What is the recommended workup and treatment for Pelvic Inflammatory Disease (PID)?

Workup and Treatment for Pelvic Inflammatory Disease (PID)

The recommended workup for PID requires a low threshold for diagnosis using the minimum clinical criteria of lower abdominal tenderness, bilateral adnexal tenderness, and cervical motion tenderness, with treatment initiated immediately using broad-spectrum antibiotics that cover N. gonorrhoeae, C. trachomatis, and anaerobes. 1

Diagnostic Approach

• Diagnosis should be made using a "low threshold" approach due to the potential for reproductive damage even with mild cases 2

• Minimum clinical criteria for PID diagnosis include:

  • Lower abdominal tenderness 2, 1
  • Bilateral adnexal tenderness 2, 1
  • Cervical motion tenderness 2, 1

• Additional criteria to increase diagnostic specificity include:

  • Oral temperature >38.3°C 2, 1
  • Abnormal cervical or vaginal discharge 2, 1
  • Elevated erythrocyte sedimentation rate and/or C-reactive protein 2, 1
  • Culture or non-culture evidence of cervical infection with N. gonorrhoeae or C. trachomatis 2, 1

• Tests recommended for all suspected cases of PID:

  • Cervical cultures for N. gonorrhoeae 2
  • Cervical culture or non-culture test for C. trachomatis 2

• More elaborate diagnostic methods when needed:

  • Histopathologic evidence on endometrial biopsy 2
  • Tubo-ovarian abscess on sonography 2
  • Laparoscopy 2

Treatment Approach

Outpatient Treatment (Mild to Moderate PID)

• Recommended regimens:
  • Ceftriaxone 250 mg IM single dose 1, 3
  • PLUS Doxycycline 100 mg orally twice daily for 14 days 1
  • WITH OR WITHOUT Metronidazole 500 mg orally twice daily for 14 days 1

Inpatient Treatment Indications

• Hospitalization is recommended for:
  • Clinically severe disease 1
  • Pregnancy 2, 1
  • HIV infection 2, 1
  • No response to oral medication 1
  • Presence of tubo-ovarian abscess 1, 4
  • Surgical emergencies that cannot be excluded 5
  • Adolescent patients 5
  • Inability to tolerate outpatient regimen 5

Management of Sex Partners

• Treatment of sex partners is imperative to prevent reinfection and complications 2, 1
• Sex partners should be empirically treated with regimens effective against both C. trachomatis and N. gonorrhoeae, regardless of the pathogens isolated from the infected woman 2
• Special arrangements should be made to provide care for male sex partners in clinical settings where only women are seen 2
• Patients should avoid sex until treatment is completed 2, 1

Follow-Up and Monitoring

• Clinical improvement should be evident within 48-72 hours of starting treatment 2, 1
• If no improvement occurs within this timeframe:
  • Consider alternative diagnoses (e.g., appendicitis, endometriosis, ruptured ovarian cyst, adnexal torsion) 2
  • Consider alternative or additional antimicrobial therapy 2
• Microbiologic re-examination is recommended 7-10 days after completing therapy due to risk of persistent infection 2
• Some experts recommend rescreening for C. trachomatis and N. gonorrhoeae 4-6 weeks after completing therapy 2

Important Clinical Considerations

• PID diagnosis is imprecise, with no single test being both sensitive and specific 2, 1
• Many episodes of PID go unrecognized due to mild or nonspecific symptoms 2, 1
• The polymicrobial nature of PID requires broad-spectrum coverage against:
  • N. gonorrhoeae 6
  • C. trachomatis 6
  • M. genitalium 6
  • Anaerobes and other bacteria associated with bacterial vaginosis 6
• Long-term sequelae of untreated or inadequately treated PID include:
  • Infertility 7, 8
  • Ectopic pregnancy 7, 8
  • Chronic pelvic pain 7, 8

Patient Education

• Emphasize the need for taking all medication, regardless of symptom improvement 2
• Review potential side effects and contraindications of prescribed medications 2
• Discuss potential compliance problems 2
• Explain the purpose of follow-up evaluation 2
• Emphasize the need to avoid sex until treatment is completed 2
• Stress the importance of partner evaluation and treatment 2

Prevention Strategies

• Regular, consistent use of condoms should be strongly encouraged 2
• Early detection and effective treatment of C. trachomatis and N. gonorrhoeae infections can reduce PID risk 2
• Screening for chlamydial infection can prevent PID 7
• Prompt response to symptoms of chlamydial or gonococcal infection can reduce PID risk 2