Clinical Review

Pelvic Inflammatory Disease: How to Recognize and Treat

Clinician Reviews. 2017 October;27(10):32-36

While rates of pelvic inflammatory disease (PID) have declined, PID and its potential complications still affect many women in the United States. Patients may present with vague or no symptoms, so clinicians must maintain a high level of suspicion and proactively offer screening for sexually transmitted infections to at-risk patients.

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References

1. Leichliter JS, Chandra A, Aral SO. Correlates of self-reported pelvic inflammatory disease treatment in sexually experienced reproductive-aged women in the United States, 1995 and 2006-2010. Sex Transm Dis. 2013;40(5):413-418.
2. Owusu-Edusei K Jr, Bohm MK, Chesson HW, Kent CK. Chlamydia screening and pelvic inflammatory disease: insights from exploratory time-series analyses. Am J Prev Med. 2010;38(6):652-657.
3. Trent M, Bass D, Ness RB, Haggerty C. Recurrent PID, subsequent STI, and reproductive health outcomes: findings from the PID evaluation and clinical health (PEACH) study. Sex Transm Dis. 2011;38(9):879-881.
4. Mitchell C, Prabhu M. Pelvic inflammatory disease: current concepts in pathogenesis, diagnosis and treatment. Infect Dis Clin North Am. 2013;27(4):793-809.
5. CDC. Pelvic inflammatory disease (PID). www.cdc.gov/std/tg2015/pid.htm. Accessed July 13, 2017.
6. Burnett AM, Anderson CP, Zwank MD. Laboratory-confirmed gonorrhea and/or chlamydia rates in clinically diagnosed pelvic inflammatory disease and cervicitis. Am J Emerg Med. 2012;30:1114–1117.
7. Bjartling C, Osser S, Persson K. The association between Mycoplasma genitalium and pelvic inflammatory disease after termination of pregnancy. BJOG. 2010;117(3):361-364.
8. Ness RB, Kip KE, Hillier SL, et al. A cluster analysis of bacterial vaginosis-associated microflora and pelvic inflammatory disease. Am J Epidemiol. 2005;162(6):585-590.
9. Ness RB, Hillier SL, Kip KE, et al. Bacterial vaginosis and risk of pelvic inflammatory disease. Obstet Gynecol. 2004;104(4):761-769.
10. Cherpes TL, Wiesenfeld HC, Melan MA, et al. The associations between pelvic inflammatory disease, Trichomonas vaginalis infection, and positive herpes simplex virus type 2 serology. Sex Transm Dis. 2006;33(12):747-752.
11. Simms I, Stephenson JM, Mallinson H, et al. Risk factors associated with pelvic inflammatory disease. Sex Transm Infect. 2006;82(6):452-457.
12. Schindlbeck C, Dziura D, Mylonas I. Diagnosis of pelvic inflammatory disease (PID): intra-operative findings and comparison of vaginal and intra-abdominal cultures. Arch Gynecol Obstet. 2014;289(6):1263-1269.
13. CDC. 2015 sexually transmitted diseases treatment guidelines. www.cdc.gov/std/tg2015/default.htm. Accessed September 6, 2017.
14. Korn AP, Hessol NA, Padian NS, et al. Risk factors for plasma cell endometritis among women with cervical Neisseria gonorrhoeae, cervical Chlamydia trachomatis, or bacterial vaginosis. Am J Obstet Gynecol. 1998;178(5):987-990.
15. Wiesenfeld HC, Sweet RL, Ness RB, et al. Comparison of acute and subclinical pelvic inflammatory disease. Sex Transm Dis. 2005;32(7):400-405.
16. Peipert JF, Ness RB, Blume J, et al. Clinical predictors of endometritis in women with symptoms and signs of pelvic inflammatory disease. Am J Obstet Gynecol. 2001;184(5):856-864.
17. Gaitán H, Angel E, Diaz R, et al. Accuracy of five different diagnostic techniques in mild-to-moderate pelvic inflammatory disease. Infect Dis Obstet Gynecol. 2002;10(4):171-180.
18. Tukeva TA, Aronen HJ, Karjalainen PT, et al. MR imaging in pelvic inflammatory disease: comparison with laparoscopy and US. Radiology. 1999;210(1):209-216.
19. Morino M, Pellegrino L, Castagna E, et al. Acute nonspecific abdominal pain. Ann Surg. 2006;244(6):881-888.
20. Woods JL, Scurlock AM, Hensel DJ. Pelvic inflammatory disease in the adolescent: understanding diagnosis and treatment as a health care provider. Pediatric Emergency Care. 2013;29(6):720-725.
21. LeFevre ML; U.S. Preventive Services Task Force. Screening for chlamydia and gonorrhea: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;161(12):902-910.
22. Hosenfeld CB, Workowski KA, Berman S, et al. Repeat infection with Chlamydia and gonorrhea among females: a systematic review of the literature. Sex Transm Dis. 2009;36(8):478-489.
23. CDC. Sexually transmitted disease surveillance. www.cdc.gov/std/stats15/STD-Surveillance-2015-print.pdf. Accessed July 13, 2017.
24. Hillis SD, Joesoef R, Marchbanks PA, et al. Delayed care of pelvic inflammatory disease as a risk factor for impaired fertility. Am J Obstet Gynecol. 1993;168(5):1503-1509.
25. Goyal M, Hersh A, Luan X, et al. National trends in pelvic inflammatory disease among adolescents in the emergency department. J Adolesc Health. 2013;53(2):249-252.
26. Gray-Swain MR, Peipert JF. Pelvic inflammatory disease in adolescents. Curr Opin Obstet Gynecol. 2006;18(5):503-510.
27. Łój B, Brodowska A, Ciecwiez S, et al. The role of serological testing for Chlamydia trachomatis in differential diagnosis of pelvic pain. Ann Agric Environ Med. 2016;23(3):506-510.
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IN THIS ARTICLE

