What is the evaluation and treatment approach for pelvic inflammatory disease?

Evaluation and Treatment Approach for Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) should be diagnosed using a low threshold approach due to its potential for serious reproductive health consequences, with treatment initiated based on minimum clinical criteria of lower abdominal tenderness, bilateral adnexal tenderness, and cervical motion tenderness. 1

Diagnostic Approach

Minimum Criteria for Clinical Diagnosis

• Lower abdominal tenderness 1
• Bilateral adnexal tenderness 1
• Cervical motion tenderness 1

Additional Criteria to Increase Diagnostic Specificity

Routine Criteria:

• Oral temperature >38.3°C 1
• Abnormal cervical or vaginal discharge 1
• Elevated erythrocyte sedimentation rate and/or C-reactive protein 1
• Laboratory evidence of cervical infection with N. gonorrhoeae or C. trachomatis 1

Elaborate Criteria:

• Histopathologic evidence on endometrial biopsy 1
• Tubo-ovarian abscess on sonography 1, 2
• Laparoscopic abnormalities consistent with PID 1

Recommended Tests for All Suspected Cases

• Cervical cultures for N. gonorrhoeae 1
• Cervical culture or non-culture test for C. trachomatis 1

Treatment Approach

Outpatient Treatment (Mild-to-Moderate PID)

• Extended-spectrum cephalosporin (single IM dose of ceftriaxone) plus doxycycline with or without metronidazole 1, 3, 4
• Complete all medication regardless of symptom improvement 1

Inpatient Treatment Indications

• Clinically severe disease 1, 4
• Pregnancy 3
• HIV infection 3
• No response to oral medication 3
• Presence of tubo-ovarian abscess 2, 4

Management of Sex Partners

• Treatment of sex partners is imperative to prevent reinfection 1
• Partners should be empirically treated with regimens effective against C. trachomatis and N. gonorrhoeae 1
• Emphasize the need to avoid sex until treatment is completed 1

Important Clinical Considerations

Diagnostic Challenges

• PID diagnosis is imprecise with no single test being both sensitive and specific 1, 5
• Many episodes of PID go unrecognized due to mild or nonspecific symptoms 1, 5
• Using minimum criteria may exclude some women with PID; clinicians should not withhold therapy when PID is suspected despite not meeting all criteria 1

Follow-Up

• Careful follow-up is necessary 1
• If no clinical improvement occurs within 48-72 hours, consider alternative diagnoses (e.g., appendicitis, endometriosis, ruptured ovarian cyst, adnexal torsion) 1
• Consider alternative or additional antimicrobial therapy if no improvement 1

Prevention of Sequelae

• Early treatment is essential to prevent long-term sequelae including infertility, ectopic pregnancy, and chronic pelvic pain 5, 3, 4
• Screening for and treatment of Chlamydia infection can prevent PID 5, 3

Patient Education

• Explain the nature of the disease and importance of treatment compliance 1
• Review potential side effects of medications 1
• Discuss the purpose of follow-up evaluation 1
• Emphasize the need for partner treatment 1

Antimicrobial Coverage Considerations

• PID therapy must provide broad-spectrum coverage against likely pathogens 1
• Coverage should include N. gonorrhoeae, C. trachomatis, gram-negative facultative bacteria, anaerobes, and streptococci 1
• When treating PID with cephalosporins, appropriate anti-chlamydial coverage must be added as cephalosporins have no activity against C. trachomatis 6, 7
• Consider coverage for anaerobic organisms in most cases 8, 9, 4