Pelvic inflammatory disease

Last updated: February 24, 2022

Summary

Pelvic inflammatory disease (PID) is caused by a bacterial infection that spreads beyond the cervix to infect the upper female reproductive tract, including the uterus, fallopian tubes, ovaries, and surrounding tissue. The most common pathogens that cause PID are Chlamydia and Gonococci. Symptoms may vary considerably; while some women are asymptomatic, others may complain of mild pressure pain and discharge or present with signs of systemic inflammation, such as fever and severe abdominal pain. Diagnosis is based on clinical findings and may be supported by ultrasound, PCR, and/or cultures of cervical and urethral discharges. Calculated parenteral antibiotic therapy is indicated in women with suspected PID. Most common complications include infertility, ectopic pregnancy, and chronic pelvic pain.

Epidemiology

Lifetime prevalence: ∼ 4.5% in women of reproductive age (18–44 years) ^[1]
> 1 million women experience an episode of PID/year. ^[2]
PID is one of the most common causes of infertility. ^[1]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

Pathogens ^[3]^[4]
- Most common: Chlamydia trachomatis, Neisseria gonorrhoeae
- Less common (consider coinfections): E. coli, Ureaplasma, Mycoplasma, and other anaerobes
Risk factors ^[4]
- Multiple sexual partners, unprotected sex
- History of prior STIs and/or adnexitis
- Intrauterine devices ^[3]
- Risk is lower during pregnancy; PID development during pregnancy increases the risk of maternal morbidity and preterm births. ^[5]
- Vaginal dysbiosis ^[6]
Pathophysiology: Infection from the lower genital tract (e.g., vagina, cervix) ascends to infect the upper reproductive tract (endometrium, fallopian tubes, ovaries) and/or peritoneal cavity.
Possible sites of infection
- Endometrium: endometritis (see also “Postpartum endometritis”)
- Fallopian tubes: salpingitis
- Ovaries: oophoritis
- Uterine adnexa: adnexitis
- Surrounding pelvic structures (parametritis) or, in some cases, the peritoneum (peritonitis)

Clinical features

Lower abdominal pain (generally bilateral), which may progress to acute abdomen ^[7]
Nausea, vomiting
Fever
Dysuria, urinary urgency
Menorrhagia, metrorrhagia
Dyspareunia
Abnormal vaginal discharge (yellow/green color)

Vaginal discharge in gonococcal infection

Diagnostics

Diagnosis is primarily based on clinical findings. Further diagnostic tests help confirm the diagnosis, especially in ambiguous cases.

Important diagnostic criteria ^[8]
- Patient history: most often a sexually active young woman
- Lower abdominal pain
- Vaginal examination
  - Cervical motion tenderness: severe cervical pain elicited by pelvic examination
  - Uterine and/or adnexal tenderness
  - Purulent, bloody cervical and/or vaginal discharge
Blood tests: : elevated ESR, leukocytosis
Pregnancy test: to rule out an (ectopic) pregnancy
Cervical and urethral swab
- Gonococcal and chlamydial DNA (PCR) and cultures (see “Gonorrhea” and “Chlamydia infections”)
- Giemsa stain of discharge can show cytoplasmic inclusions in C. trachomatis infections, but not in N. gonorrhoeae infection.
Imaging
- Ultrasound: free fluid, abscesses, pyosalpinx/hydrosalpinx
- Exploratory laparoscopy ^[9]
  - Indicated in ambiguous cases and if patient does not respond to treatment
  - Characteristic findings include tubal edema, erythema, and purulent exudate.
- Endometrial biopsy: to confirm the presence of endometritis ^[1]
- Culdocentesis: aspiration of intraperitoneal fluid from the pouch of Douglas ^[10]
  - Reveals nature of the fluid (e.g., serous, purulent, bloody)
  - Culdocentesis is no longer a routine procedure and it has been largely replaced by ultrasound.

PID may manifest with symptoms of appendicitis due to periappendicitis or perihepatitis. Symptoms may also mimic ectopic pregnancy.

PID should be suspected in young, sexually active women who present with lower abdominal pain and adnexal/cervical motion tenderness.

