Pelvic Inflammatory Disease (PID)

Pelvic Inflammatory Disease (PID)

Pelvic inflammatory disease is a polymicrobial infection of the upper genital tract. It primarily affects young, sexu­ally active women. The diagnosis is made clinically; no single test or study is sensitive or specific enough for a defini­tive diagnosis. Pelvic inflammatory disease should be suspected in at-risk patients who present with pelvic or lower abdominal pain with no identified etiology, and who have cervical motion, uterine, or adnexal tenderness. Chlamydia trachomatis and Neisseria gonorrhoeae are the most commonly implicated microorganisms; however, other micro­organisms may be involved. The spectrum of disease ranges from asymptomatic to life-threatening tubo-ovarian abscess. Patients should be treated empirically, even if they present with few symptoms. Most women can be treated successfully as outpatients with a single dose of a parenteral cephalosporin plus oral doxycycline, with or without oral metronidazole. Delay in treatment may lead to major sequelae, including chronic pelvic pain, ectopic pregnancy, and infertility. Hospitalization and parenteral treatment are recommended if the patient is pregnant, has human immunodeficiency virus infection, does not respond to oral medication, or is severely ill.

Pelvic inflammatory disease (PID) is a polymicrobial infection of the upper genital tract that primarily affects young, sexually active women. Approximately 10 to 20 percent of women with chlamydial or gonorrheal infections may develop PID if not treated. Women with PID have a 20 percent chance of developing infertility from tubal scarring, a  9%percent chance of having an ectopic pregnancy, and an 18 percent chance of developing chronic pelvic.

 Pathophysiology

The microorganisms that are implicated in PID are thought to spread in three ways:

·       cervix to the endometrium, through the salpinx, and into the peritoneal cavity (caus­ing endometritis, salpingitis, tubo-ovarian abscess, or pelvic peritonitis)

·       Through the lymphatic systems, such as infection of the parametrium from an intra­uterine device (IUD)

·       Through hematogenous routes, such as with tuberculosis, although this is rare. Intra-abdominally, traveling from the pain.The diagnosis of PID is based primarily on clinical evaluation. Because of the potential for significant consequences if treatment is delayed, physicians should treat on the basis of clinical judgment without waiting for con­firmation from laboratory or imaging tests. Most importantly, physicians must consider PID in the differential diagnosis in women 15 to 44 years of age who present with lower abdominal or pelvic pain and cervical motion or pelvic tenderness, even if these symptoms are mild. However, there is no single symp­tom, physical finding, or laboratory test that is sensitive or specific enough to definitively diagnose PID; clinical diagnosis alone is 87 percent sensitive and 50 percent specific.8

History and Physical Examination:

The diagnosis of PID is based primarily on clinical evaluation. Because of the potential for significant consequences if treatment is delayed, physicians should treat on the basis of clinical judgment without waiting for con­firmation from laboratory or imaging tests. Most importantly, physicians must consider PID in the differential diagnosis in women 15 to 44 years of age who present with lower abdominal or pelvic pain and cervical motion or pelvic tenderness, even if these symptoms are mild. However, there is no single symp­tom, physical finding, or laboratory test that is sensitive or specific enough to definitively diagnose PID; clinical diagnosis alone is 87 percent sensitive and 50 percent specific.8especially IUD or oral contraceptives; new, multiple, or symptomatic sex partners; a history of PID or sexually transmitted infec­tion; or recent IUD insertion. Black women may be at higher risk of PID, although there are inconsistencies among physicians in their criteria for diagnosing PID and biases in reporting. Vaginal douching also may be a risk factor.

Typically, women will present with some degree of lower abdominal or pelvic pain, although it may be mild. Other symptoms although it may be mild. Other symptoms may include a new or abnormal vaginal dis­charge, fever or chills, cramping, dyspareunia, dysuria, and abnormal or postcoital bleeding. Some women also may have low back pain, nausea, and vomiting. At-risk women who present with pelvic or lower abdominal pain and have no other identified etiology for their pain should be presumed to have PID if they have cervi­cal motion, uterine, or adnexal tenderness. The differential diagnosis also may include gastrointestinal conditions (e.g., acute appendicitis, inflammatory bowel disease); genitourinary conditions (e.g., urinary tract infection/pyelonephritis, nephrolithiasis); obstetric/gynecologic conditions (e.g., ovar­ian tumor/cyst/torsion, ectopic pregnancy); or functional pelvic pain.

