Infectious Diseases in Obstetrics and Gynecology 2:38-48 (I 994) (C) 1994 Wiley-Liss, Inc. Diagnostic Evaluation of Pelvic Inflammatory Disease Jeffrey F. Peipert and David E. Soper Department of Obstetrics and Gynecology, Women and lnfants' Hospital, Brown University School of Medicine, Providence, RI (J.F.P.), and Department of Obstetrics and Gynecology, Medical College of Virginia, Richmond, VA (D.E.S.) ABSTRACT Pelvic inflammatory disease (PID) is a serious public health and reproductive health problem in the United States. An early and accurate diagnosis of PID is extremely important for the effective management of the acute illness and for the prevention of long-term sequelae. The diagnosis of PID is difficult, with considerable numbers of false-positive and false-negative diagnoses. An abnormal vaginal discharge or evidence of lower genital tract infection is an important and predictive finding that is often underemphasized and overlooked. This paper reviews the clinical diagnosis and sup- portive laboratory tests for the diagnosis of PID and outlines an appropriate diagnostic plan for the clinician and the researcher. (C) 1994 .Wiley-Liss, Inc. KEY WORDS Pelvic inflammatory disease, salpingitis, adnexitis n early and accurate diagnosis of pelvic inflam- urination and abdominal discomfort. Symptoms of matory disease (PID) is of paramount impor- abdominal and pelvic discomfort and dysuria be- tance for the effective management of the acute gan 1-2 days prior to evaluation. The patient had illness and for the prevention of long-term sequelae never been pregnant, had no significant medical or such as infertility, ectopic pregnancy, chronic pel- surgical history or history of sexually transmitted vic pain, and recurrent PID. The diagnosis of diseases (STDs), used condoms for contraception, PID, however, is problematic as patients often and was in a monogomous relationship for the past present with minimal signs or symptoms and the 2-3 years. severity of clinical signs varies widely. The chang- The practitioner evaluating the patient noted white ing etiologic, epidemiologic, and clinical profile of blood cells (WBCs) in the clean-catch urinalysis the disease magnifies this difficulty. Patients with and abdominal tenderness on examination. No pel- PID may have minimal pain and atypical symp- vic examination or cultures were performed. The toms and remain undiagnosed, or they may be mis- patient was diagnosed with a urinary tract infection diagnosed as having gastrointestinal or noninfec- and was told she might also have PID. She was tious gynecologic illnesses. 1-s Undiagnosed PID given a prescription for ofloxacin, 300 mg b.i.d., results in failure to treat or delay of treatment, which she filled and started immediately. which has been associated with an increased risk of The patient followed-up with the student health long-term sequelae. 6-8 clinic and was seen by a nurse practitioner 2 days later. On pelvic examination, she was noted to have CASE ILLUSTRATION abdominal, cervical motion, and adnexal tender- A 20-year-old university undergraduate presented ness. She was told that her examination was consis- to a medical clinic for evaluation of burning with tent with PID, and her prescription was changed to Address correspondence/reprint requests to Dr. Jeffrey F. Peipert, Department of Obstetrics and Gynecology, Women and Infants' Hospital, 101 Dudley Street, Providence, R102905. Received March 3, 1994 Review Article Accepted June 2, 1994 PID DIAGNOSIS PEIPERT AND SOPER ofloxacin, 400 mg b.i.d., and metronidazole, 500 TABLE I. Differential diagnosis of PID mg b.i.d., for 14 days. Instructions were given to Acute appendicitis have her sexual partner evaluated and treated. Ectopic pregnancy Concerned with a 2-week course of antibiotic Endometriosis therapy and the implication of an STD, the patient Ovarian cyst or tumor Hemorrhage sought consultation with a gynecologist, then 5 days Rupture after the onset of symptoms. By this time, her Torsion symptoms were almost resolved with the exception Peritonitis of mild vulvar On examination at this Pyelonephritis pruritus. Ruptured or perforated viscus evaluation, she had a cloudy-white discharge in the Intraperitoneal hemorrhage vaginal vault but no abdominal or pelvic tender- Generalized sepsis ness. The vaginal pH was 4.2. Microscopic evalu- Urinary tract infection Uterine myoma ation of the discharge revealed no WBCs, trich- Pelvic adhesions omonads, or clue cells; occasional pseudohyphae Chronic salpingitis were noted. She was given a prescription for can- Acute gastrointestinal inflammation Miscellaneous didal vaginitis and was told to continue her course of antibiotics for "presumed" PID. The patient had numerous questions regarding her diagnosis, prog- nosis, and therapy. pected PID. By using more stringent criteria for This case illustrates the difficulties encountered the diagnosis, such as the presence of fever or leu- in the routine diagnosis of PID. Many primary kocytosis; the specificity of the diagnosis can be practitioners are reluctant to perform a pelvic ex- increased. However, this increase in specificity will amination. In addition, the importance of evaluat- result in a marked reduction in sensitivity. 