What are the symptoms and treatment of Pelvic Inflammatory Disease (PID)?

Symptoms and Treatment of Pelvic Inflammatory Disease (PID)

PID should be diagnosed clinically when patients present with lower abdominal tenderness, adnexal tenderness, and cervical motion tenderness, with no other causes identified, and treatment should be initiated promptly with broad-spectrum antibiotics to prevent reproductive damage. 1

Clinical Presentation and Diagnosis

Key Symptoms

• Lower abdominal pain (typically bilateral)
• Abnormal vaginal or cervical discharge (often purulent)
• Cervical motion tenderness
• Adnexal tenderness
• Additional symptoms may include:
  • Fever (>38.3°C/101°F)
  • Abnormal vaginal bleeding (postcoital, intermenstrual, breakthrough)
  • Deep dyspareunia (painful intercourse)
  • Dysuria

Diagnostic Approach

The CDC recommends maintaining a low threshold for diagnosis due to the potential for reproductive health damage, even in mild or atypical cases 1. Many PID cases go unrecognized due to asymptomatic or subtle presentations 2.

Minimum Diagnostic Criteria:

• Lower abdominal tenderness
• Adnexal tenderness
• Cervical motion tenderness

Additional Criteria to Increase Diagnostic Specificity:

• Oral temperature >38.3°C (>101°F)
• Abnormal cervical or vaginal discharge
• Elevated erythrocyte sedimentation rate (ESR)
• Elevated C-reactive protein (CRP)
• Laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis 2, 1

Diagnostic Tests

For all suspected PID cases, perform:

• Cervical cultures or nucleic acid amplification tests for N. gonorrhoeae and C. trachomatis
• Complete blood count
• C-reactive protein
• Pregnancy test (to rule out ectopic pregnancy) 1

Diagnostic Challenges

• Clinical diagnosis has a positive predictive value of 65-90% compared to laparoscopy 1
• No single finding is both sensitive and specific for diagnosis 2
• Many cases go unrecognized due to subtle presentations or failure to recognize mild symptoms 2, 1

Treatment

Empiric Treatment

Treatment should be initiated promptly upon clinical suspicion to prevent long-term sequelae 1. PID therapy must provide broad-spectrum coverage of likely pathogens including N. gonorrhoeae, C. trachomatis, Gram-negative facultative bacteria, anaerobes, and streptococci 2.

Antibiotic Regimens

For PID caused by N. gonorrhoeae, ceftriaxone is indicated 3. Since PID has a polymicrobial etiology, treatment should be broad-spectrum 4.

Outpatient Treatment (Mild to Moderate PID):

• IM ceftriaxone plus oral doxycycline with or without metronidazole 1, 5
• Duration is typically 14 days 5

Inpatient Treatment (Severe PID):

• Parenteral broad-spectrum antibiotics with activity against polymicrobial flora, particularly Gram-negative aerobes and anaerobes 6

Important Treatment Considerations

• When cephalosporins are used in PID treatment and Chlamydia trachomatis is suspected, appropriate antichlamydial coverage should be added 3
• Partner treatment is necessary to prevent reinfection 1
• Patients should avoid sexual intercourse until they and their partner(s) have completed treatment 5

Follow-up and Complications

Follow-up

• Evaluation within 48-72 hours is essential to assess clinical improvement 1, 7
• Failure to improve clinically within this timeframe should prompt reconsideration of the diagnosis 1

Potential Complications

Untreated PID can lead to:

• Tubal factor infertility
• Ectopic pregnancy
• Chronic pelvic pain
• Tubo-ovarian abscess 1, 4, 8

Common Pitfalls to Avoid

• Relying on a single clinical finding
• Waiting for fever or elevated inflammatory markers before diagnosis
• Failing to consider PID in women with subtle symptoms
• Overlooking the diagnosis in adolescents 1
• Inadequate antibiotic coverage for the polymicrobial nature of PID 6