Cervical discharge in gonorrhea (speculum view) Vaginal discharge in gonococcal infection Chlamydia trachomatis in McCoy cell culture

Differential diagnoses

Differential diagnosis of lower abdominal pain in women of reproductive age
Disorder	Clinical features	Diagnostic clues	Therapy
Ectopic pregnancy	Lower unilateral abdominal pain and guarding Vaginal bleeding Amenorrhea	Positive pregnancy test Ultrasound: echogenic mass	Methotrexate or surgical removal
PID	Lower bilateral abdominal pain Fever Menorrhagia and metrorrhagia Dyspareunia	Cervical discharge CMT	Antibiotics
Appendicitis	Initially diffuse epigastric pain Later localized right lower quadrant pain Nausea and vomiting Fever	McBurney's point tenderness Ultrasound: appendiceal diameter of > 6 mm	Appendectomy
Kidney stones	Unilateral colicky flank pain Pain may radiate to the lower abdomen and genital area.	Hematuria Ultrasound: urinary tract obstruction and radiolucent stones	Destruction or removal of stone
Ovarian cyst rupture	Sudden onset unilateral lower abdominal pain Usually after physical activity (exercise, sexual intercourse) Minimal vaginal bleeding (spotting) can occur.	Ultrasound: adnexal mass and fluid in the pelvis (most commonly in the rectouterine pouch) Negative pregnancy test	Continued surveillance or emergency exploratory laparoscopy/laparotomy to obtain hemostasis
Ovarian torsion	Sudden onset unilateral lower abdominal and/or pelvic pain Nausea and vomiting Adnexal mass may be palpable.	Ultrasound with Doppler: enlarged, edematous ovary with decreased blood flow MRI abdomen and pelvis with contrast: twisted vascular pedicle (whirlpool sign)	Emergency exploratory laparoscopy: adnexal detorsion
Pelvic cellulitis ^[11]	Fever Dull abdominal pain or the sensation of pelvic fullness Absence of gastrointestinal and/or urinary signs, masses, or peritoneal signs	Medical history: recent gynecological surgery or procedure, infections (e.g., cervicitis, endometritis) Ultrasound: hyperemic, edematous tissue surrounding the uterus	Antibiotics

Cervicitis ^[12]

Definition: inflammation of the uterine cervix
Etiology
- Infectious (most common): C. trachomatis, N. gonorrhea, HSV-2 , T. vaginalis
- Noninfectious
  - Localized trauma (e.g., cervical caps, diaphragms, tampons)
  - Chemical irritation (e.g., contraceptive creams, latex exposure)
  - Malignancy
- Risk factors
  - Young age
  - Multiple sexual partners
  - New sexual partner within the last 6 months
  - Unprotected intercourse
Clinical features
- Often asymptomatic
- Usually no fever
- Vaginal discharge: may be purulent, blood-tinged, and/or malodorous
- Dyspareunia
- Postcoital or intermenstrual bleeding
- Lower abdominal or pelvic pain
- Symptoms of the underlying condition (e.g., genital lesions in HSV infections)
- Physical examination
  - Abdominal palpation: possible tenderness/discomfort (if concomitant PID is present) ^[13]
  - Bimanual examination: motion tenderness of the cervix
  - Pelvic examination: erythematous, edematous, friable cervix ; possibly visible discharge
Diagnostics
- Diagnosis mainly clinical ^[3]
  - Mucopurulent discharge
  - Friable cervix on pelvic examination
- Further tests for identification of a pathogen
  - Assess vaginal secretions for appearance, pH , leukocyte count, and visible pathogens (e.g., protozoa in T. vaginalis infections)
  - Swab samples for bacterial culture
  - NAAT for N. gonorrhea and C. trachomatis
Treatment
- Antibiotics; are tailored to the causative agent (see “Treatment” section below).
- Evaluate sex partner(s) of patients with infectious cervicitis.
- Follow-up to evaluate treatment success.
Complications: PID

The differential diagnoses listed here are not exhaustive.

