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    Pelvic Inflammatory Disease

    Infections, Obstetrics and Gynecology

    Last Updated Jun 13, 2023
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    By Damian Feldman-Kiss, Gord McInnes, Aneesha Thouli

    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.

    Diagnostic Process

    • 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):
        • Fever
        • Mucopurulent cervical discharge
        • Cervical friability
        • Elevated CRP or ESR
        • WBCs on microscopy of vaginal secretions
        • Endocervical swabs positive for gonorrhea or chlamydia
    • If PID is diagnosed, also test for HIV and syphilis.

    Recommended Treatment

    • 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:
      • Pregnancy.
      • 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?


    This resource is based on moderate to high-quality evidence from emergency medicine texts and American STI treatment guidelines.


    Related Information


    Reference List

    1. 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.

    2. 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&sectionid=219643712

    3. 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


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