Pelvic inflammatory disease
(Redirected from Pelvic Inflammatory Disease)
Background
- Pelvic Inflammatory Disease (PID) comprises spectrum of infections of the upper reproductive tract:
- Salpingitis, endometritis, myo/parametritis, and oophoritis
- Perihepatitis (Fitz-Hugh-Curtis) is caused by lymphatic spread
- Tubo-ovarian abscess is caused by direct extension
- 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
- Pelvic Pain (90%)
- Vaginal discharge (75%)
- Vaginal and postcoital bleeding (>33%)
- Dysuria, fever, malaise, nausea and vomiting
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
Acute Pelvic Pain
Gynecologic/Obstetric
- Normal variants may be noted on exam but generally do not cause pain or other symptoms
- Nabothian cysts: Epithelial cells within mucous glans that appear as yellow inclusions on the cervix
- Cervial Ectropion: Edothelial cells on the exterior of the cervix
- Parous cervix: The is no longer round but may have multiple shapes after birth
- Pregnancy-related
- Ectopic Pregnancy
- Spontaneous abortion, threatened or incomplete
- Septic abortion
- Pelvic organ prolapse
- Acute Infections
- Vulvovaginitis
- Adnexal Disorders
- Hemorrhage/rupture of ovarian cyst
- Ovarian torsion
- Twisted paraovarian cyst
- Other
- Myoma (degenerating)
- Genitourinary trauma
- Ovarian hyperstimulation syndrome
- Sexual assault
- Recurrent
- Mittelschmerz
- Primary/Secondary Dysmenorrhea
- Pelvic Congestion Syndrome
- Endometriosis
Genitourinary
Gastrointestinal
- Gastroenteritis
- Appendicitis
- Bowel obstruction
- Perirectal abscess
- Diverticulitis
- Inflammatory bowel disease
- Irritable bowel syndrome
- Mesenteric adenitis
Musculoskeletal
- Abdominal wall hematoma
- Psoas hematoma, psoas abscess
- Hernia
Vascular
- Pelvic thrombophlebitis
- Abdominal aortic aneurysm
- Ischemic bowel (Mesenteric Ischemia)
Evaluation
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]
- Consider CT to rule-out other causes of lower abdominal/pelvic pain
- Multiple intra-abdominal processes can cause cervical motion tenderness, including appendicitis
CDC Empiric Diagnosis Criteria[6]
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
- 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:
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
- Ceftriaxone 500mg IM (1g if >150kg)[7][8] x1 + doxycycline 100mg PO BID x14d + metronidazole 500mg PO BID x14d [9][10]
- Cefoxitin 2 g IM in a single dose and Probenecid, 1 g PO administered concurrently in a single dose[13] + Doxycycline 100 mg PO BID x 14 days + metronidazole
Inpatient Antibiotic Options
- Recommended[14]: Ceftriaxone 1gm IV q24hr OR Cefoxitin 2gm IV q6hr OR cefotetan 2gm IV q12hr) + doxycycline PO or IV 100 mg q12hr + Metronidazole 500mg IV or PO Q12hr OR
- Clindamycin 900mg IV q8h + gentamicin 2mg/kg loading -> 1.5 mg/kg q8hr IV OR
- Ampicillin-sulbactam 3gm IV q6hr + doxycycline 100mg IV/PO q12hr
IUD
- No change in treatment if IUD in place (may treat without removal)
Disposition
Admit
- Tubo-ovarian abscess
- Hemodynamically unstable, TOA > 9 cm, postmenopausal, outpatient failure --> admit for surgical or VIR drainage
- Fitz-Hugh-Curtis
- Pregnancy
- Sepsis/Peritonitis
- Unable to tolerate PO
- Failed outpatient treatment
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
Complications
- Tubo-ovarian abscess
- Fitz-Hugh-Curtis
- Perihepatic inflammation seen only on CT, not US; LFTs are normal
- Responds to standard antibiotic regimen
- Infertility
- Ectopic pregnancy
- Chronic pelvic pain
See Also
References
- ↑ Shepherd SM et al. Pelvic Inflammatory Disease Clinical Presentation. Jan 2017. https://emedicine.medscape.com/article/256448-clinical#b1.
- ↑ Simms I et al. Risk factors associated with pelvic inflammatory disease. Sex Transm Infect. 2006 Dec; 82(6): 452–457.
- ↑ https://www.cdc.gov/std/tg2015/pid.htm
- ↑ Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
- ↑ 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
- ↑ http://www.cdc.gov/std/tg2015/pid.htm
- ↑ 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.
- ↑ Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm
- ↑ 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
- ↑ 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
- ↑ 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
- ↑ 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.
- ↑ CDC PID Treatment http://www.cdc.gov/std/treatment/2010/pid.htm
- ↑ 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