Symptoms and Treatment of Pelvic Inflammatory Disease (PID)
Pelvic inflammatory disease (PID) is characterized by unexplained lower abdominal or pelvic pain, signs of pelvic inflammation on physical examination, and the absence of other causes that explain the symptoms, with the diagnosis relying primarily on clinical findings including bilateral adnexal tenderness and cervical motion tenderness. 1
Clinical Presentation of PID
Primary Symptoms
- Lower abdominal pain (typically bilateral)
- Adnexal tenderness on examination
- Cervical motion tenderness
Additional Symptoms and Signs
- Oral temperature >38.3°C (>101°F)
- Abnormal cervical or vaginal mucopurulent discharge
- Dyspareunia (painful intercourse)
- Abnormal vaginal bleeding (postcoital, intermenstrual, breakthrough)
- Urinary symptoms (frequency, dysuria)
Important Diagnostic Findings
- 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
Diagnostic Approach
Diagnosis of PID is challenging as no single test is both sensitive and specific enough for definitive diagnosis 1. The CDC recommends a low threshold for diagnosis due to the potential for serious sequelae.
Imaging
- Transvaginal ultrasound is the first-line imaging modality for evaluating acute lower pelvic/suprapubic pain
- Ultrasonographic findings may show thickened tubes with fluid or tubo-ovarian abscess
- CT is reserved for cases with nonspecific presentation or when gynecologic and non-gynecologic causes cannot be distinguished
Differential Diagnosis
- Acute appendicitis
- Ectopic pregnancy
- Functional pelvic pain
- Endometriosis
- Complicated ovarian cysts
- Urinary tract infections
Treatment of PID
Treatment should be initiated as soon as the presumptive diagnosis of PID is made, as prevention of long-term sequelae is directly linked to immediate administration of appropriate antibiotics. 1
Outpatient Treatment (Mild to Moderate PID)
The recommended regimen should include broad-spectrum antibiotics covering:
- N. gonorrhoeae
- C. trachomatis
- Gram-negative facultative bacteria
- Anaerobes
- Streptococci
Typical outpatient regimens include:
- Extended-spectrum cephalosporin (such as ceftriaxone IM) 2 plus either:
- Doxycycline
- Azithromycin
- Metronidazole is often added to cover anaerobes
Inpatient Treatment (Severe PID)
Indications for hospitalization:
- Severe symptoms
- Tubo-ovarian abscess
- Inability to follow or tolerate outpatient regimen
- Failure to improve within 48-72 hours of outpatient therapy
Parenteral regimens typically include:
- Cefoxitin IV 3 or another broad-spectrum antibiotic with activity against:
- Polymicrobial flora
- Gram-negative aerobes
- Anaerobes
Important Treatment Considerations
- Evaluation within 48-72 hours is essential to assess clinical improvement
- Failure to improve within 48-72 hours should prompt reconsideration of alternative diagnoses
- Partner treatment is necessary to prevent reinfection
- When C. trachomatis is suspected, appropriate anti-chlamydial coverage should be added 3, 2
- Duration of outpatient treatment is typically 14 days
Complications and Long-Term Sequelae
Untreated PID can lead to severe complications:
- Tubal factor infertility
- Ectopic pregnancy
- Chronic pelvic pain
- Tubo-ovarian abscess
Risk Factors for PID
- Young, sexually active women
- Multiple sexual partners
- Intrauterine contraceptive device use
- History of sexually transmitted infections
Clinical Pitfalls to Avoid
- Delayed diagnosis: Many women with PID may be asymptomatic or have mild symptoms. Maintain a low threshold for diagnosis.
- Incomplete treatment: Ensure full course of antibiotics is completed by both patient and partner(s).
- Inadequate follow-up: Always reassess within 48-72 hours to confirm clinical improvement.
- Missing C. trachomatis: Remember that cephalosporins have no activity against Chlamydia trachomatis, so appropriate coverage must be added.
- Overlooking alternative diagnoses: If no improvement occurs within 48-72 hours, reconsider diagnoses like ectopic pregnancy or appendicitis.