From the Guidelines
Pelvic inflammatory disease (PID) is primarily a clinical diagnosis based on signs and symptoms. Diagnosis typically relies on the presence of lower abdominal pain along with cervical motion tenderness, adnexal tenderness, or uterine tenderness on pelvic examination, as recommended by the Centers for Disease Control and Prevention in their 2002 guidelines 1. Additional supporting findings include:
- Fever above 38.3°C (101°F)
- Abnormal cervical or vaginal discharge
- Elevated erythrocyte sedimentation rate or C-reactive protein
- Documented infection with Neisseria gonorrhoeae or Chlamydia trachomatis
Laboratory tests like nucleic acid amplification tests for gonorrhea and chlamydia should be performed, but treatment should not be delayed while awaiting results, as emphasized in the 2002 guidelines 1. Imaging studies such as transvaginal ultrasound or MRI may help exclude other diagnoses but are not required for diagnosis. The clinical approach is justified because PID can cause serious complications like infertility, ectopic pregnancy, and chronic pelvic pain if treatment is delayed, as noted in the 1998 guidelines 1. Therefore, clinicians should maintain a low threshold for diagnosis and promptly initiate empiric antibiotic therapy when PID is suspected, typically with regimens covering a broad spectrum of potential pathogens including ceftriaxone plus doxycycline, with or without metronidazole, as recommended in the 2002 guidelines 1.
The most specific criteria for diagnosing PID include endometrial biopsy with histopathologic evidence of endometritis, transvaginal sonography or magnetic resonance imaging techniques showing thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex, and laparoscopic abnormalities consistent with PID, as outlined in the 2002 guidelines 1. A diagnostic evaluation that includes some of these more extensive studies may be warranted in certain cases.
It is essential to note that the optimal treatment regimen and long-term outcome of early treatment of women with asymptomatic or atypical PID are unknown, as stated in the 2002 guidelines 1. However, the potential for damage to the reproductive health of women even by apparently mild or atypical PID justifies a low threshold for diagnosis and prompt initiation of empiric antibiotic therapy, as emphasized in the 1998 guidelines 1 and the 2002 guidelines 1.
From the Research
Diagnosis of Pelvic Inflammatory Disease
- Pelvic inflammatory disease (PID) is generally a clinical diagnosis, representing a diagnostic challenge 2.
- The diagnosis is made primarily on clinical suspicion, and empiric treatment is recommended in sexually active young women or women at risk for sexually transmitted infections who have unexplained lower abdominal or pelvic pain and cervical motion, uterine, or adnexal tenderness on examination 3.
- A definitive diagnosis of PID is made by laparoscopic visualization of inflamed, purulent fallopian tubes, but this is not always possible 2.
Clinical Features and Laboratory Findings
- The following clinical features are suggestive of a diagnosis of PID: bilateral lower abdominal tenderness, abnormal vaginal or cervical discharge, fever (higher than 38 degrees C), abnormal vaginal bleeding, dyspareunia, cervical motion tenderness and adnexal tenderness, with or without a palpable mass 4.
- Laboratory findings may include the presence of excess leucocytes, elevated erythrocyte sedimentation rate or C-reactive protein 4.
- Transvaginal ultrasound scanning may be helpful, and its sensitivity is up to 85% 4.
- Magnetic resonance imaging can be helpful in a final diagnosis in 95% of cases 4.
Challenges in Diagnosis
- In 15-30% of suspected cases, there is no laparoscopic evidence of disease 4.
- PID can be acute, chronic, or subclinical and is often underdiagnosed 3.
- The etiology of PID is complex, and a wide range of potential causal pathogens have been associated with the disease, making diagnosis and treatment challenging 5.