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  • Pelvic Inflammatory Disease

Uterine Disorders

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Pelvic Inflammatory DiseaseAka: PID

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  1. Etiology
    1. Chlamydia trachomatis
    2. Neisseria Gonorrhea
    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 sedimentation rate or C-Reactive Protein
      6. PID findings on diagnostic study (see below)
  6. Diagnosis: Historic Criteria (prior to 2002 CDC)
    1. All Major Criteria
      1. Abdominal tenderness and rebound Abdominal Pain
      2. Cervical motion tenderness
      3. Adnexal tenderness
    2. And one or more minor criteria (no longer required)
      1. Temperature over 38 C
      2. White Blood Cell count > 10,000
      3. Pus in cul-de-sac
      4. Pelvic abscess or inflammatory complex
      5. Cervical Mucus findings
        1. Gram Stain: Gram Positive diplococci
        2. Intracellular parasites
  7. Differential Diagnosis
    1. Ruptured Ovarian Cyst
      1. Sudden onset of mid-cycle pain
    2. Ectopic Pregnancy
      1. Unilateral pain
      2. Positive Pregnancy Test
      3. Afebrile
      4. White Blood Cell count normal
    3. Appendicitis
      1. Right Lower Quadrant Abdominal Pain
      2. More bowel Symptoms
    4. Urinary Tract Infection
      1. No Cervical Motion Tenderness or Vaginal Discharge
    5. Ovarian Torsion
      1. More localized pain
      2. Sudden onset
      3. Afebrile
      4. White Blood Cell count normal
  8. 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)
  9. Diagnostic Studies
    1. Endometrial Biopsy: Endometritis
    2. Transvaginal pelvic ultrasound
      1. Pelvic free fluid in cul-de-sac
      2. Tubo-ovarian abscess may be present
      3. 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
    5. Laparoscopy
      1. Indicated for unclear diagnosis
      2. Pelvic Inflammatory Disease misdiagnosed 25% time
  10. 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
  11. 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
  12. 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
  13. Prevention
    1. Screen all sexually active women <25 for Chlamydia
  14. Complications
    1. Infertility (20%)
    2. Chronic Pelvic Pain (18%)
    3. Tubal Pregnancy (9%)
  15. References
    1. (2002) MMWR Recomm Rep 51(RR-6):1
    2. Crossman (2006) Am Fam Physician 73(5):859
    3. Miller (2003) Am Fam Physician 67(9):1915

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