PELVIC INFLAMMATORY

CHAPTER 11

DISEASE
Mary Anne M. Baquing, MD

1. What is pelvic inflammatory disease (PID)?

  PID is a clinical syndrome that comprises a spectrum of inflammatory diseases of the upper female
genital tract: endometritis (infection of endometrium), salpingitis (infection of the fallopian tubes),
tubo-ovarian abscess, and pelvic peritonitis. It is caused by ascending infection from the vagina to the
upper genital organs.
2. What causes PID?
  Most cases are polymicrobial. Previously, the most common pathogens were thought to be the sexu-
ally transmitted organisms Neisseria gonorrhoeae and Chlamydia trachomatis. More recent studies
have shown that other organisms in the vaginal flora may also play a crucial role in the development
of PID. These other organisms include enteric gram-negative rods and anaerobes such as Myco-
plasma genitalium, Ureaplasma urealyticum, and Gardnerella vaginalis. Less than half of PID cases
have cervical infection with gonorrhea or Chlamydia, likely from the active screening and treatment of
sexually active women. Cervical or uterine instrumentation may increase the risk of PID.
3. What are the incidence and prevalence of PID?
  PID is estimated to occur in more than 750,000 women in the United States every year. These estimates
are limited by the poor sensitivity of clinical diagnostic criteria and the lack of national surveillance.
4. What are risk factors for PID?
• Young age: higher risk of acquiring sexually transmitted infections (STIs)
• History of PID: damaged fallopian tubes are at higher risk for reinfection
• History of gonorrhea or Chlamydia infection
• High-risk sexual behaviors: multiple partners, male partners with gonorrhea or Chlamydia infection
• Bacterial vaginosis
• Socioeconomic status: related to health care access
5. Are intrauterine devices (IUDs) associated with PID?
  The risk of developing PID after IUD insertion is highest within the first 3 weeks. Historically, the IUD
would be removed at the time of PID diagnosis. More recent studies, however, do not support this
practice; patients respond just as well to treatment with the IUD in place.
6. What are the clinical symptoms of PID?
  Variable. PID may be asymptomatic, or it can manifest with moderate or even severe symptoms (also
known as acute PID). In patients with symptoms, the most common are lower abdominal pain, cramp-
ing, postcoital bleeding, abnormal discharge, fever, nausea, and vomiting. Subclinical PID is more
frequent and leads to misdiagnosis and mistreatment.
7. What are the physical examination findings associated with PID?
  During a pelvic examination, the classic sign of PID is cervical motion tenderness or the “chandelier
sign.” This is characterized by severe tenderness or an accompanying reaction to the pain the patient
feels on manipulation of the cervix. Other physical examination findings include adnexal tenderness,
right upper quadrant (RUQ) tenderness (associated with Fitz-Hugh-Curtis syndrome), and mucopu-
rulent discharge on speculum examination.
8. What are the diagnostic criteria for PID?
  The Centers for Disease Control and Prevention (CDC) recommend treatment in sexually active
patients if one of the following are met in the absence of any other explanation:
• Uterine tenderness
• Adnexal tenderness (bilateral or unilateral)
46
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 Pelvic Inflammatory Disease  47

• Cervical motion tenderness (“chandelier sign”)

