From the Guidelines
If a patient with presumed Pelvic Inflammatory Disease (PID) has worsening abdominal pain, they should be immediately referred to the emergency department for evaluation, as this could indicate treatment failure, development of a tubo-ovarian abscess, or another serious complication. The patient should not continue outpatient management when symptoms are progressing. In the emergency setting, the patient will likely need intravenous antibiotics, and imaging studies like ultrasound or CT scan will be performed to evaluate for abscess formation or other complications, as suggested by the 2017 WSES guidelines for management of intra-abdominal infections 1. Worsening pain in PID can indicate spreading infection, rupture of an abscess, or development of peritonitis, all of which require prompt intervention. Some key points to consider in management include:
- The possibility of tubo-ovarian abscess, which may require surgical drainage if not responsive to antibiotics, as recommended by the guidelines 1.
- The importance of broad-spectrum antibiotics, considering the potential causes of PID, including Neisseria gonorrhoeae, Chlamydia trachomatis, and other microorganisms.
- The need for close monitoring for signs of sepsis or other complications that may necessitate urgent surgical intervention. Given the potential for serious complications, a low threshold for hospitalization is advisable, especially if the patient presents with high fever, severe nausea/vomiting, or signs of sepsis accompanying the worsening abdominal pain.
From the Research
Patient with Presumed PID and Worsening Abdominal Pain
- If a patient with presumed Pelvic Inflammatory Disease (PID) has worsening abdominal pain, it is essential to reassess the patient to exclude other serious conditions such as acute appendicitis, ectopic pregnancy, or complications of pregnancy 2.
- The patient should be carefully evaluated, and if PID is suspected, treatment for gonococcal, chlamydial, and anaerobic bacterial infection should be initiated 2.
- Imaging studies, such as computed tomography (CT) or ultrasonography (US), may be necessary to facilitate an accurate and reproducible diagnosis in urgent conditions 3.
- CT is the most sensitive technique for depicting free intraperitoneal air and is valuable for determining the cause of the perforation, while US is the primary imaging technique of choice for patients clinically suspected of having acute cholecystitis 3.
- Diagnostic pathways can improve the quality of the diagnostic process, but the use of routine imaging has not been proven to reduce complication rates or hospital length of stay 4.
- Close reassessment of pain, vital signs, and physical examination are necessary to ensure safe discharge, and strict verbal and written return precautions should be provided to the patient 5.
- Antibiotic treatment should be started within the first hour after recognition of sepsis, and administration of opioids (analgesics) can decrease the intensity of the pain without affecting the accuracy of physical examination 6.