Pelvic inflammatory disease: Difference between revisions

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==Background==
==Background==
[[File:Blausen 0732 PID-Sites.png|thumb|Pelvic anatomy.]]
*Pelvic Inflammatory Disease (PID) comprises spectrum of infections of the upper reproductive tract:
*Pelvic Inflammatory Disease (PID) comprises spectrum of infections of the upper reproductive tract:
**Salpingitis, endometritis, myo/parametritis, oophoritis
**Salpingitis, endometritis, myo/parametritis, and oophoritis
***Perihepatitis ([[Fitz-Hugh-Curtis]]) is caused by lymphatic spread
**Perihepatitis ([[Fitz-Hugh-Curtis]]) is caused by lymphatic spread
***Tubo-ovarain abscess is caused by direct extension
**[[Tubo-ovarian abscess]] is caused by direct extension
*Most common serious infection in women aged 16 to 25 years
*It is the most common serious infection in women aged 16 to 25 years and begins as [[cervicitis]] (commonly due to [[GC]] or [[chlamydia]]) that may progress to polymicrobial infection.
**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
**Initial lower tract infection may be asymptomatic
**Most common cause of death is rupture of a [[tubo-ovarian abscess]]
**Can be caused by organisms such as [[M. genitalium]] which is very difficult to isolate and will not be picked up on routine testing
*Bilateral tubal ligation does not confer protection against risk<ref>Shepherd SM et al. Pelvic Inflammatory Disease Clinical Presentation. Jan 2017. https://emedicine.medscape.com/article/256448-clinical#b1.</ref>


==Diagnosis==
===Risk factors<ref>Simms I et al. Risk factors associated with pelvic inflammatory disease. Sex Transm Infect. 2006 Dec; 82(6): 452–457.</ref>===
*Age < 25
*Age at first sexual intercourse < 20
*Non-white ethnicity
*Nulliparous
*History of transmitted diseases, especially chlamydia
*[[IUD]] within 21 days after insertion<ref>https://www.cdc.gov/std/tg2015/pid.htm</ref>
 
==Clinical Features==
===History===
===History===
#[[Pelvic Pain]] (90%)
*[[Pelvic Pain]] (90%)
#Vaginal discharge (75%)
*[[Vaginal discharge]] (75%)
#Vaginal and postcoital bleeding (>33%)
*[[vaginal bleeding|Vaginal and postcoital bleeding]] (>33%)
#Dysuria, [[fever]], malaise, [[N/V]]
*[[Dysuria]], [[fever]], malaise, [[nausea and vomiting]]


===Physical Exam===
===Physical Exam===
#CMT
*Cervical motion tenderness
#Adnexal tenderness
*Adnexal tenderness (Most sensitive finding - Sn ~95%)
#*Most sensitive finding (Sn ~95%)
*Mucopurulent cervicitis
#Mucopurulent cervicitis
**Absence should prompt consideration of another diagnosis
#*Absence should raise consideration of another dx
*[[RUQ Pain]]
#[[RUQ Pain]]
**May indicate perihepatic inflammation (particularly if [[jaundice]] also present)
#*May indicate perihepatic inflammation (particularly w/ [[jaundice]])


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


==Work-Up==
===Complications===
#Urine pregnancy
*[[Tubo-ovarian abscess]]
#Wet mount
*[[Fitz-Hugh-Curtis]]
#Endocervical swab (for [[GC]], [[Chlamydia]])
**Perihepatic inflammation seen only on CT, not US; LFTs are normal
#CBC
**Responds to standard antibiotic regimen
#ESR/CRP
*Infertility
#Urine culture, analysis (to excl [[UTI]])
*[[Ectopic pregnancy]]
 
*Chronic [[Pelvic pain|pelvic pain]]
===Imaging===
#Pelvic U/S
##Ultrasound sensitivity may be as low as 56% and specificity of 85% <ref>Lee DC, Swaminathan AK. Sensitivity of ultrasound for the diagnosis of tubo-ovarian abscess: a case report and literature review. J Emerg Med.
2011 Feb;40(2):170-5. doi: 10.1016 PMID 20466506 </ref>
#CT


==Differential Diagnosis==
==Differential Diagnosis==
{{Pelvic pain DDX}}
{{Pelvic pain DDX}}


