Pelvic Inflammatory Disease
Infections, Obstetrics and Gynecology
First 5 Minutes
- Pelvic inflammatory disease (PID) is an urgent cause of lower abdominal/pelvic pain that must be considered in any patient with a female reproductive tract.
- PID is an ascending infection of the female reproductive tract presenting on a spectrum from asymptomatic infection to systemic illness, causing cervicitis, endometritis, salpingitis, and/or peritonitis. The clinical features of PID are listed in Table 1.
- Causative organisms include Neisseria gonorrhoeae, Chlamydia trachomatis, and Mycoplasma genitalium, but polymicrobial infection is common.
- Complications of PID are severe and include tubo-ovarian abscess, pyosalpinx, perihepatitis (Fitz-Hugh-Curtis syndrome), chronic pelvic pain, infertility, and ectopic pregnancy, and, if pregnant, miscarriage or premature labour.
- The differential diagnosis of PID includes but is not limited to ectopic pregnancy, ovarian cyst, ovarian torsion, endometriosis, appendicitis, colitis, renal colic, and urinary tract infection.
- Perform a history and physical, including a pelvic exam.
- Obtain endocervical swabs for gonorrhea and chlamydia, a pregnancy test, and inflammatory markers (e.g., CRP, ESR).
- Consider pelvic ultrasonography and/or CT abdo/pelvis with contrast. Imaging can demonstrate findings suggestive of PID, assess for complications, and rule out alternative diagnoses. However, imaging should not replace a good physical, including a pelvic exam.
- PID is a challenging diagnosis as there is no finding(s) with sufficient test characteristics for a definitive diagnosis. Rosen’s and the CDC recommend applying the following criteria to optimize sensitivity and specificity in the diagnosis of PID in a patient with risk factors presenting with lower abdominal/pelvic pain with no alternative cause.
- One minimum criterion (high sensitivity, low specificity):
- Cervical motion tenderness,
- Adnexal tenderness, or
- Uterine tenderness.
- One or more additional criteria (decrease sensitivity, but increase specificity):
- Mucopurulent cervical discharge
- Cervical friability
- Elevated CRP or ESR
- WBCs on microscopy of vaginal secretions
- Endocervical swabs positive for gonorrhea or chlamydia
- One minimum criterion (high sensitivity, low specificity):
- If PID is diagnosed, also test for HIV and syphilis.
- Begin antibiotics as soon as presumptive diagnosis is made (i.e., do not wait for swab results). See Table 2 for antibiotic options.
- Provide symptomatic treatment (e.g., anti-pyrectics, anti-emetics, analgesia) and hydration PRN.
- Consult OB-GYN for outpatient follow-up or inpatient management.
- For an IUD in situ, there is insufficient evidence to remove the IUD as it is usually not the source of infection. If the device was inserted in the previous 3 weeks or there is no improvement with treatment in 48 to 72 hours, consult OB-GYN to consider removal.
Criteria For Hospital Admission
- Indications for admission include:
- Tubo-ovarian abscess or perihepatitis.
- Severe systemic illness.
- Alternative emergent diagnoses cannot be ruled out.
- Oral antibiotic therapy failure.
- Outpatient treatment unlikely to be successful.
Criteria For Transfer To Another Facility
- Depends on local guidelines.
Criteria For Safe Discharge Home
- Return precautions:
- If there is no clinical improvement within 72 hours of treatment, return to the ED for reassessment.
- Discharge instructions
- Refrain from sexual intercourse until symptom resolution, completion of antibiotic therapy, and sexual partner(s) have been treated.
- Sexual partner(s) should be tested and treated.
- Can continue any contraceptive method during treatment.
- Chlamydial and gonococcal PID should be retested at 3 months (ideal) or within 12 months.
- Any sexual partners in the last 60 days should be tested and empirically treated for gonorrhea and chlamydia.
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
This resource is based on moderate to high-quality evidence from emergency medicine texts and American STI treatment guidelines.
OTHER RELEVANT INFORMATION
McKinzie J. Sexually Transmitted Infections. In: Walls RM, Hockberger RS, Gausche-Hill M, Erickson TB, Wilcox SR, editors. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 10th ed. Philadelphia (US): Elsevier; 2023. p. 1181-1192.
Weiss B, Shepherd SM. Pelvic Inflammatory Disease. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH, editors. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide [Internet]. 9th ed. United States: McGraw Hill Medical; 2020 [cited 2023 June 7]. Chapter 103. Available from: https://accessmedicine.mhmedical.com/content.aspx?bookid=2353§ionid=219643712
Pelvic Inflammatory Disease (PID) [Internet]. [place unknown: Centre of Disease Control and Prevention]; [updated 2022 Sept 21]. Available from: https://www.cdc.gov/std/treatment-guidelines/pid.htm
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by Emergency Care BC (formerly the BC Emergency Medicine Network) and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. Emergency Care BC is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. Emergency Care BC also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Jun 13, 2023
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