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

Signs and Symptoms of Pelvic Inflammatory Disease (PID)

The diagnosis of PID should be considered in sexually active women who present with pelvic or lower abdominal pain, particularly when accompanied by cervical motion tenderness or uterine/adnexal tenderness, as these are the minimum diagnostic criteria. 1

Primary Diagnostic Criteria

• Minimum criteria for empiric PID treatment in sexually active women at risk for STDs:

  • Uterine/adnexal tenderness OR
  • Cervical motion tenderness 2, 1

• Common presenting symptoms:

  • Lower abdominal pain (typically bilateral) 2, 3
  • Abnormal vaginal or cervical discharge (often purulent) 2, 3
  • Dyspareunia (painful intercourse) 2, 3
  • Abnormal vaginal bleeding (postcoital, intermenstrual, or breakthrough) 2, 3
  • Dysuria 3

Additional Supporting Criteria

• Clinical findings that enhance diagnostic specificity:
  • Oral temperature >101°F (>38.3°C) 2, 1
  • Abnormal cervical or vaginal mucopurulent discharge 2, 1
  • Presence of white blood cells (WBCs) on saline microscopy of vaginal secretions 2, 1
  • Elevated erythrocyte sedimentation rate (ESR) 2, 1
  • Elevated C-reactive protein (CRP) 2, 1
  • Laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis 2, 1

Definitive Diagnostic Criteria

• Most specific criteria for diagnosing PID (warranted in selected cases):
  • Endometrial biopsy with histopathologic evidence of endometritis 2
  • Transvaginal sonography or MRI showing thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex 2, 4
  • Laparoscopic abnormalities consistent with PID 2

Important Clinical Considerations

• Many PID cases go unrecognized or undiagnosed because:

  • Some cases are asymptomatic 2, 5
  • Symptoms may be mild or nonspecific 2, 5
  • Patients or healthcare providers may fail to recognize implications of subtle symptoms 2

• Common diagnostic pitfalls:

  • No single finding is both sensitive and specific for PID diagnosis 2
  • Normal cervical discharge and absence of WBCs on wet prep make PID diagnosis unlikely 2
  • Requiring multiple criteria increases specificity but reduces sensitivity 2

• Clinical approach:

  • Maintain a low threshold for diagnosis due to potential reproductive health damage 2
  • Consider PID in patients with pelvic tenderness and signs of lower genital tract inflammation 2
  • Early treatment is crucial to prevent complications like infertility, ectopic pregnancy, and chronic pelvic pain 6, 5

• Microbial etiology:

  • Most commonly caused by Chlamydia trachomatis and Neisseria gonorrhoeae (30-50% of cases) 4, 5
  • Also associated with Mycoplasma genitalium and bacterial vaginosis-associated microorganisms 7, 5

Healthcare providers should maintain a high index of suspicion for PID in sexually active women with pelvic pain or other genital tract symptoms, as early diagnosis and treatment are essential for preventing long-term sequelae affecting reproductive health.