Pelvic inflammatory disease
Background
Commonly begins as cervical infection (cervicitis) with gonorrhea or chlamydia
Diagnosis
- Pelvic pain (90%)
- Constitutional sx-Vaginal discharge (75%)
- Abnl pelvic exam (60%)
- Vaginal bleeding (40%)
CDC Criteria^^
- Cervical motion tenderness (CMT)
- OR, B. Pelvic/adenexal TTP (in pt with no other identifiable cause)
Additional Criteria
- Fever
- WBC >10k
- Abnl cervical discharge (50%)
- WBC on wet mounte) GC/Chlamy
^^CDC Criteria are sensitive, but not specific (i.e. many intr-abominal processes have CMT)
Work-Up
- Upreg (negative)
- Pelvic exam (send GC/Chlamy, wet mount)
- Pelvic US if toxic (r/o TOA)
- R/O other intra-abd pathology (consider CT, UA, labs)
Treatment
Outpatient
1) Ceftriaxone (250 mg IM x 1)
+ doxycycline (100mg PO BID x 14 days)
+/- metronidazole (500mg PO BID x 14 days)
OR
2) Cefoxitin (2g IM x 1)
+ probebenecid (1gm PO x 1)
+ doxycycline (100mg PO BID x 14 days)
+/- metronidazole (500mg PO BID x 14 days)
OR
3) 3-gen cephalosporin [cefotaxime (1gm IM x1) OR ceftizoxime (1gm IM x 1)
+ doxycycline (100mg PO BID x 14 days)
+/- metronidazole (500mg PO BID x 14 days)
^Metronidazole based upon assessment of risk for anaerobs. Consider in:
- Pelvic abscess
- Proven or suspected infection Trichomonas vaginalis or bacterial vaginosis
- History of gynecological instrumentation in the preceding two to three weeks.
Inpatient
1) Cefotetan 2gm IV q12h OR cefoxitin 2mg IV q6h
+ doxy 100mg IV/PO q12hOR2) Clinda 900mg IV q8h
+ 4.5 mg/kg QD
+ (after) doxy 100mg PO BID x 14dy
^Rising levels of fluoroquinolone resistance, use them only where prevalence of resistant GC <5%.
^^Treat all partners that had sexual contact with the patient during the previous 60 days prior to the patient's onset of symptoms (advise to avoid sex until treated)
Disposition
Admit for:
- TOA, Fitz-Hugh-Curtis
- Sepsis/peritonitis
- Unable to tol POs
- Failed outpt Rx
Complications
- TOA/sepsis
- Infertility
- Ectopic
- Chronic pelvic pain
Source
CDC, KajiQuestions