10,11 ing the vaginal discharge is illustrated in this exam- The limitations of the clinical diagnosis of PID ple. Was the urine contaminated with excess vaginal underscore the need for more accurate diagnostic WBCs secondary to a lower genital tract infection? techniques that are widely available and cost-effec- Was the pyuria the result of inflammation of the tive. 12 What follows is a critical review of the bladder due to infection of the pelvic organs adja- current techniques used in the clinical diagnosis of cent to the bladder? Or was the vaginal discharge PID, including historical risk factors, physical ex- normal and the patient had a case of urethritis and amination, laboratory testing, and more elaborate cystitis? A simple saline preparation of the vaginal tests such as endometrial biopsy, endovaginal ultra- discharge would add important diagnostic informa- sonography, and laparoscopy. As these data are re- tion. viewed, the reader should consider how the accu- rate diagnosis of PID can be made with concer.n for PROBLEMS WITH THE CLINICAL both patient and health-care costs. DIAGNOSIS OF PID The clinical diagnosis of PID based on a bimanual HISTORIC RISK FACTORS AND pelvic examination and traditional laboratory test- RISK MARKERS ing has serious limitations. 9'1 Both overdiagnosis From case-control studies in the United States of and underdiagnosis are quite common, and the list women with confirmed PID, the patients with PID of conditions that must be considered in the differ- were younger, more often nonwhite, single, unem- ential diagnosis of PID is extensive (Table 1). ployed, had less education, consumed more alco- Jacobson and Westrom3 noted that one-third of hol, were more likely to use tobacco, and were women with the clinical diagnosis of PID have more likely to douche than a sexually active control been misdiagnosed. Twelve percent were found to group without PID. 1, 14 They also initiated sexual have other pathology such as appendicitis, endo- activity earlier, reported a higher number of life- metriosis, hemorrhagic corpus luteum, or ectopic time sexual partners, had intercourse more fre- pregnancy; 23% were normal upon laparoscopic quently, had frequent change of sexual partners, evaluation. 3 Laparoscopic evaluation of patients and reported a history of Neisseria gonorrhoeae, with other clinical diagnoses can also reveal unsus- Chlamydia trachomatis, or PID more often than did INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY 39 PID DIAGNOSIS PEIPERT AND SOPER controls. In addition, cases with proven PID were TABLE 2. Prevalence of symptoms in cases of less likely than control subjects to use any birth- laparoscopically proven PID 13 control method. Symptom Percent Health-care behavior impacts on the risk of ac- quiring PID. The risk of an upper genital tract Abnormal vaginal discharge 55-75 Reported elevated temperature 35-45 infection increases when there is late medical con- Irregular bleeding 30-35 sultation for the diagnosis and treatment of STDs, Urinary symptoms 15-20 when there is noncompliance with medical therapy, Chills 0-15 13 Nausea and 5-I 0 and when the sexual partner is not treated. vomiting Anorectal symptoms 5-I 0 Contraceptive history influences the occurrence Right upper-quadrant pain 5 of PID. Studies have shown that barrier methods may decrease the risk of PID, presumably by pro- tecting against cervical infection, is The intrauter- ine device (IUD) may be associated with an in- intense, and medical consultation is sought usually creased risk of PID, but his risk appears to be within a few days. In contrast, chlamydial PID is limited to the 1st several months after IUD inser- less intense, and the patient may wait a week or tion. 16-8 However, women at low risk of acquir- longer prior to seeking medical attention. In ing an STD have little increased risk of PID with "asymptomatic salpingitis," or "atypical PID," pain IUD use. 19 A tubal ligation markedly decreases the may not be present. risk of ascending infection from the lower genital Symptoms typically occur during menstruation tract. 2 The literature is unclear with regard to the or the proliferative phase, rather than the luteal effect of oral contraceptives on the risk of PID. It phase of the cycle. 9'1 Abnormal uterine bleeding, would appear that, while