep)
- Vaginal PMNs (Negative Predictive Value 95%)
- Other initial labs
- DNA probe for Gonorrhea and Chlamydia
- Cervical specimen recommended over urine specimen
- Blood Cultures
- Urine Pregnancy Test
- Rapid Plasma Reagin (RPR)
- Diagnostic Studies
- Endometrial Biopsy: Endometritis
- Transvaginal pelvic ultrasound
- Pelvic free fluid in cul-de-sac
- Tubo-ovarian abscess may be present
- Fallopian tube changes
- Thickened fallopian tube wall >5 mm
- Fluid filled fallopian tubes
- Incomplete septae in fallopian tube
- Cogwheel sign on tube cross-section view
- CT Pelvis
- Pelvic floor fascial, adnexal inflammation
- Uterosacral ligament thickening
- Pelvic free fluid
- MRI Pelvis (Test Sensitivity: 95%, Specificity: 89%)
- Tubo-ovarian abscess may be present
- Pelvic free fluid
- Fallopian tube changes
- Fluid filled fallopian tubes
- Ovaries have polycystic appearance
- References
- Tukeva (1999) Radiology 210:209
- Laparoscopy
- Indicated for unclear diagnosis
- Pelvic Inflammatory Disease misdiagnosed 25% time
- Management: General
- Remove Intrauterine Device (IUD)
- Treat patient's sexual contacts within last 60 days
- Start empiric therapy if minimal criteria present
- Do not delay treatment
- Delay >3 days increases ectopic and Infertility risk
- Antibiotic should cover Gonorrhea and Chlamydia
- Fluoroquinole resistant Gonorrhea is increasing
- Do not use Fluoroquinolones in high risk groups
- Cohorts at risk for resistance
- Homosexual men and any female sexual contacts
- Endemic areas
- Asia: China, Japan, Korea, Philippines, Vietnam
- Other: England, Wales, Australia
- US: California
- Management Outpatient
- Step 1: Initial Treatment at Diagnosis (with step 2)
- Cefoxitin 2g IM and Probenecid 1g PO or
- Ceftriaxone 250 mg IM for 1 dose or
- Other third generation Cephalosporin (e.g Cefotaxime)
- Step 2: Outpatient 14 day antibiotic course
- Select general antibiotic coverage
- Ofloxacin 400 mg PO bid for 14 days (95% cure) or
- Levofloxacin 500 mg PO daily for 14 days or
- Doxycycline 100 mg PO bid for 14 days (75% cure)
- Add anaerobic coverage (consider)
- Clindamycin 450 mg PO qid for 14 days or
- Metronidazole 500 mg PO bid for 14 days
- References
- Ross (2001) BMJ 322:251
- Management Inpatient
- Hospitalization Indications
- Toxic appearance
- Unable to take oral fluids
- Unclear diagnosis
- Appendicitis
- Ectopic Pregnancy
- Ovarian torsion
- Pelvic abscess
- Pregnancy
- HIV positive
- Adolescents
- Outpatient treatment failure
- Unreliable patient
- Inpatient treatment Regimens
- General
- Treat for at least 48 hours IV
- Regimen A (preferred)
- Cefoxitin 2g IV q6h OR Cefotetan 2g IV q12h and
- Doxycycline 100 mg PO or IV q12h
- Regimen B
- Clindamycin 900 mg IV q8h and
- Gentamicin 2 mg/kg IV load, then 1.5 mg/kg IV q8h
- Alternative: Conversion to single daily dosing
- Regimen C
- Ofloxacin 400 mg IV q12h or Levoquin 500 IV qd and
- Consider adding Metronidazole 500 IV q8 hours
- Regimen D
- Unasyn 3g IV q6 hours and
- Doxycycline 100 mg PO or IV q12 hours
- Discharge Regimen (after IV antibiotics above)
- See Outpatient Management Step 2 above
- Prevention
- Screen all sexually active women <25 for Chlamydia
- Complications
- Infertility (20%)
- Chronic Pelvic Pain (18%)
- Tubal Pregnancy (9%)
- References
- (2002) MMWR Recomm Rep 51(RR-6):1
- Crossman (2006) Am Fam Physician 73(5):859
- Miller (2003) Am Fam Physician 67(9):1915
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