Treatment

Empirical antibiotic therapy (also consider coinfections) ^[1]^[3]

Outpatient regimen
- One single dose of IM ceftriaxone and oral therapy with doxycycline
- Signs of vaginitis or recent gynecological instrumentation: Add oral metronidazole.
Inpatient regimen (parenteral antibiotics)
- Indications
  - No response to or inability to take outpatient oral regimen
  - Non-compliance concerns (e.g., teenagers)
  - Severe illness with nausea, vomiting, and/or high fever
  - Tuboovarian abscess
  - Pregnancy
- Possible combinations (should be administered for 14 days)
  - Cefoxitin or cefotetan plus doxycycline
  - Clindamycin plus gentamicin
  - In the case of tuboovarian abscess: Add oral metronidazole or clindamycin (to enhance anaerobic coverage).
- Switch to oral therapy with doxycycline after clinical improvement.

It is better to overtreat rather than delay treatment if PID is suspected.

Complications

Short-term complications
- Pelvic peritonitis
- Fitz-Hugh-Curtis syndrome (perihepatitis)
  - Inflammation of the liver capsule
  - Characterized by violin-string-like adhesions extending from the peritoneum to the liver
- Tubo-ovarian abscess
  - A confined pus collection of the uterine adnexa
  - May spread to adjacent organs (e.g., bladder, bowel)
Long-term complications
- Infertility: caused by adnexitis, adhesions of the fallopian tubes and ovaries, and tubal scarring, which result in impaired ciliary function and tubal occlusion
- Ectopic pregnancy
- Chronic pelvic pain
- Hydrosalpinx/pyosalpinx: accumulation of fluid/pus in the fallopian tubes due to chronic inflammation and consequent stenosis
- Chronic salpingitis

Fitz-Hugh-Curtis syndrome (perihepatitis)

We list the most important complications. The selection is not exhaustive.

References

2015 Sexually Transmitted Diseases Treatment Guidelines - Pelvic Inflammatory Disease (PID). https://www.cdc.gov/std/tg2015/pid.htm. Updated: June 4, 2015. Accessed: July 3, 2017.
Sweet RL, Gibbs RS. Infectious Diseases of the Female Genital Tract. Lippincott Williams & Wilkins ; 2012
Gradison M. Pelvic inflammatory disease.. Am Fam Physician. 2012; 85 (8): p.791-6.
Van de Wijgert JHHM, Jespers V. The global health impact of vaginal dysbiosis. Res Microbiol. 2017; 168 (9-10): p.859-864.doi: 10.1016/j.resmic.2017.02.003 . | Open in Read by QxMD
Pelvic Inflammatory Disease (PID). http://www.merckmanuals.com/professional/gynecology-and-obstetrics/vaginitis,-cervicitis,-and-pelvic-inflammatory-disease-pid/pelvic-inflammatory-disease-pid. Updated: January 1, 2015. Accessed: April 9, 2017.
Pelvic Inflammatory Disease (PID) Statistics. https://www.cdc.gov/std/pid/stats.htm. Updated: January 27, 2017. Accessed: April 9, 2017.
Ross J, Chacko MR. Pelvic inflammatory disease: Clinical manifestations and diagnosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/pelvic-inflammatory-disease-clinical-manifestations-and-diagnosis?source=see_link. Last updated: June 13, 2016. Accessed: February 17, 2017.
Jaiyeoba O, Soper DE. A Practical Approach to the Diagnosis of Pelvic Inflammatory Disease. Infect Dis Obstet Gynecol. 2011; 2011: p.1-6.doi: 10.1155/2011/753037 . | Open in Read by QxMD
Bieber EJ, Horowitz IR, Sanfilippo JS. Clinical Gynecology. ScienceDirect ; 2006
Lachiewicz MP, Moulton LJ, Jaiyeoba O. Pelvic surgical site infections in gynecologic surgery.. Infect Dis Obstet Gynecol. 2015; 2015: p.614950.doi: 10.1155/2015/614950 . | Open in Read by QxMD
Cervicitis. https://medlineplus.gov/ency/article/001495.htm. Updated: January 27, 2020. Accessed: September 30, 2020.
Mushlin SB, Greene HL. Decision Making in Medicine. Elsevier Health Sciences ; 2009
Pelvic Inflammatory Disease (PID). https://www.acog.org/patient-resources/faqs/gynecologic-problems/pelvic-inflammatory-disease. . Accessed: September 30, 2020.
Fitz Hugh Curtis Syndrome. https://rarediseases.org/rare-diseases/fitz-hugh-curtis-syndrome/. Updated: April 9, 2017. Accessed: April 9, 2017.

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