Table 1. Clinical Diagnostic Criteria for PID

One or more of the following minimum criteria must be present on pelvic examination to diagnose PID:

Cervical motion tenderness

Uterine tenderness

Adnexal tenderness

The following criteria can improve the specificity of the diagnosis:

Oral temperature > 101°F (> 38.3°C)

Abnormal cervical or vaginal mucopurulent discharge

Presence of abundant numbers of white blood cells on saline microscopy of vaginal fluid

Elevated erythrocyte sedimentation rate

Elevated C-reactive protein level

Laboratory documentation of cervical infection with gonorrhea or chlamydia

The following test results are the most specific criteria for diagnosing PID:

Endometrial biopsy with histopathologic evidence of endometritis

Transvaginal sonography or magnetic resonance imaging techniques showing thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex, or Doppler studies suggesting pelvic infection (e.g., tubal hyperemia)

Laparoscopic abnormalities consistent with PID

Treatment and Management

According to consensus data, the treatment of PID must be empiric because a definitive diagnosis is rarely known or confirmed at the time of presentation. Empiric treatment may result in adverse effects from the antibiotics, including allergic reactions, gas­trointestinal symptoms, or drug resistance; however, the benefits are thought to outweigh the risks. Because these infections are polymicrobial, broad-spectrum antimi­crobial agents are recommended to cover the most likely pathogens. The antibiotics employed should be effective against C. tra­chomatis and N. gonorrhoeae even if the tests are negative, because women may have upper genital tract disease without cervical cultures that are positive for these organisms.

 The first option for oral treatment includes a one-time 250-mg intramuscular dose of ceftriax­one (Rocephin) plus 100 mg of doxycycline orally twice per day plus metronidazole 400mg twice daily for 14 days. Women with mild to moderate PID may receive outpatient oral medical treatment without increased risk of long-term sequelae. The patient’s age does not affect the response to treatment, whether inpatient or outpatient. If parenteral therapy is required, the patient should be transitioned to oral treat­ment 24 to 48 hours after clinical improve­ment. Women with tubo-ovarian abscesses should have at least 24 hours of inpatient treatment, and may require additional treatment, such as surgery. There is wide­spread emergence of N. gonorrhoeae resis­tance to fluoroquinolones, and these agents are no longer recommended unless there is a positive culture with confirmed sensitiv­ity. Otherwise, a parenteral cephalosporin is suggested.

Follow-up is important to ensure that the patient is responding to outpatient treat­ment.

Male partners of women with PID should be evaluated and treated if they have had sexual contact within 60 days of a diagnosis of PID. Men are often asymptomatic even when their partners are positive for chla­mydia or gonorrhea. To decrease the chance of recurrence, women and their partners should abstain from sexual intercourse until they have completed the course of treatment.

Women with PID should be counseled about the prevention of sexually transmitted infections and PID because there is a high risk of reinfection even when partners have been treated. Repeat testing for women with chlamydia or gonorrhea is suggested three to six months after treatment.

PID is uncommon during pregnancy, although if it occurs, it is usually within the first 12 weeks before the mucous plug can act as an adequate barrier. Pregnant women with suspected PID should be hospitalized and given parenteral antibiotics. PID dur­ing pregnancy increases the risk of preterm delivery and increases maternal morbidity.24

Women with IUDs have an increased risk of PID only within the first three weeks after insertion of the IUD. There is no evidence that suggests removal of the IUD is necessary in patients with acute PID; however, close follow-up is recommended. Data indicate no difference in outcomes of PID in women with copper IUDs versus the levonorgestrel-releasing intrauterine system (Mirena). There are insufficient data to suggest that antibiotics should be given to patients at the time of IUD insertion to decrease the risk of developing infection.25

Table 2. Oral Treatment Regimens for Pelvic Inflammatory Disease
Drug	Dosage
Option 1
Ceftriaxone (Rocephin)	250 mg IM in a single dose
plus
Doxycycline	100 mg orally twice per day for 14 days
with or without
Metronidazole (Flagyl)	400 mg orally twice per day for 14 days
Option 2
Cefoxitin plus	2 g IM in a single dose administered concurrently with probenecid (1 g orally)
Doxycycline	100 mg orally twice per day for 14 days
with or without
Metronidazole	400 mg orally twice per day for 14 days
Option 3
Other parenteral third-generation cephalosporin (e.g., ceftizoxime [Cefizox], cefotaxime [Claforan])
plus
Doxycycline	100 mg orally twice per day for 14 days
with or without
Metronidazole	400 mg orally twice per day for 14 days