Pelvic Inflammatory Disease MARGARET GRADISON, MD, MHS-CL, Duke University Medical Center, Durham, North Carolina Pelvic inflammatory disease is a polymicrobial infection of the upper genital tract. It primarily affects young, sexu- ally active women. The diagnosis is made clinically; no single test or study is sensitive or specific enough for a defini- tive diagnosis. Pelvic inflammatory disease should be suspected in at-risk patients who present with pelvic or lower abdominal pain with no identified etiology, and who have cervical motion, uterine, or adnexal tenderness. Chlamydia trachomatis and Neisseria gonorrhoeae are the most commonly implicated microorganisms; however, other micro- organisms may be involved. The spectrum of disease ranges from asymptomatic to life-threatening tubo-ovarian abscess. Patients should be treated empirically, even if they present with few symptoms. Most women can be treated successfully as outpatients with a single dose of a parenteral cephalosporin plus oral doxycycline, with or without oral metronidazole. Delay in treatment may lead to major sequelae, including chronic pelvic pain, ectopic pregnancy, and infertility. Hospitalization and parenteral treatment are recommended if the patient is pregnant, has human immunodeficiency virus infection, does not respond to oral medication, or is severely ill. Strategies for preventing pelvic inflammatory disease include routine screening for chlamydia and patient education. (Am Fam Physician. 2012;85(8):791-796. Copyright © 2012 American Academy of Family Physicians.) ▲ Patient information: elvic inflammatory disease (PID) is a cervix to the endometrium, through the A handout on pelvic polymicrobial infection of the upper salpinx, and into the peritoneal cavity (caus- inflammatory disease, genital tract that primarily affects ing endometritis, salpingitis, tubo-ovarian written by the author of this article, is provided on young, sexually active women. abscess, or pelvic peritonitis) page 797. P There are 750,000 cases of PID each year in Through the lymphatic systems, such as • the United States, mainly in women 15 to infection of the parametrium from an intra- 29 years of age.1 This number has remained uterine device (IUD) constant since the early 1990s, after decreas- • Through hematogenous routes, such as ing in the previous decades. Most women are with tuberculosis, although this is rare.6 treated in the outpatient setting. The num- ber of hospitalizations has steadily decreased Diagnosis over the past decade.1 The cost of PID is The diagnosis of PID is based primarily on approximately $2,000 per patient, which clinical evaluation. Because of the potential equals about $1.5 billion annually.2 It is esti- for significant consequences if treatment is mated that 80 to 90 percent of women with a delayed, physicians should treat on the basis genital chlamydial infection and 10 percent of clinical judgment without waiting for con- with gonorrheal infection are asymptomatic. firmation from laboratory or imaging tests. Approximately 10 to 20 percent of women Most importantly, physicians must consider with chlamydial or gonorrheal infections PID in the differential diagnosis in women may develop PID if not treated. Women with 15 to 44 years of age who present with lower PID have a 20 percent chance of developing abdominal or pelvic pain and cervical motion infertility from tubal scarring, a 9 percent or pelvic tenderness, even if these symptoms chance of having an ectopic pregnancy, and are mild. However, there is no single symp- an 18 percent chance of developing chronic tom, physical finding, or laboratory test that pelvic pain.3,4 In 2010, the Centers for Dis- is sensitive or specific enough to definitively ease Control and Prevention updated its PID diagnose PID7; clinical diagnosis alone is guidelines, which are the basis of this review.5 87 percent sensitive and 50 percent specific.8 When compared with laparoscopy, clinical Pathophysiology diagnosis of PID in symptomatic patients The microorganisms that are implicated in has a positive predictive value of 65 to PID are thought to spread in three ways: 90 percent.5 This depends on the risk factors • Intra-abdominally, traveling from the within the population being evaluated. Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2012 American Academy of Family Physicians. For the private, noncommer- April 15,cial 2012 use of◆ Volumeone individual 85, Numberuser of the 8Web site. All other rights reserved.www.aafp.org/afp Contact [email protected] for copyright questionsAmerican and/or permission Family Physician requests. 