Pelvic inflammatory disease is an acute ascending polymicrobial infection of the female gynaecological tract that is frequently associated with Neisseria gonorrhoeae or Chlamydia trachomatis.
Symptoms and physical findings vary widely and may include lower abdominal tenderness, adnexal tenderness, and cervical motion tenderness. Fever and cervical or vaginal discharge may also be present.
Diagnosis may be difficult because symptoms range from absent to severe and may be non-specific. Possible laboratory findings include abundant white blood cells on saline microscopy of vaginal secretions, elevated erythrocyte sedimentation rate, elevated C-reactive protein, and laboratory documentation of cervical infection with Neisseria gonorrhoeae or Chlamydia trachomatis. Laparoscopy is the definitive procedure but is invasive and is not recommended for routine diagnosis.
Antibiotic treatment should be initiated in patients who are sexually active and who have pelvic pain, cervical motion tenderness, or adnexal or uterine tenderness for which no other cause can be found. Patients may need hospitalisation and parenteral antibiotics.
Complications include tubo-ovarian abscess and subsequent infertility or ectopic pregnancy due to scarred or obstructed fallopian tubes.
Pelvic inflammatory disease (PID) comprises a spectrum of inflammatory disorders of the upper female genital tract, including any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis. Sexually transmitted organisms, especially Neisseria gonorrhoeae and Chlamydia trachomatis, are implicated in many cases; however, micro-organisms that comprise the vaginal flora (e.g., anaerobes, Gardnerella vaginalis, Haemophilus influenzae, enteric gram-negative rods, and Streptococcus agalactiae) have also been associated with PID. In addition, cytomegalovirus (CMV), Trichomonas vaginalis, Mycoplasma hominis, Mycoplasma genitalium, and Ureaplasma urealyticum might be associated with some cases of PID. Symptoms include fever, vomiting, back pain, dyspareunia, and bilateral lower abdominal pain, as well as symptoms of lower genital tract infection such as abnormal vaginal odour, itching, bleeding, or discharge. In some instances, symptoms are mild or even absent.
History and exam
Key diagnostic factors
- presence of risk factors
- uterine tenderness
- cervical motion tenderness
- adnexal tenderness
Other diagnostic factors
- lower abdominal pain
- abnormal cervical or vaginal discharge
- prior infection with chlamydia or gonorrhoea
- young age at onset of sexual activity
- unprotected sexual intercourse with multiple sexual partners
- prior history of PID
- IUD use
- low socio-economic status
- current vaginal douching
- intercourse during menstruation
1st investigations to order
- white blood cell count
- polymorphonuclear cells on wet mount of vaginal secretions
- genetic probe or culture of vaginal secretions for Neisseria gonorrhoeae and Chlamydia trachomatis
- nucleic acid amplification test for Mycoplasma genitalium
Investigations to consider
- serum erythrocyte sedimentation rate (ESR)
- transvaginal ultrasound
- pelvic CT
- pelvic MRI
- endometrial biopsy
suspected or confirmed mild-to-moderate PID at initial presentation
severe PID, complications, or no response to intramuscular/oral therapy
Madhavi Manoharan, MD, FRCOG
Consultant Obstetrician and Gynaecologist
Integra Healthcare Ltd
MM declares that she has no competing interests.
Dr Madhavi Manoharan would like to gratefully acknowledge Dr Dan Selo-Ojeme and Dr Susan Arjmand, previous contributors to this topic.
DSO and SA declare that they have no competing interests.
Bradford Fenton, MD
Department of Obstetrics and Gynecology
Summa Health System
BF declares that he has no competing interests.
Edmond Edi-Osagie, MBBS, MRCOG, MD
Central Manchester University Hospitals
St. Mary's Hospital
EEO declares that he has no competing interests.
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