PELVIC INFLAMMATORY DISEASE (April 22, 2009)

I. Background

A. Pelvic Inflammatory Disease (PID) comprises a spectrum of inflammatory disorders of the upper female genital tract involving the uterus (endometritis), fallopian tubes (salpingitis), and sometimes the ovaries (oophoritis, tubo-ovarian abscess) or the peritoneal cavity (pelvic or generalized peritonitis). Sexually transmitted organisms, especially N. gonorrhoeae (GC) and C. trachomatis (CT), are implicated in many cases involving sexually active young women; however, other causes include non-sexually transmitted aerobic and anaerobic bacteria such as Gardnerella vaginalis, Haemophilus influenzae, enteric Gram-negative rods and Streptococcus agalactiae. Mixed infections with sexually and non-sexually transmitted pathogens are common. Previous PID and the presence of bacterial vaginosis may predispose to ascending infection with non-sexually transmitted bacteria. Long-term complications, which may occur after either overt or clinically silent PID, include tubal infertility, ectopic pregnancy, and chronic pelvic pain. B. Acute PID is difficult to diagnose because of the wide variation in its signs and symptoms. Many women with PID have subtle or mild symptoms that may not readily indicate PID. Consequently, delay in diagnosis and effective treatment may contribute to inflammatory sequelae in the upper reproductive tract. Laparoscopy can be used to obtain a more accurate diagnosis; however, this diagnostic tool often is not available, and its use is not easy to justify when symptoms are mild or vague. Moreover, laparoscopy will not detect endometritis and may not detect subtle inflammation of the fallopian tubes. Consequently, a diagnosis of PID usually is based on clinical findings. C. The clinical diagnosis of acute PID is imprecise. Data indicate that a clinical diagnosis of symptomatic PID may be accurate in less than 65% of cases in comparison with laparoscopy. Accuracy of the clinical diagnosis depends on epidemiologic characteristics of the population served and is higher among sexually active young (especially teenaged) women and among patients attending STD clinics or other settings where rates of GC or CT are high. D. Many episodes of PID go unrecognized. Although some cases are asymptomatic, others are undiagnosed because the patient or the health care provider fails to recognize the implications of mild or nonspecific symptoms or signs, such as abnormal bleeding (especially bleeding after intercourse), dyspareunia, or vaginal discharge. Because of the potential damage to the reproductive health of women who have apparently mild or atypical PID, it is important to maintain a low threshold for the diagnosis of PID. Even so, the long-term outcome of early treatment of women with asymptomatic or atypical PID is unknown. E. Combinations of diagnostic findings that improve either sensitivity or specificity do so only at the expense of the other. The minimum diagnostic criteria given below aim to increase the sensitivity of the diagnosis, but do lower specificity. F. In cases in which the empiric administration of antibiotics to cover possible PID is problematic, further criteria may help to increase specificity. These include current use of an IUD; history of previous PID; history of tubal ligation; or history of laparoscopy. G. No increase of WBC seen on wet prep suggests that PID may not be the cause of the pelvic pain. Given the high risk for STI seen in most women attending the DMHC, however, this is not used by us as a criterion to exclude PID unless other factors also suggest that PID is not present. H. CT or GC tests may be negative despite the actual presence of the organisms in the uterus or fallopian tubes. II. Diagnosis

A. All patients with suspected PID should be evaluated by the attending physician.

B. History: Lower abdominal pain and/or dyspareunia are usually present. In addition, vaginal discharge, altered menstrual pattern, or contact bleeding may be present as well as constitutional symptoms including fever, nausea, or vomiting. However, symptoms may be subtle or completely absent, even when marked tubal inflammation is present.

C. Examination: The minimum criteria for PID include the presence of cervical motion tenderness OR uterine tenderness OR adnexal tenderness. In addition the following may be present: enlargement or induration of fallopian tubes, pelvic mass, or direct or rebound abdominal tenderness.

D. Laboratory: 1. Wet prep 2. Vaginal Aptima (NAAT) for CT/GC 3. Urine pregnancy test to rule out ectopic pregnancy. a. Clinic physician should refer pregnant women to an appropriate facility for evaluation of possible ectopic pregnancy if the pregnancy test is positive.

