Diagnosis and Treatment of Pelvic Inflammatory Disease (PID)
The diagnosis of PID should be made when sexually active women present with lower abdominal pain, adnexal tenderness, and cervical motion tenderness, and empiric broad-spectrum antibiotic therapy should be initiated immediately to prevent long-term reproductive sequelae. 1
Diagnostic Criteria
Minimum 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 mucopurulent discharge
- Presence of white blood cells (WBCs) on saline microscopy of vaginal secretions
- Elevated erythrocyte sedimentation rate (ESR)
- Elevated C-reactive protein (CRP)
- Laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis 1
Definitive Diagnostic Criteria
- Endometrial biopsy with histopathologic evidence of endometritis
- Transvaginal sonography showing thickened, fluid-filled tubes or tubo-ovarian complex
- Laparoscopic abnormalities consistent with PID 2
Diagnostic Testing
For all suspected cases of PID, obtain:
- Cervical cultures for N. gonorrhoeae
- Cervical culture or non-culture test for C. trachomatis
- Pregnancy test (urine or serum β-hCG)
- Complete blood count with differential
- Urinalysis 1
Imaging
- Transvaginal ultrasound is the first-line imaging modality
- CT is reserved for cases with nonspecific presentation or when gynecologic and non-gynecologic causes cannot be distinguished 1
Treatment Approach
Indications for Hospitalization
- Uncertain diagnosis with possible surgical emergencies (appendicitis, ectopic pregnancy)
- Suspected tubo-ovarian abscess
- Pregnancy
- Adolescent patients (compliance concerns)
- HIV infection
- Severe illness, nausea, or vomiting preventing outpatient management
- Inability to follow or tolerate outpatient regimen 2
Antibiotic Therapy
PID treatment must provide empiric, broad-spectrum coverage of likely pathogens including:
- N. gonorrhoeae
- C. trachomatis
- Gram-negative facultative bacteria
- Anaerobes
- Streptococci 1
Note: When treating PID, appropriate anti-chlamydial coverage must be added as cephalosporins have no activity against C. trachomatis 3, 4
Follow-up
- Evaluation within 48-72 hours is essential to assess clinical improvement
- Failure to improve within this timeframe should prompt reconsideration of alternative diagnoses 1
Complications of Untreated PID
- Tubal factor infertility
- Ectopic pregnancy
- Chronic pelvic pain
- Tubo-ovarian abscess 1
High-Risk Groups
- Young, sexually active women
- Women with multiple sexual partners
- Intrauterine contraceptive device users
- History of sexually transmitted infections 1
Important Clinical Considerations
- Maintain a low threshold for diagnosis, as PID is often underdiagnosed due to mild or nonspecific symptoms
- Even mild or atypical PID can cause serious reproductive sequelae
- Initiate treatment as soon as the presumptive diagnosis is made, as prevention of long-term sequelae is directly linked to immediate administration of appropriate antibiotics 2, 1
- Partner treatment is necessary to prevent reinfection 1
The polymicrobial nature of PID requires comprehensive antibiotic coverage, and early intervention is crucial to prevent serious long-term reproductive complications. Clinicians should maintain a high index of suspicion in sexually active women presenting with lower abdominal pain.