  These additional findings support PID diagnosis but are not required:
• Fever higher than 38.3° C
• Abnormal discharge or friable cervix
• White blood cells (WBCs) on saline microscopy (the absence of WBCs makes the diagnosis less likely)
• Cervical infection with gonorrhea or Chlamydia
• Leukocytosis
• Elevated erythrocyte sedimentation rate
• Elevated C-reactive protein
• Imaging suggestive of a tubo-ovarian abscess or pyosalpinx
• Endometrial biopsy showing endometritis
• Laparoscopic findings consistent with PID
9. What options exist for outpatient treatment of PID?
  The following regimens are recommended by the CDC for treatment of PID in the outpatient setting:
•  Ceftriaxone 250 mg intramuscularly (IM) in a single dose AND doxycycline 100 mg orally twice a
day for 14 days
• Cefoxitin 2 g IM AND probenecid 1 g orally in a single dose AND doxycycline 100 mg orally twice a
day for 14 days
• Other parenteral third-generation cephalosporin AND doxycycline 100 mg orally twice a day for
14 days
• Consider adding metronidazole to any of the foregoing regimens, especially in patients with bacte-
rial vaginosis.
10. How should patients who receive outpatient treatment be followed?
  Patients should be reexamined within 72 hours of treatment. If they do not show significant clinical
improvement, they need to be admitted for parenteral treatment.
11. What are the criteria for inpatient treatment of PID?
• Failed outpatient treatment
• Inability to tolerate or be compliant with an outpatient oral regimen
• Pregnancy
• Presence of tubo-ovarian abscess
• Inability to exclude surgical emergencies such as appendicitis or ectopic pregnancy
• Severe illness (vomiting, high fever)
12. What are the recommended inpatient treatment options for PID?
  The CDC recommends the following parenteral regimens:
• Cefotetan 2 g intravenously (IV) every 12 hours OR cefoxitin 2 g IV every 6 hours AND doxycycline
100 mg orally or IV every 12 hours
• Clindamycin 900 mg IV every 8 hours AND gentamicin loading dose of 2 mg/kg
followed by maintenance dose 1.5 mg/kg every 8 hours (A single daily gentamicin dosing of 3 to 5
mg/kg may be considered.)
• Alternative regimen: ampicillin/sulbactam 3 g IV every 6 hours AND doxycycline 100 mg orally or IV
every 12 hours
• If a tubo-ovarian abscess is present, clindamycin or metronidazole should be added to provide
improved anaerobic coverage.
13. What other considerations should be made when treating women for PID?
  Women diagnosed with PID should be offered testing for all other STIs. Those who test positive for
gonorrhea or Chlamydia infection during evaluation should be retested 3 to 6 months after treatment
because of high rates of reinfection.
14. How should sexual partners of women diagnosed with PID be managed?
  Men who have had sexual contact within 60 days of a women diagnosed with PID should be tested for
STIs and empirically treated for both Chlamydia infection and gonorrhea.
15. What are the potential long-term consequences of PID?
• Infertility
• Tubo-ovarian abscess
• Increased risk of ectopic pregnancy
• Chronic pelvic pain

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 48  GENERAL GYNECOLOGY

K EY POIN T S: PE LV IC I N F L A M M AT O RY D I S E A S E
1. PID is diagnosed by any of the following findings on physical examination: uterine tenderness,
adnexal tenderness, or cervical motion tenderness.
2. The CDC recommends different oral and parenteral regimens for the treatment of PID.
3. Women in whom outpatient therapy fails or who are poor candidates for it should be hospitalized.
4. Long-term sequelae of PID include infertility, tubo-ovarian abscesses, chronic pelvic pain, and
ectopic pregnancy.

Bibliography
1. Centers for Disease Control and Prevention. U.S. Selected practice recommendations for contraceptive use, 2013:
Adapted from the World Health Organization Selected Practice Recommendations for Contraceptive Use. 2nd ed. MMWR
Recomm Rep; 2013. 62.
2. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm
Rep. 2015;64:1–137. Available at http://www.cdc.gov/std/tg2015/default.htm. Accessed October 15, 2015.
3. Hoffman B, Schorge J, Schaffer J, et al., eds. Williams Gynecology. 2nd ed. New York: McGraw-Hill; 2012.
4. Wiesenfeld HC, Hillier SL, Meyn LA, et al. Subclinical pelvic inflammatory disease and infertility. Obstet Gynecol.
2012;120:37–43.
5. Wiesenfeld HC, Hillier SL, Meyn L, et al. Mycoplasma genitalium: is it a pathogen in acute pelvic inflammatory disease
(PID)?. Vienna, Austria: Presented at the STI and AIDS World Congress; 2013 (Joint Meeting of the 20th ISSTDR and 14th
IUSTI Meeting), July 14-27, 2013.

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