Pelvic inflammatory disease

Background

• Comprises spectrum of infections of the upper reproductive tract:
  • Salpingitis, endometritis, myo/parametritis, oophoritis
    • Perihepatitis (Fitz-Hugh-Curtis) is caused by lymphatic spread
    • Tubo-ovarain abscess is caused by direct extension

• Most common serious infection in women aged 16 to 25 years
  • Most common cause of death is rupture of a tubo-ovarian abscess
• Begins as cervicitis w/ GC or chlamydia that may progress to polymicrobial infection
  • Initial lower tract infection may be asymptomatic

Diagnosis

History

1. Pelvic pain (90%)
2. Vaginal discharge (75%)
3. Vaginal and postcoital bleeding (>33%)
4. Dysuria, fever, malaise, N/V

Physical Exam

1. CMT
2. Adnexal tenderness
   1. Most sensitive finding (Sn ~95%)
3. Mucopurulent cervicitis
   1. Absence should raise consideration of another dx
4. RUQ pain
   1. May indicate perihepatic inflammation (particularly w/ jaundice)

Work-Up

1. Urine pregnancy
2. Wet mount
3. GC/Chlam swab
4. CBC
5. ESR/CRP
6. UA

Imaging

1. Pelvic US
2. CT

DDX

1. Cervicitis
2. Ectopic pregnancy
3. Endometriosis
4. Ovarian cyst
5. Ovarian torsion
6. Spontaneous abortion
7. Septic abortion
8. Cholecystitis
9. Gastroenteritis
10. Appendicitis
11. Diverticulitis
12. Pyelonephritis
13. Renal colic

CDC Treatment Criteria

1. Woman at risk for STIs
2. Pelvic or lower abdominal pain
3. No cause for the illness other than PID can be identified
4. At least one of the following on pelvic exam:
   1. CMT
   2. Uterine tenderness
   3. Adnexal tenderness.
5. Additional criteria that make the dx more likely:
   1. Oral temperature >101° F (>38.3° C)
   2. Abnormal cervical or vaginal mucopurulent discharge
   3. Pesence of abundant numbers of WBC on saline microscopy of vaginal fluid
   4. Elevated ESR
   5. Elevated CRP
   6. Laboratory documentation of cervical infection with GC or chlamydia

Treatment

1. Tx all partners who had sex w/ pt during previous 60d prior to onset of sx

Outpatient

1. CTX 250mg IM x1 + doxycycline 100mg PO BID x14d +/- metronidazole 500mg PO BID x14d
   1. Metronidazole based upon assessment of risk for anaerobes; consider in:
      1. Pelvic abscess
      2. Proven or suspected infection w/ trichomonas or bacterial vaginosis
      3. History of gynecological instrumentation in the preceding 2-3wks

Inpatient

1. Cefoxitin 2gm IV q6hr OR cefotetan 2gm IV q12hr) + doxycycline PO or IV 100 mg q12hr OR
2. Clindamycin 900mg IV q8h + genamicin 2mg/kg QD OR
3. Ampicillin/sulbactam 3gm IV q6hr + doxycycline 100mg IV/PO q12hr

Disposition

Admit:

1. TOA
2. Fitz-Hugh-Curtis
3. Pregnancy
4. Sepsis/peritonitis
5. Unable to tolerate PO
6. Failed outpt Rx
7. HIV+

Discharge:

1. 72hr f/u
2. Instruct pt to abstain from sex or adhere strictly to condom use until sx have abated

Complications

1. Tubo-ovarian abscess
   1. Disproportionate unilateral adnexal tenderness or adnexal mass or fullness
   2. Suspect in pt who does not respond after 72hr of tx
   3. Majority (60-80%) resolve w/ abx alone
2. Fitz-Hugh-Curtis
   1. Perihepatic inflammation seen only on CT, not US; LFTs are normal
   2. Responds to standard abx regimen
3. Infertility
4. Ectopic Pregnancy
5. Chronic pelvic pain

See Also

• Sexually Transmitted Diseases (STD)
• Ectopic Pregnancy
• Pelvic Pain

Source

CDC 2010, Tintinalli