What are the clinical manifestations of Pelvic Inflammatory Disease (PID)?

Clinical Manifestations of Pelvic Inflammatory Disease (PID)

Pelvic Inflammatory Disease (PID) presents with a spectrum of symptoms ranging from subtle or mild to severe, with many cases being asymptomatic or unrecognized due to nonspecific symptoms, making it essential to maintain a low threshold for diagnosis to prevent reproductive health damage. 1, 2

Primary Clinical Manifestations

Minimum Diagnostic Criteria

• Lower abdominal pain (typically bilateral, sometimes radiating to the legs) - present in 65% of cases 3, 4
• Adnexal tenderness - present in 83% of cases 4
• Cervical motion tenderness - present in 75% of cases 4

Common Symptoms

• Abnormal vaginal or cervical discharge (often purulent) - present in 68% of cases 3, 4
• Dyspareunia (especially deep) - present in 57% of cases 4
• Abnormal vaginal bleeding (postcoital, intermenstrual, breakthrough) 1, 3
• Dysuria 3
• Urinary frequency 5

Additional Clinical Findings

Supportive Diagnostic Criteria

• Fever (oral temperature >101°F/38.3°C) 1
• Mucopurulent cervical or vaginal discharge 1
• Presence of white blood cells (WBCs) on saline microscopy of vaginal secretions 1
• Elevated erythrocyte sedimentation rate (ESR) 1
• Elevated C-reactive protein (CRP) 1
• Laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis 1

Most Specific Diagnostic Criteria

• Endometrial biopsy with histopathologic evidence of endometritis 1
• Transvaginal sonography or MRI showing thickened, fluid-filled tubes with/without free pelvic fluid or tubo-ovarian complex 1, 6
• Laparoscopic abnormalities consistent with PID 1

Diagnostic Challenges

• The clinical diagnosis of acute PID is imprecise with a positive predictive value of 65-90% compared to laparoscopy 1, 2
• No single historical, physical, or laboratory finding is both sensitive and specific for diagnosis 1
• Many cases go unrecognized because:
  • Some cases are asymptomatic
  • Patients or providers fail to recognize mild or nonspecific symptoms 1, 2
  • Poor recording of signs and symptoms (only 22% of diagnosed cases met CDC criteria in one study) 4

Risk Factors to Consider

• Young, sexually active women 6
• Multiple sexual partners 6
• Intrauterine contraceptive device users 6
• History of sexually transmitted infections 6, 7

Clinical Pitfalls to Avoid

1. Underdiagnosis: Maintain a low threshold for diagnosis due to potential reproductive health damage even in mild or atypical cases 1, 2

2. Misdiagnosis: Consider alternative diagnoses for lower abdominal pain such as:

   • Ectopic pregnancy
   • Acute appendicitis
   • Functional pain 1

3. Delayed treatment: Initiate empiric treatment promptly in sexually active young women with minimum criteria, as delay contributes to inflammatory sequelae in the upper reproductive tract 1, 2

4. Incomplete evaluation: If cervical discharge appears normal and no white blood cells are found on wet prep, PID is unlikely and alternative causes should be investigated 1

5. Failure to recognize complications: Be vigilant for tubo-ovarian abscess formation, which requires more aggressive management 7

Remember that PID can lead to serious long-term sequelae including chronic pelvic pain, tubal factor infertility, ectopic pregnancy, and intra-abdominal infections if not properly diagnosed and treated 3, 6, 7.