791 SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References No single clinical finding or laboratory test is sensitive or specific enough to definitively diagnose PID. C 7 Empiric antibiotic treatment should be initiated at the time of presentation in patients with symptoms B 15 suspicious for PID, even if the diagnosis has not been confirmed. Women with mild to moderate PID may receive outpatient oral medical treatment without increased B 18, 19 risk of long-term sequelae. Unless there is proven sensitivity, fluoroquinolones should not be used in women with PID because C 20 of widespread resistance in Neisseria gonorrhoeae; a parenteral cephalosporin is recommended instead. Screening for lower genital tract chlamydial infection in younger and high-risk populations is A 26, 27 recommended to reduce the incidence of PID. Asymptomatic disease should be treated. The frequency and cost-effectiveness of screening for asymptomatic lower genital tract chlamydial C 28, 29 infection are not clear. PID = pelvic inflammatory disease. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease- oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp. org/afpsort.xml. HISTORY AND PHYSICAL EXAMINATION especially IUD or oral contraceptives; new, The history should focus on high-risk behav- multiple, or symptomatic sex partners; a iors and symptoms. Risk factors for PID history of PID or sexually transmitted infec- include age younger than 25 years; young tion; or recent IUD insertion.9 Black women age at first sexual encounter (younger than may be at higher risk of PID, although there 15 years); use of nonbarrier contraception, are inconsistencies among physicians in their criteria for diagnosing PID and biases in reporting.1,10 Vaginal douching also may Table 1. Clinical Diagnostic Criteria for PID be a risk factor.11 Typically, women will present with some One or more of the following minimum criteria must be present on pelvic degree of lower abdominal or pelvic pain, examination to diagnose PID: although it may be mild. Other symptoms Cervical motion tenderness may include a new or abnormal vaginal dis- Uterine tenderness charge, fever or chills, cramping, dyspareunia, Adnexal tenderness dysuria, and abnormal or postcoital bleeding. The following criteria can improve the specificity of the diagnosis: Some women also may have low back pain, Oral temperature > 101°F (> 38.3°C) nausea, and vomiting.6 It is less common Abnormal cervical or vaginal mucopurulent discharge for women to have no symptoms or atypical Presence of abundant numbers of white blood cells on saline microscopy symptoms, such as right upper quadrant pain of vaginal fluid from perihepatitis (i.e., Fitz-Hugh–Curtis Elevated erythrocyte sedimentation rate syndrome). At-risk women who present with Elevated C-reactive protein level pelvic or lower abdominal pain and have no Laboratory documentation of cervical infection with gonorrhea or other identified etiology for their pain should chlamydia be presumed to have PID if they have cervi- The following test results are the most specific criteria for diagnosing PID: cal motion, uterine, or adnexal tenderness. Endometrial biopsy with histopathologic evidence of endometritis Additional diagnostic criteria are outlined in Transvaginal sonography or magnetic resonance imaging techniques Table 1.5 The differential diagnosis also may showing thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex, or Doppler studies suggesting pelvic infection include gastrointestinal conditions (e.g., acute (e.g., tubal hyperemia) appendicitis, inflammatory bowel disease); Laparoscopic abnormalities consistent with PID genitourinary conditions (e.g., urinary tract infection/pyelonephritis, nephrolithiasis); PID = pelvic inflammatory disease. obstetric/gynecologic conditions (e.g., ovar- Information from reference 5. ian tumor/cyst/torsion, ectopic pregnancy); or functional pelvic pain. 792 American Family Physician www.aafp.org/afp Volume 85, Number 8 ◆ April 15, 2012 Pelvic Inflammatory Disease DIAGNOSTIC STUDIES Treatment and Management Nucleic acid amplification tests (e.g., strand According to consensus data, the treatment displacement amplification, ligase chain of PID must be empiric because a definitive reaction, or polymerase chain reaction test- diagnosis is rarely known or confirmed at the ing) for Chlamydia trachomatis and Neisseria time of presentation.15 Empiric gonorrhoeae are sensitive (90 to 98 percent treatment may result in adverse Women with pelvic and 88.9 to 95.2 percent, respectively), spe- effects from the antibiotics, inflammatory disease have cific (98 to 100 percent and 99.1 to 100 per- including allergic reactions,