What is pelvic inflammatory disorder (PID)?

Pelvic Inflammatory Disease (PID)

Pelvic inflammatory disease (PID) is a spectrum of inflammatory disorders of the upper female genital tract, including any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis, primarily caused by sexually transmitted organisms, especially Neisseria gonorrhoeae and Chlamydia trachomatis. 1

Definition and Etiology

• PID is an infection of the upper genital tract occurring predominantly in sexually active young women 2
• Primary causative organisms include N. gonorrhoeae and C. trachomatis, but PID can also involve other microorganisms that comprise the vaginal flora 1:
  • Anaerobes
  • Gardnerella vaginalis
  • Haemophilus influenzae
  • Enteric gram-negative rods
  • Streptococcus agalactiae
• Mycoplasma hominis, Ureaplasma urealyticum, and cytomegalovirus may also be etiologic agents in some cases 1

Clinical Presentation and Diagnosis

PID is difficult to diagnose due to the wide variation in symptoms and signs. Many women present with subtle or mild symptoms that may not be readily recognized as PID 1.

Minimum Criteria for Clinical Diagnosis (treat if present)

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

Additional Criteria to Increase Diagnostic Specificity

• Routine criteria 1:

  • Oral temperature >38.3°C (101°F)
  • Abnormal cervical or vaginal mucopurulent discharge
  • Elevated erythrocyte sedimentation rate and/or C-reactive protein
  • Laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis

• Elaborate criteria 1:

  • Histopathologic evidence on endometrial biopsy
  • Tubo-ovarian abscess on sonography
  • Laparoscopy findings consistent with PID

Diagnostic Challenges

• Clinical diagnosis of PID has a positive predictive value of 65-90% compared with laparoscopy 1
• No single historical, physical, or laboratory finding is both sensitive and specific for the diagnosis of PID 1
• A "low threshold for diagnosis" is recommended due to potential damage to reproductive health even in mild cases 1

Recommended Tests

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

Treatment

Treatment must provide empiric, broad-spectrum coverage of likely pathogens, including N. gonorrhoeae, C. trachomatis, anaerobes, gram-negative facultative bacteria, and streptococci 1.

Outpatient Treatment (Mild to Moderate PID)

• Single intramuscular injection of a recommended cephalosporin followed by oral doxycycline for 14 days 2
• Additionally, metronidazole for 14 days is recommended in cases of bacterial vaginosis, trichomoniasis, or recent uterine instrumentation 2

Inpatient Treatment Indications

Hospitalization for parenteral antibiotics is recommended for patients who are 2:

• Pregnant
• Severely ill
• Not responding to outpatient treatment
• Have tubo-ovarian abscess
• When surgical emergencies cannot be excluded

Treatment Response

• Patients should demonstrate substantial clinical improvement within 72 hours after starting therapy 1
• Those who do not improve within this time usually require hospitalization, additional diagnostic tests, and possible surgical intervention 1
• Parenteral therapy may be discontinued 24 hours after clinical improvement, with oral doxycycline continued to complete 14 days of therapy 1

Management of Sex Partners

• Male sex partners should be examined and treated if they had sexual contact with the patient during the 60 days before onset of symptoms 1
• Treatment of sex partners is imperative to prevent reinfection and complications 1
• Expedited partner treatment is recommended where legal 2

Complications and Sequelae

Untreated PID can lead to serious long-term consequences 3, 2, 4:

• Chronic pelvic pain
• Infertility
• Ectopic pregnancy
• Tubo-ovarian abscess
• Hydrosalpinx
• Recurrent PID

Special Considerations

HIV Infection

• PID among immunocompromised women may be more clinically severe and more refractory to treatment 1
• HIV-infected women with PID may be less likely to have elevated white blood cell counts but more likely to have tubo-ovarian abscesses requiring surgical intervention 1
• HIV-infected women who develop PID should be followed closely with early hospitalization and IV therapy with a recommended antibiotic regimen 1

Prevention

• Screening for C. trachomatis and N. gonorrhoeae in all women younger than 25 years and those at risk or pregnant 2
• Intensive behavioral counseling for adolescents and adults at increased risk of sexually transmitted infections 2
• Regular, consistent use of condoms for sexually active individuals 1

Follow-Up

• If no clinical improvement has occurred at 48-72 hours, alternate diagnoses (e.g., appendicitis, endometriosis, ruptured ovarian cyst, or adnexal torsion) should be reconsidered 1
• Use of alternate or additional antimicrobial therapy should also be considered if no improvement 1