== Treatment ==
==Evaluation==
#Tx all partners who had sex w/ pt during previous 60d prior to onset of sx
[[File:PMC3369119 13244 2012 157 Fig8 HTML.png|thumb|PID with pyosalpinx on transvaginal ultrasound: bilateral adenexal cysts consistent with pyosalpinges (white arrows).]]
[[File:PMC3369119 13244 2012 157 Fig9 HTML.png|thumb|PID on CT with bilateral adnexal complex fluid-filled and thick-walled cysts typical for tubo-ovarian abcess formation and an associated ileus.]]
===Workup===
*Urine pregnancy
*Wet mount
*Endocervical swab (for [[GC]], [[Chlamydia]])
*CBC
*ESR/CRP
*Urine culture, analysis (to exclude [[UTI]])
*[[Pelvic ultrasound]]
**Ultrasound sensitivity may be as low as 56% and specificity of 85% <ref>Lee DC, Swaminathan AK. Sensitivity of ultrasound for the diagnosis of tubo-ovarian abscess: a case report and literature review. J Emerg Med.
2011 Feb;40(2):170-5. doi: 10.1016 PMID 20466506 </ref>
*CT
 
===CDC Empiric Diagnosis Criteria<ref>http://www.cdc.gov/std/tg2015/pid.htm </ref>===
*Woman at risk for [[STIs]]
*Pelvic or lower abdominal pain
*No cause for the illness other than PID can be identified
*At least one of the following on pelvic exam:
**CMT
**Uterine tenderness
**Adnexal tenderness.
*Additional criteria that make the diagnosis more likely:
**Oral temperature >101° F (>38.3° C)
**Abnormal cervical or vaginal mucopurulent discharge
**Presence of abundant numbers of WBC on saline microscopy of vaginal fluid
**Elevated ESR
**Elevated CRP
**Laboratory documentation of cervical infection with [[GC]] or [[chlamydia]]


=== Outpatient Options ===
==Management==
#[[Ceftriaxone]] 250mg IM x1 + [[doxycycline]] 100mg PO BID x14d +/- [[metronidazole]] 500mg PO BID x14d <ref>Ness RB et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol 2002;186:929–37</ref>
{{PID antibiotics}}
##[[Metronidazole]] based upon assessment of risk for [[anaerobes]]; consider in:
###Pelvic abscess
###Proven or suspected infection w/ [[Trichomonas]] or [[Bacterial Vaginosis]]
###History of gynecological instrumentation in the preceding 2-3wks


#[[Cefoxitin]] 2 g IM in a single dose and Probenecid, 1 g PO administered concurrently in a single dose<ref>CDC PID Treatment http://www.cdc.gov/std/treatment/2010/pid.htm</ref> + [[Doxycycline]] 100 mg PO BID x 14 days +/- flagyl based on above criteria
===[[IUD]]===
*No change in treatment if IUD in place (may treat without removal)


===Alternative Outpatient Options===
#[[Ceftriaxone]] 250mg IM x1 + 1 g of [[Azithromycin]] per week, x 2 weeks<ref name="Savaris">Savaris RF. et al. Comparing ceftriaxone plus azithromycin or doxycycline for pelvic inflammatory disease: a randomized controlled trial. Obstet Gynecol. 2007 Jul;110(1):53-60</ref> +/- flagyl based on above criteria
##Great cure rates in the Azithromycin group (98.2% vs 87.5%)<ref name="Savaris"></ref>


=== Inpatient ===
'''Due to inability to test for all causative pathogens and the potential for serious complications such as infertility, the CDC has made this a purposefully vague condition with a low threshold for empiric treatment'''
#[[Cefoxitin]] 2gm IV q6hr OR [[cefotetan]] 2gm IV q12hr) + [[doxycycline]] PO or IV 100 mg q12hr OR
#[[Clindamycin]] 900mg IV q8h + [[gentamicin]] 2mg/kg QD OR
#Ampicillin/sulbactam 3gm IV q6hr + [[doxycycline]] 100mg IV/PO q12hr


==Disposition==
==Disposition==
Admit:
===Admit===
#[[Tubo-ovarian abscess]]
*[[Tubo-ovarian abscess]]
#[[Fitz-Hugh-Curtis]]
**Hemodynamically unstable, TOA > 9 cm, postmenopausal, outpatient failure --> admit for surgical or VIR drainage
#Pregnancy
*[[Fitz-Hugh-Curtis]]
#[[Sepsis]]/peritonitis
*[[Pregnancy]]
#Unable to tolerate PO
*[[Sepsis]]/[[Peritonitis]]
#Failed outpt Rx
*Unable to tolerate PO
#HIV+
*Failed outpatient treatment
Discharge:
#72hr f/u
#Instruct pt to abstain from sex or adhere strictly to condom use until sx have abated


==Complications==
===Discharge===
#[[Tubo-Ovarian Abscess]]
*72hr follow up
#[[Fitz-Hugh-Curtis]]
*Instruct patient to abstain from sex or adhere strictly to condom use until partner treatment and symptoms have abated
##Perihepatic inflammation seen only on CT, not US; LFTs are normal
*HIV+ is not an automatic criteria for admission, consider overall clinical impression
##Responds to standard abx regimen
#Infertility
#[[Ectopic Pregnancy]]
#Chronic pelvic pain