III. Treatment

A. Therapy is the same whether gonococcal or non-gonococcal PID is suspected:

B. Recommended (use if no history of cephalosporin or severe [hives, anaphylaxis] PCN allergy): 1. Ceftriaxone 250 mg in a single intramuscular injection 2. Plus: doxycycline 100 mg orally twice a day for 14 days 3. If Bacterial vaginosis is present add: metronidazole 500 mg orally twice a day for 14 Days

C. Alternative (use if allergic to cephalosporin/PCN or if patient categorically refuses IM treatment): 1. Ofloxacin 800 mg in a single oral dose and Azithromycin 2 grams orally once 2. Plus: doxycycline 100 mg orally twice a day for 14 days 3. If Bacterial vaginosis is present add: metronidazole 500 mg orally twice a day for 14 Days

IV. Other considerations

A. Test-of-cure: recommended for patients receiving the alternative treatment listed above due to the possibility of QRNG (quinolone resistant N. gonorrhoeae). if the GC test was positive from the initial visit. As culture depends on finding live organisms, it can be performed as soon as 3 days after treatment. Because the Aptima (NAAT) can be positive when only dead organisms are present, it should not be performed until at least 3 weeks after treatment. B. Quinolones should not be used routinely to treat PID due to the increasing prevalence of QRNG.

C. There is insufficient data to recommend routine use of azithromycin for treatment of PID. However, in the woman thought to be at risk for poor compliance with doxycycline, azithromycin 1gm (one single oral dose) should be administered in the clinic, along with therapy for GC (e.g., ceftriaxone, ofloxacin), to be followed by a 14 day course of doxycycline and a follow-up exam in 1-3 days.

D. The role of anti-anaerobic therapy for PID in the absence of bacterial vaginosis is controversial and should be determined by the attending physician on a case-by-case basis.

E. Women with PID who have an IUD should be carefully evaluated by the attending physician. No evidence suggests that IUDs should be removed in women diagnosed with acute PID. However, caution should be exercised if the IUD remains in place, and close clinical follow-up is mandatory. Failure to see any improvement after 3 days of antibiotic therapy is a reason to remove the IUD.

F. Pregnancy: Because of the possibility of ectopic pregnancy, as well as the high risk for maternal morbidity and preterm delivery, pregnant women with possible PID should be referred for immediate OBGYN evaluation.

G. Referral for OBGYN evaluation and possible hospitalization should also occur if one of the following is the case: 1. The patient is severely ill. 2. The diagnosis is uncertain and a surgical condition (appendicitis, ectopic pregnancy) cannot be excluded. 3. A pelvic abscess is suspected. 4. The patient is unable to follow or tolerate an outpatient regimen. 5. If the patient is not improving with outpatient therapy. 6. Because of potentially worse compliance and more severe reproductive sequelae in adolescents, greater consideration should be given to their referral to OBGYN than for older women.

V. Counseling

A. Patients with PID should be counseled about the risk of long term sequelae (e.g., infertility, ectopic pregnancy and chronic pain) and thus the great importance of completing therapy.

B. Bed rest for 1-3 days, or until pain is significantly improved, is helpful if possible.

C. Patients should abstain from sexual intercourse until patient and partner(s) have completed therapy.

D. Patients should be counseled to return for evaluation if they have worsening symptoms or non-response with therapy. E. Patients should be advised that their CT/GC tests may be negative but that infection may simply be beyond the reach of the test swab. They should continue antibiotics whether the test is positive or negative.

VI. Follow-up

A. Frequency of clinical follow-up should be individualized by the clinic physician. 1. Patients who are at least moderately ill, those in whom the diagnosis or compliance with therapy is uncertain, and all adolescents should be re-examined 1-3 days after starting treatment. 2. Patients who are not improving should be reviewed by the clinic physician, with consideration of hospitalization or change in antibiotic therapy. 3. Ideally, all patients should be examined 4-7 days after completing treatment to determine the need for additional therapy or the presence of baseline post-therapy discomfort on pelvic exam.

VII. Management of contacts

A. Examination, including a urethral culture or urine Aptima (NAAT) for GC and urine Aptima (NAAT) for CT, should be performed for all contacts within the preceding 60 days regardless of symptoms.

B. Clients should be given contact cards for all recent sexual contacts, to increase the likelihood that partners will be treated.

C. Treatment of contacts to PID: 1. Recommended (use if no history of cephalosporin or severe [hives, anaphylaxis, respiratory compromise] PCN allergy): a. Ceftriaxone 125 mg IM once b. And: i. Azithromycin 1 gram orally once ii. or Doxycycline 100 mg orally twice a day for 7 days

2. Alternative (use if severe allergy to cephalosporin/PCN or if patient categorically refuses IM treatment): a. Ofloxacin 400 mg orally once and Azithromycin 2 grams orally once