Updated: 3/13/2017

Pelvic Inflammatory Disease (PID)

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  • A sexually active 17-year-old girl is brought to the emergency department due to lower abdominal pain of acute onset. She has no nausea or vomiting. Vital signs are significant for a temperature of 101.4°F (38.5°C). Bimanual pelvic exam shows cervical exudate and cervical motion tenderness. There is bilateral lower quadrant tenderness. Her β-HCG is within normal limits.
Introduction
  • Clinical definition
    • pelvic inflammatory disease (PID) is an infection of the upper female genital tract that is often polymicrobial
      • may include
        • endometritis
        • salpingitis
        • tubo-ovarian abscess
        • pelvic peritonitis
  • Epidemiology
    • incidence
      • US incidence
        • 750,000 cases annually
    • demographics
      • sexually active women
      • 15-29 years of age
    • location
      • upper female genital tract
    • risk factors
      • age < 25 years of age
      • risky sexual behavior
      • earlier age at first intercourse
      • increasing number of sex partners
  • Pathophysiology
    • pathobiology
      • usually polymicrobia
      • likely microbes
        • Neisseria gonorrhoeae
        • Chlamydia trachomatis
        • anaerobes
        • gram-negative rods
        • Streptococcus agalactiae
        • Gardnerella vaginalis
        • Haeomphilus influenza
        • Cytomegalovirus
        • Mycoplasma genitalium
    • pathoanatomy
      • ascending infection of microbes from endocervix to upper genital tract
  • Associated conditions
    • other sexually transmitted diseases (e.g., chlamydia, chancroid, herpes, etc.)
  • Prognosis
    • may recur
    • prognostic variable
      • negative
        • salpingitis
        • multiple recurrence
Presentation
  • Symptoms
    • may be asymptomatic if subclinical
    • primary symptoms
      • lower abdominal or pelvic pain
      • chills
      • dyspareunia
      • dysuria
      • nausea or vomiting
  • Physical exam
    • inspection
      • fever
      • abnormal cervical discharge or bleeding
      • cervical friability
      • abnormal vaginal odor
      • ecchymosis and swelling
      • diffuse tenderness
    • provocative tests
      • cervical motion tenderness
        • also known as “chandelier test”
      • adnexal tenderness
      • uterine tenderness

Imaging
  • Ultrasonography
    • indication
      • if diagnosis is uncertain with physical exam and clinical history
    • view
      • transvaginal
    • findings
      • thickened fluid-filled tubes
      • with or without free pelvic fluid
      • with or without tubo-ovarian abscess
Studies
  • Labs
    • may test positive for sexually transmitted diseases
      • Neisseria gonorrhoeae
      • Chlamydia trachomatis
  • Diagnostic criteria
    • positive physical exam findings
      • uterine tenderness
      • adnexal tenderness
      • cervical motion tenderness
Differential
  • Ectopic pregnancy
    • positive pregnancy test
  • Appendicitis
    • PID typically presents with bilateral abdominal tenderness
Treatment
  • Medical
    • cephalosporin plus doxycycline (outpatient)
      • indications
        • clinical findings of PID alone is often enough to indicate treatment of PID
        • uncomplicated PID
    • cefoxitin plus doxycycline
      • indications for intravenous medication or hospitalization
        • uncertain diagnosis
        • tubo-ovarian abscess
        • unstable patient
        • failure to respond to outpatient treamtment within 72 hours
Complications
  • Infertility
    • 15% after one episode of PID
  • Ectopic pregnancy
    • 10x risk after PID
  • Fitz-Hugh-Curtis syndrome
    • clinical definition
      • infection of liver capsule with multiple peritoneal adhesions
    • incidence
      • 10% of women with PID
 

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