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Pelvic Inflammatory
Disease Clinical Presentation
Updated: May 03, 2019
Author: Kristi A Tough DeSapri, MD; Chief Editor: Nicole W Karjane, MD more...

PRESENTATION

History
The classic patient at high risk for pelvic inflammatory disease (PID) is a menstruating woman
younger than 25 years who has multiple sex partners, does not use contraception, and lives in an
area with a high prevalence of sexually transmitted infections (STIs). Young age at first intercourse
is also a risk factor for PID. Use of an intrauterine device (IUD) for contraception confers a relative
risk of 2.0-3.0 for the first 4 months following insertion, but risk subsequently decreases to baseline.
Follow-up is recommended within the first month after IUD insertion.

Women who are not sexually active have a very low incidence of upper genital tract infection, as do
women who have undergone total abdominal hysterectomy. Bilateral tubal ligation (BTL) does not
provide protection against PID; however, patients who have had BTL may have delayed and milder
forms of the disease.

Depending on the severity of the infection, patients with PID may be minimally symptomatic or may
present with toxic symptoms of fever (temperature 38° C [100.4° F] or higher), nausea, vomiting,
and severe pelvic and abdominal pain. Gonococcal PID is thought to have an abrupt onset with
more toxic symptoms than nongonococcal disease. Gonorrhea- and chlamydia-associated
infections are more likely to cause symptoms toward the end of menses and in the first 10 days
following menstruation.

Lower abdominal pain is usually present. The pain is typically described as dull, aching or crampy,
bilateral, and constant; it begins a few days after the onset of the last menstrual period and tends to
be accentuated by motion, exercise, or coitus. Pain from PID usually lasts less than 7 days; if the
pain lasts longer than 3 weeks, the likelihood that PID is the correct diagnosis declines
substantially.

Abnormal vaginal discharge is present in approximately 75% of cases. Unanticipated vaginal

bleeding, often postcoital, is reported in about 40% of cases. [55] Temperature higher than 38°C
(found in 30% of cases), nausea, and vomiting manifest late in the clinical course of the disease.
Abnormal uterine bleeding is present in more than one-third of patients. [94]

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Pelvic Inflammatory Disease Clinical Presentation: History, Physical Ex... https://emedicine.medscape.com/article/256448-clinical#showall

Physical Examination
Because of the potential serious complications of untreated PID and the endemic prevalence of the
infection, the Centers for Disease Control and Prevention (CDC) has adopted an approach
designed to maximize diagnosis by using minimal criteria. The CDC also urges clinicians to
maintain a low threshold for diagnosis and empiric treatment.

The CDC recommends instituting empiric treatment of PID when a sexually active young woman
who is at risk for STI has:

Pelvic or lower abdominal pain (no identifiable cause for her illness)

AND, on pelvic examination, 1 or more of the following minimal criteria [6] :

Cervical motion tenderness

Uterine tenderness
Adnexal tenderness

A temperature higher than 38.3° C (101° F) and the presence of an abnormal cervical or vaginal
mucopurulent discharge enhance the specificity of the minimum criteria, as do selected laboratory
tests.

Rebound lower abdominal tenderness and involuntary guarding may be noted and suggest
associated peritonitis. The positive predictive value of these findings will vary, depending on the
prevalence of PID in a given population.

A large multicenter trial found adnexal tenderness to be the most sensitive physical examination
finding (sensitivity, 95%). [56] Mucopurulent cervicitis is common and, if absent, has substantial
negative predictive value. Adnexal fullness or disproportionate unilateral adnexal tenderness may
indicate the development of a tubo-ovarian abscess (TOA).

Molander et al found the following 3 variables to be significant predictors of the diagnosis, correctly
classifying 65% of patients with laparoscopically documented PID [57] :

Adnexal tenderness

Fever

Elevated erythrocyte sedimentation rate (ESR)

Right upper quadrant tenderness, especially if associated with jaundice, may indicate associated
Fitz-Hugh−Curtis syndrome. A prospective cohort study in 117 incarcerated adolescents
documented a 4% incidence of Fitz-Hugh−Curtis syndrome in those with mild-to-moderate PID. [58]

Differential Diagnoses
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