Diagnostic tests
Complications of PID
CDC treatment regimens

Pelvic inflammatory disease (PID) is an ascending polymicrobial infection of the female upper reproductive tract that primarily affects sexually active women ages 15 to 29. Around 5% of sexually active women in the United States were treated for PID from 2011-2013.¹ The rates and severity of PID have declined in North America and Western Europe due to overall decrease in sexually transmitted infection (STI) rates, improved screening initiatives for Chlamydia trachomatis, better treatment compliance secondary to increased access to antibiotics, and diagnostic tests with higher sensitivity.² Despite this rate reduction, PID remains a major public health concern given the significant long-term complications, which include infertility, ectopic pregnancy, and chronic pelvic pain.³

EPIDEMIOLOGY AND PATHOGENESIS

PID is caused by sexually transmitted bacteria or enteric organisms that have spread to internal reproductive organs. Historically, the two most common pathogens identified in cases of PID have been Chlamydia trachomatis and Neisseria gonorrhoeae; however, the decline in rates of gonorrhea has led to a diminished role for N gonorrhoeae (though it continues to be associated with more severe cases).^4,5

More recent studies have suggested a shift in the causative organisms; less than half of women diagnosed with acute PID test positive for either N gonorrhoeae or C trachomatis.⁶ Emerging infectious agents associated with PID include Mycoplasma genitalium, Gardnerella vaginalis, and bacterial vaginosis–associated bacteria.^5,7,8-10

RISK FACTORS

Women ages 15 to 25 are at an increased risk for PID. The high prevalence in this age group may be attributable to high-risk behaviors, including a high number of sexual partners, high frequency of new sexual partners, and engagement in sexual intercourse without condoms.¹¹

Taking an accurate sexual history is imperative. Clinicians should maintain a high level of suspicion for PID in women with a history of the disease, as 25% will experience recurrence.¹²

Clinicians should not be deterred from screening for STIs and cervical cancer in women who report having sex with other women. In addition, transgender patients should be assessed for STIs and HIV-related risks based on current anatomy sexual practices.¹³

PHYSICAL EXAM

While some cases of PID are asymptomatic, the typical presentation includes bilateral abdominal pain and/or pelvic pain, with onset during or shortly after menses. The pain often worsens with movement and coitus. Associated signs and symptoms include abnormal uterine bleeding or vaginal discharge; dysuria; fever and chills; frequent urination; lower back pain; and nausea and/or vomiting.^14,15

All females suspected of having PID should undergo both a bimanual exam and a speculum exam. On bimanual examination, adnexal tenderness has the highest sensitivity (93% to 95.5%) for ruling out acute PID, whereas on speculum exam, purulent endocervical discharge has the highest specificity (93%).^16,17 Bimanual exam findings suggestive of PID include cervical motion tenderness, uterine tenderness, and/or adnexal tenderness. Suggestive speculum exam findings include abnormal discoloration or texture of the cervix and/or endocervical mucopurulent discharge.^5,16,17

One cardinal rule that should not be overlooked is that all females of reproductive age who present with abdominal pain and/or pelvic pain should take a pregnancy test to rule out ectopic pregnancy and any other pregnancy-related complications.

DIAGNOSIS

The diagnosis of PID relies on clinical judgement and a high index of suspicion.^5,18 The CDC’s diagnostic criteria for acute PID include

Sexually active female AND
Pelvic or lower abdominal pain AND
Cervical motion tenderness OR uterine tenderness OR adnexal tenderness.⁵

Additional findings that support the diagnosis include

Abnormal cervical mucopurulent discharge or cervical friability
Abundant white blood cells (WBCs) on saline microscopy of vaginal fluid
Elevated C-reactive protein
Elevated erythrocyte sedimentation rate
Laboratory documentation of infection with C trachomatis or N gonorrhea
Oral temperature > 101°F.^5,18

The CDC notes that the first two findings (mucopurulent discharge and evidence of WBCs on microscopy) occur in most women with PID; in their absence, the diagnosis is unlikely and other sources of pain should be considered.⁵ The differential for PID includes acute appendicitis; adhesions; carcinoid tumor; cholecystitis; ectopic pregnancy; endometriosis; inflammatory bowel disease; and ovarian cyst.¹⁹

Given the variability in presentation, clinicians may find it useful to perform further diagnostic testing. There are additional laboratory tests that may be ordered for patients with a suspected diagnosis of PID (see Table 1).

References

Tdap during pregnancy, or before, offers infants pertussis protection

Pelvic Inflammatory Disease: How to Recognize and Treat

References

EPIDEMIOLOGY AND PATHOGENESIS

RISK FACTORS

PHYSICAL EXAM

DIAGNOSIS

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