Pelvic inflammatory disease

Revision as of 20:43, 22 December 2018 by Teapotter (talk | contribs) (Discharge)


  • 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
  • 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 4 months of insertion

Clinical Features


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)

Differential Diagnosis

Pelvic Pain

Pelvic origin

Abdominal origin



  • Urine pregnancy
  • Wet mount
  • Endocervical swab (for GC, Chlamydia)
  • CBC
  • Urine culture, analysis (to exclude UTI)


  • Pelvic U/S
    • 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
    • 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


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

Outpatient Options

Alternative Outpatient Options



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




  • 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


  1. Shepherd SM et al. Pelvic Inflammatory Disease Clinical Presentation. Jan 2017.
  2. Simms I et al. Risk factors associated with pelvic inflammatory disease. Sex Transm Infect. 2006 Dec; 82(6): 452–457.
  3. Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
  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
  7. Hayes BD. Trick of the Trade: IV ceftriaxone for gonorrhea. October 9th, 2012 ALiEM. Accessed October 23, 2018.
  8. 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
  9. CDC PID Treatment
  10. 10.0 10.1 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