==See Also==
==See Also==
*[[Sexually Transmitted Diseases (STD)]]
*[[Sexually Transmitted Diseases (STD)]]
*[[Ectopic Pregnancy]]
*[[Pelvic pain]]
*[[Pelvic Pain]]


== Source ==
==References==
<references/>
<references/>
[[Category:ID]] [[Category:OB/GYN]]
 
[[Category:ID]]  
[[Category:OBGYN]]

Revision as of 18:19, 13 February 2020

Background

Pelvic anatomy.
  • Pelvic Inflammatory Disease (PID) comprises spectrum of infections of the upper reproductive tract:
  • It is the most common serious infection in women aged 16 to 25 years and begins as cervicitis (commonly due to GC or chlamydia) that may progress to polymicrobial infection.
    • Initial lower tract infection may be asymptomatic
    • Most common cause of death is rupture of a tubo-ovarian abscess
    • Can be caused by organisms such as M. genitalium which is very difficult to isolate and will not be picked up on routine testing
  • Bilateral tubal ligation does not confer protection against risk[1]

Risk factors[2]

  • Age < 25
  • Age at first sexual intercourse < 20
  • Non-white ethnicity
  • Nulliparous
  • History of transmitted diseases, especially chlamydia
  • IUD within 21 days after insertion[3]

Clinical Features

History

Physical Exam

  • Cervical motion tenderness
  • Adnexal tenderness (Most sensitive finding - Sn ~95%)
  • Mucopurulent cervicitis
    • Absence should prompt consideration of another diagnosis
  • RUQ Pain
    • May indicate perihepatic inflammation (particularly if jaundice also present)


Complications

Differential Diagnosis

Acute Pelvic Pain

Differential diagnosis of acute pelvic pain

Gynecologic/Obstetric

Genitourinary

Gastrointestinal

Musculoskeletal

Vascular

Evaluation

PID with pyosalpinx on transvaginal ultrasound: bilateral adenexal cysts consistent with pyosalpinges (white arrows).
PID on CT with bilateral adnexal complex fluid-filled and thick-walled cysts typical for tubo-ovarian abcess formation and an associated ileus.

Workup

  • Urine pregnancy
  • Wet mount
  • Endocervical swab (for GC, Chlamydia)
  • CBC
  • ESR/CRP
  • Urine culture, analysis (to exclude UTI)
  • Pelvic ultrasound
    • Ultrasound sensitivity may be as low as 56% and specificity of 85% [5]
  • CT

CDC Empiric Diagnosis Criteria[6]

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

Management

Antibiotics

  • No sexual activity for 2 weeks;
  • Treat all partners who had sex with patient during previous 60 days prior to symptom onset

Outpatient Antibiotic Options

Inpatient Antibiotic Options

IUD

  • No change in treatment if IUD in place (may treat without removal)


Due to inability to test for all causative pathogens and the potential for serious complications such as infertility, the CDC has made this a purposefully vague condition with a low threshold for empiric treatment

Disposition

Admit

Discharge

  • 72hr follow up
  • Instruct patient to abstain from sex or adhere strictly to condom use until partner treatment and symptoms have abated
  • HIV+ is not an automatic criteria for admission, consider overall clinical impression

See Also

References

  1. Shepherd SM et al. Pelvic Inflammatory Disease Clinical Presentation. Jan 2017. https://emedicine.medscape.com/article/256448-clinical#b1.
  2. Simms I et al. Risk factors associated with pelvic inflammatory disease. Sex Transm Infect. 2006 Dec; 82(6): 452–457.
  3. https://www.cdc.gov/std/tg2015/pid.htm
  4. Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
  5. Lee DC, Swaminathan AK. Sensitivity of ultrasound for the diagnosis of tubo-ovarian abscess: a case report and literature review. J Emerg Med. 2011 Feb;40(2):170-5. doi: 10.1016 PMID 20466506
  6. http://www.cdc.gov/std/tg2015/pid.htm
  7. Hayes BD. Trick of the Trade: IV ceftriaxone for gonorrhea. October 9th, 2012 ALiEM. https://www.aliem.com/2012/10/trick-of-trade-iv-ceftriaxone-for/. Accessed October 23, 2018.
  8. Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm
  9. Ness RB et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol 2002;186:929–37
  10. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
  11. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
  12. Ross J, Guaschino S, Cusini M, Jensen J, 2017 European guideline for the management of pelvic inflammatory disease. Int J STD AIDS. 2018 Feb;29(2):108-114. doi: 10.1177/0956462417744099. Epub 2017 Dec 4.
  13. CDC PID Treatment http://www.cdc.gov/std/treatment/2010/pid.htm
  14. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon