Pelvic Inflammatory Disease (PID)

Definition

  • Pelvic Inflammatory Disease (PID) is Acute Infection of Female Upper Genital Tract Structures (Endometritis, Salpingitis, tubo-Ovarian Abscess, Oophoritis, Peritonitis), Other Surrounding Pelvic Organs, and Occasionally Distant Organs (Perihepatitis)
    • PID is Initiated by a Sexually-Transmitted Organism, Which Ascends to Involve the Upper Genital Tract
      • This Differentiates PID from Pelvic Infection Which Occurs as a Result go Trans-Cervical Procedures, Pregnancy, and Other Primary Abdominal Infections

Epidemiology

  • xxx

Background

Normal Vaginal Flora

  • Normal Vagina Flora Consists of Predominantly Non-Pathogenic Bacteria
    • Lactobacillus (see Lactobacillus, [[Lactobacillus]])
      • Produces Hydrogen Peroxide
  • Normal Vaginal Flora Also Consists of Relatively Small Numbers of Potentially Pathogenic Bacteria (Clin Obstet Gynecol, 1976) [MEDLINE] (PLoS One, 2012) [MEDLINE]
    • Pathogenic Organisms Fluctuate in Number in the Vaginal Flora as a Result of Hormonal Fluctuations (Related to Menstrual Cycles and Pregnancy), Contraceptive Method, Sexual Activity, Vaginal Hygiene, and Other Factors
    • Pathogenic Organisms

Role of the Endocervical Canal

  • Endocervical Canal Functions as an Anatomical Barrier Between the Vaginal Flora and the Normally Sterile Upper Genital Tract
    • Endocervical Sexually-Transmitted Infections Can Disrupt this Barrier, Resulting in Infection of the Endometrium, Endosalpinx, Ovarian Cortex, and Pelvic Peritoneum
    • Risk of Upper Genital Tract Infection is Related to Multiple Factors
      • Bacterial Pathogen Load
      • Estrogen Levels (Which Affect Cervical Mucus Viscosity)
      • Genetic Variations In Immune Response

Etiology and Physiology

Anatomic Course of Infection

  • Inflammation Spreads from the Vagina or Cervix to the Upper Genital Tract, with Endometritis as an Intermediate Stage of Disease (NEJM, 2015) [MEDLINE]
    • Distribution of Sources
      • Approximately 85% of PID Cases are Caused by Sexually Transmitted Organisms or Bacterial Vaginosis-Associated Organisms
      • Approximately 15% of PID Cases are Caused by Other Organisms Which Have Colonized the Lower Genital Tract
    • Retrograde Menstruation and Sexual Intercourse May Be Involved in the Movement of Organisms from the Lower Genital Tract to the Upper Genital Tract (NEJM, 2015) [MEDLINE]
    • Infection of the Upper Genital Tract Results in Fibrinous/Suppurative Inflammatory Damage Along the Epithelial Surface of the Fallopian Tubes and Peritoneal Surface of the Fallopian Tubes and Ovaries (NEJM, 2015) [MEDLINE]
      • Results in Scarring, Adhesions, and Possibly Partial/Total Fallopian Tube Obstruction
    • Role of Multiple Organisms
      • In Patients with PID, Different Organisms Can Be Isolated from Various Levels of the Genital Tract (Am J Obstet Gynecol. 1979) [MEDLINE]
      • PID May Be a Polymicrobial/Mixed Infection (Involving Facultative, Anaerobic Organisms)
        • Studies Have Isolated Various Organisms in PID (Am J Obstet Gynecol, 1975) [MEDLINE] (NEJM, 1975) [MEDLINE] (Am J Obstet Gynecol, 1980) [MEDLINE]

Microbiology

Acute Pelvic Inflammatory Disease (≤30 Days in Duration)

  • Sexually-Transmitted Cervical Pathogens
    • Neisseria Gonorrhoeae (Gonococci) (see Neisseria Gonorrhoeae, [[Neisseria Gonorrhoeae]])
    • Epidemiology
      • Genital Neisseria Gonorrhoeae Infection was the First Identified Etiology of PID
      • Genital Neisseria Gonorrhoeae Infection is Common in Sexually Active Pre-Menopausal Females
      • Approximately 15% of Endocervical Neisseria Gonorrhoeae Infections Progress to PID ( J Am Vener Dis Assoc, 1974) [MEDLINE] (Br J Vener Dis, 1978) [MEDLINE]
      • Gonococcal PID Has a Higher Risk of Hospitalization/Emergency Department Presentation for PID than Chlamydia Trachomatis PID (Clin Infect Dis, 2018) [MEDLINE]
    • Physiology
      • In Patients with Gonococcal PID, Other Organisms Have Been Isolated in 50% of Cases (Obstet Gynecol, 1981) [MEDLINE]
    • Chlamydia Trachomatis (se eChlamydia Trachomatis, [[Chlamydia Trachomatis]])
    • Epidemiology
      • Genital Chlamydia Trachomatis Infection is the Most Common Bacterial Sexually Transmitted Infection
      • In the US, Genital Chlamydia Trachomatis Infection is the Most Commonly Reported Infectious Disease
      • Genital Chlamydia Trachomatis is Common in Sexually Active Pre-Menopausal Females
      • Genital Chlamydia Trachomatis Infection Accounts for Approximately 33% of PID Cases
      • Approximately 15% of Untreated Endocervical Chlamydia Trachomatis Infections Progress to PID (NEJM, 2015) [MEDLINE]
    • Clinical
      • Asymptomatic or Subclinical Genital Chlamydia Trachomatis Infections are Common
    • Mycoplasma Genitalium (see Mycoplasma Genitalium, [[Mycoplasma Genitalium]])
    • Epidemiology
      • Likely to Be an Etiology of PID in Pre-Menopausal Females (Clin Infect Dis, 2015) [MEDLINE]
  • Bacterial Vaginosis Pathogens
    • General Comments
      • Anaerobic, Facultative Organisms Which are Found in the Vaginal Flora are Present in Greater Numbers in Bacterial Vaginosis, Resulting in Decreased Vaginal Lactobacilli and Overgrowth of a More Complex Anaerobic Biofilm-Associated Microbiome (NEJM, 2015) [MEDLINE]
      • Bacterial Vaginosis is Associated with Local Enzyme Production Which Degrades the Cervical Mucus and Associated Antimicrobial Peptides, Disrupting the Cervical Barrier and Facilitating the Spread of Organisms to the Upper Genital Tract (NEJM, 2015) [MEDLINE]
    • Atopobium (see Atopobium, [[Atopobium]])
      • Has Been Isolated from the Fallopian Tubes of Patients with PID
    • Bacteroides (see Bacteroides, [[Bacteroides]])
    • Clostridium (see Clostridium, [[Clostridium]])
    • Leptotrichia (see Leptotrichia, [[Leptotrichia]])
      • Has Been Isolated from the Fallopian Tubes of Patients with PID
    • Mycoplasma Hominis (see Mycoplasma Hominis, [[Mycoplasma Hominis]])
    • Peptococcus (see Peptococcus, [[Peptococcus]])
    • Peptostreptococcus (see Peptostreptococcus, [[Peptostreptococcus]])
    • Sneathia (see Sneathia, [[Sneathia]])
      • Has Been Isolated from the Fallopian Tubes of Patients with PID
    • Ureaplasma Urealyticum (see Ureaplasma Urealyticum, [[Ureaplasma Urealyticum]])
  • Enteric Pathogens
  • Respiratory Pathogens

Subclinical Pelvic Inflammatory Disease

Chronic Pelvic Inflammatory Disease (>30 Days in Duration)

  • Actinomyces (see Actinomycosis, [[Actinomycosis]])
  • Mycobacterium Tuberculosis (see Tuberculosis, [[Tuberculosis]])
  • While Many of the Pathogens Below (Chlamydia Trachomatis, Neisseria Gonorrhoeae, Mycoplasma Genitalium, etc) May Be Involved in the Initiation of PID, PID Should Be Thought of as a Polymicrobial/Mixed Infection (Involving Facultative and Anaerobic Organisms)
    • Studies Have Isolated Various Organisms in PID (Am J Obstet Gynecol. 1975) [MEDLINE] (NEJM, 1975) [MEDLINE] (Am J Obstet Gynecol, 1980) [MEDLINE]
      • Actinomyces (seee Actinomycosis, [[Actinomycosis]])
        • Rare Etiology
      • Atopobium (see Atopobium, [[Atopobium]])
        • Has Been Isolated from the Fallopian Tubes of Patients with PID
      • Bacteroides (see Bacteroides, [[Bacteroides]])
      • Enterococcus (see Enterococcus, [[Enterococcus]])
        • Rare Etiology
      • Escherichia Coli (see Escherichia Coli, [[Escherichia Coli]])
        • May Be Associated with PID in in Postmenopausal Females
      • Haemophilus Influenzae (see Haemophilus Influenzae, [[Haemophilus Influenzae]])
        • Rare Etiology
      • Leptotrichia (see Leptotrichia, [[Leptotrichia]])
        • Has Been Isolated from the Fallopian Tubes of Patients with PID
      • Mycobacterium Tuberculosis (see Tuberculosis, [[Tuberculosis]])
        • Rare Etiology
      • Peptococcus (see Peptococcus, [[Peptococcus]])
      • Peptostreptococcus (see Peptostreptococcus, [[Peptostreptococcus]])
      • Prevotella (see Prevotella, [[Prevotella]])
      • Proteus Mirabilis (see Proteus Mirabilis, [[Proteus Mirabilis]])
      • Sneathia (see Sneathia, [[Sneathia]])
        • Has Been Isolated from the Fallopian Tubes of Patients with PID
      • Streptococcus Agalactiae (Group B Streptococcus) (see Streptococcus Agalactiae, [[Streptococcus Agalactiae]])
      • Streptococcus Pneumoniae (Pneumococcus) (see Streptococcus Pneumoniae, [[Streptococcus Pneumoniae]])
        • Rare Etiology
      • Streptococcus Pyogenes (Group A Streptococcus) (see Streptococcus Pyogenes, [[Streptococcus Pyogenes]])

Diagnosis

Recommended Testing

  • Complete Blood Count (CBC) (see Complete Blood Count, [[Complete Blood Count]])
    • Recommended for Patients with Fever and More Severe Clinical Presentations
  • C-Reactive Protein (CRP) (see C-Reactive Protein, [[C-Reactive Protein]])
    • Suggested for Patients with Fever and More Severe Clinical Presentations
  • Elevated Erythrocyte Sedimentation Rate (ESR) (see Erythrocyte Sedimentation Rate, [[Erythrocyte Sedimentation Rate]])
    • Suggested for Patients with Fever and More Severe Clinical Presentations
  • Pregnancy Test (see Pregnancy Test, [[Pregnancy Test]])
    • Recommended to Rule Out Ectopic Pregnancy (see Ectopic Pregnancy, [[Ectopic Pregnancy]])
    • Recommended to Rule Out Complication of a Intrauterine Pregnancy (see Pregnancy, [[Pregnancy]])
  • Vaginal Discharge Microscopy
    • Saline Microscopy of Vaginal Discharge with Examination for Increased White Blood Cells is Sensitive for the Diagnosis of PID, But Not Specific
    • Saline Microscopy Can Also Identify Coexisting Bacterial Vaginosis and Trichomoniasis
  • Gram Stain of Cervical Discharge
    • If the Cervical Discharge Gram Stain is Positive for Gram-Negative Intracellular Diplococci (Suggestive of Neisseria Gonorrhoeae) When Interpreted by an Experienced Microscopist, this Significantly Increases the Probability of PID (Int J STD AIDS, 2014) [MEDLINE] (MMWR Recomm Rep, 2015) [MEDLINE]
    • A Negative Cervical Discharge Gram Stain is of Limited Value Because Most Cases of PID are Not Caused by Gonorrhoea, and the Sensitivity of Microscopy is Only 60%
  • Nucleic Acid Amplification Tests (NAAT) for Chlamydia Trachomatis and Neisseria Gonorrhoeae (see xxxx, [[xxxx]])
    • Recommended to Evaluate for Chlamydia and Gonococcal Infections, But Negative Testing Does Not Rule Out the Diagnosis of PID
  • Nucleic Acid Amplification Tests (NAAT) for Mycoplasma Genitalium (see xxxx, [[xxxx]])
    • Recommended to Evaluate for Mycoplasma Genitalium Infection, But Negative Testing Does Not Rule Out the Diagnosis of PID
    • Testing for Mycoplasma Genitalium is Also Recommended to Guide Antibiotic Therapy (Int J STD AIDS, 2018) [MEDLINE]
  • Human Immunodeficiency Virus (HIV) Test (see Human Immunodeficiency Virus Test, [[Human Immunodeficiency Virus Test]]) Recommended to Evaluate for Coexistent HIV Infection
  • Serologic Testing for Syphilis (see xxxx, [[xxxx]])
    • Recommended to Evaluate for Coexistent Syphilis Infection
  • Urinalysis and Urine Culture (see Urinalysis, [[Urinalysis]] and Urine Culture, [[Urine Culture]])
    • Recommended for Cases with Urinary Symptoms

Transvaginal Ultrasound (see Transvaginal Ultrasound, [[Transvaginal Ultrasound]])

  • Recommended to Evaluate for Ectopic Pregnancy, Tubo-Ovarian Abscess, and Other Adnexal Pathology
    • Studies Suggest Limited Ability to Diagnose Acute PID, Although Some Specific Findings May Be Detected (Arch Gynecol Obstet, 2014)[MEDLINE]
      • Thickened, Fluid-Filled Fallopian Tube
      • Cogwheel Sign: cogwheel appearance on a cross-section of the tube
      • Fluid/Gas within the Endometrial Canal/Heterogeneous Endometrial Thickening/Indistinctness of the Endometrial Stripe: may occur in patients with endometritis
      • Complex Thick-Walled, Multilocular Cystic Collection in the Adnexa (Typically with Internal Echoes or Multiple Fluid Levels): in patients with tubo-ovarian abscess
      • Doppler Studies Demonstrating Tubal Hyperemia May Suggest Pelvic Infection

Abdominal/Pelvic CT (see Abdominal/Pelvic Computed Tomography, [[Abdominal-Pelvic Computed Tomography]])

  • Recommended to Evaluate for Ectopic Pregnancy, Tubo-Ovarian Abscess, and Other Adnexal Pathology
    • CT May Be Useful in the Diagnosis of PID (Radiographics, 2002) [MEDLINE]

Abdominal/Pelvic MRI (see xxxx, [[xxxx]])

  • Recommended to Evaluate for Ectopic Pregnancy, Tubo-Ovarian Abscess, and Other Adnexal Pathology
    • MRI May Be Useful in the Diagnosis of PID (Radiology, 1999) [MEDLINE]

Transcervical Endometrial Biopsy (see Transcervical Endometrial Biopsy, [[Transcervical Endometrial Biopsy]])

  • Typically Not Required, But Can Be Used to Diagnose Endometritis
    • Rationale
      • Presence of Endometritis is Correlated with the Presence of Salpingitis
    • Disadvantages
      • Requires Time for Biopsy Processing/Interpretation: treatment decisions are often made before biopsy results are finalized
      • Endometritis May Be Patchy in Distribution, Suggesting that Sampling Error Might Occur

Laparoscopy (see Laparoscopy, [[Laparoscopy]])

  • Clinical Utility
    • Laparoscopy for the Diagnosis of PID Has Low Sensitivity (50%), But High Specificity (Am J Obstet Gynecol, 1991) [MEDLINE]
      • Laparoscopy Does Not Allow Visualization of Endometritis or Mild Intratubal Inflammation (Infect Dis Obstet Gynecol, 2002) [MEDLINE] (Obstet Gynecol, 2003) [MEDLINE]
    • Laparoscopy May Be Useful in an Outpatient Who is Not Responding to Treatment of PID, to Evaluate for an Alternative Etiology
    • Laparoscopy May Be Useful in an Inpatient Who is Not Improving or Worsening After 72 hrs of Treatment, to Evaluate for an Alternative Etiology

Clinical Manifestations

Acute Symptomatic Pelvic Inflammatory Disease

General Comments

  • Sensitivity of Clinical Diagnosis of PID is 65-90% (Am J Obstet Gynecol, 1969) [MEDLINE] (Am J Obstet Gynecol, 1992) [MEDLINE] (Am J Obstet Gynecol, 1992) [MEDLINE] (Infect Dis Obstet Gynecol, 1997) [MEDLINE]
    • Since the Reproductive Consequences of PID are High, Treatment with Antibiotics is Often Made Based Upon a Presumptive Diagnosis
    • Adding Diagnostic Criteria Increases the Specificity, But Decreases the Sensitivity of the Diagnosis (MMWR Recomm Rep, 2015) [MEDLINE]
      • Fever >101°F (>38.3°C)
      • Abnormal Vaginal/Cervical Mucopurulent Discharge or Cervical Friability
      • Presence of Abundant White Blood Cells (>15-20 Per High Power Field or White Blood Cells > Epithelial Cells) on Saline Microscopy of Vaginal Secretions
      • Evidence of Cervical Infection with Neisseria Gonorrhoeae or Chlamydia Trachomatis

Hematologic Manifestations

  • Leukocytosis (see Leukocytosis, [[Leukocytosis]])
    • Occurs in Only a Minority of PID Cases (NEJM, 1975) [MEDLINE]
  • Elevated Erythrocyte Sedimentation Rate (ESR) (see Elevated Erythrocyte Sedimentation Rate, [[Elevated Erythrocyte Sedimentation Rate]])
    • Low Sensitivity/Specificity in the Diagnosis of PID (Am J Obstet Gynecol, 1993) [MEDLINE]
      • Patients with Severe PID Have Higher ESR and CRP Levels than Did Those with Mild Disease
      • In Detecting Severe PID with an ESR ≥40 mm/hr and CRP ≥60 mg/L Had a Sensitivity of 97%, Specificity of 61%, Negative Predictive Value of 96%, and a Positive Predictive Value of 70%
      • All Patients with Tubo-Ovarian Abscess or Perihepatitis and 86% of Patients Who Had Anaerobic Bacteria Isolated from the Fallopian Tubes Tested Positive with These Cutoff Levels
  • Elevated C-Reactive Protein (CRP) (see Elevated C-Reactive Protein, [[Elevated C-Reactive Protein]])
    • Low Sensitivity/Specificity in the Diagnosis of PID (Am J Obstet Gynecol, 1993) [MEDLINE]
      • Patients with Severe PID Have Higher ESR and CRP Levels than Did Those with Mild Disease
      • In Detecting Severe PID with an ESR ≥40 mm/hr and CRP ≥60 mg/L Had a Sensitivity of 97%, Specificity of 61%, Negative Predictive Value of 96%, and a Positive Predictive Value of 70%
      • All Patients with Tubo-Ovarian Abscess or Perihepatitis and 86% of Patients Who Had Anaerobic Bacteria Isolated from the Fallopian Tubes Tested Positive with These Cutoff Levels

Infectious Manifestations

  • Fever (see Fever, [[Fever]])
    • More Commonly Occurs in Cases with Peritonitis and/or Pelvic Abscess
  • Sepsis (see Sepsis, [[Sepsis]])
    • May Occur in Some Cases

Reproductive Manifestations

  • General Comments
    • Anatomic Sites of Infection
      • Endometritis
      • Salpingitis
        • Inflammation of Fallopian Tubes and Adjacent Structures
      • Tubo-Ovarian Abscess (see Tubo-Ovarian Abscess, [[Tubo-Ovarian Abscess]])
        • inflammatory Mass Involving the Fallopian Tube, Ovary, and Occasionally Other Adjacent Structures
        • Presents with a Palpable Adnexal Mass
      • Pelvic Abscess (see Abdominal Abscess, [[Abdominal Abscess]]): occurs in only a small percentage of cases
      • Peritonitis (see Peritonitis, [[Peritonitis]]): occurs in only a small percentage of cases
      • Perihepatitis (Fitz-Hugh Curtis Syndrome)
        • Inflammation of the Liver Capsule and Peritoneal Surfaces of the Anterior Right Upper Quadrant (with Minimal Hepatic Parenchymal Involvement)
        • Occurs in 10% of Patients with Acute PID (Associated with Both Neisseria Gonorrhoeae and Chlamydia Trachomatis Infections) (Am J Obstet Gynecol, 1980) [MEDLINE]
        • Clinically Presents with RUQ Abdominal Pain (and Tenderness) with Pleuritic Component (Which May Be Referred to the Right Shoulder in Some Cases)
        • May Be Misdiagnosed as Cholecystitis (J Gynecol Obstet Biol Reprod-Paris), 1990) [MEDLINE]
        • Minimal Transaminitis May Be Observed (JAMA, 1978) [MEDLINE] (Br Med Bull, 1983) [MEDLINE]
        • Laparoscopic Findings Include Patchy Fibrinous/Purulent Exudate (“Violin String Adhesions”), Predominantly Involving the Anterior Liver Surface (But Not the Liver Parenchyma)
    • Severity of Infection
      • Most Patients Present with Mild-Moderate Disease
  • Lower Abdominal Pain/Tenderness (see Abdominal Pain, [[Abdominal Pain]])
    • Lower Abdominal Pain in PID Has Been Classically Described as Severe and Abrupt in Onset During or Shortly After Menstruation (Am J Obstet Gynecol, 1998) [MEDLINE] (NEJM, 2015) [MEDLINE]
      • However, in the Era of Decreasing Incidence of Neisseria Gonorrhoeae infections, the Presentation is Frequently Less Well-Defined and More Variable
      • Pain May Be Subtle and Worsening During Intercourse or with Jarring Movement May Be the Presenting Symptom in Some Cases
      • Pain is Generally More Severe in Cases with Peritonitis and/or Pelvic Abscess
    • Pain is Rarely >2 wks in Duration (MMWR Recomm Rep, 2015) [MEDLINE]
    • Abdominal Pain/Tenderness is Usually Bilateral, But May Be Asymmetric in Some Cases
    • Consideration of Alternative Diagnoses of Lower Abdominal Pain
      • Sudden Onset of Severe Abdominal Pain Suggests the Diagnosis of Ovarian Cyst Rupture or Ovarian Torsion
      • Abdominal Pain Localized to the Right Iliac Fossa Suggests the Diagnosis of Appendicitis
      • Abdominal Pain Associated with Bowel Symptoms in an Older Female Suggests the Diagnosis of Diverticulitis
  • Abnormal Uterine Bleeding (Menorrhagia, Post-Coital Bleeding, Inter-Menstrual Bleeding) (see xxxx, [[xxxx]])
    • Occurs in >33% of Cases (Sex Transm Dis, 2005) [MEDLINE]
  • Vaginal Discharge (see Vaginal Discharge, [[Vaginal Discharge]])
    • Common
  • Endocervical Discharge
    • Common
  • Urinary Frequency (see Urinary Frequency, [[Urinary Frequency]])
    • Occurs in Some Cases
  • Rebound Tenderness
    • May Occur in More Severe Cases with Peritonitis and/or Pelvic Abscess
  • Decreased Bowel Sounds
    • May Occur in More Severe Cases with Peritonitis and/or Pelvic Abscess
  • Cervical Motion/Uterine/Adnexal Tenderness
    • Classical Findings in PID (Am J Obstet Gynecol, 2001) [MEDLINE] (Sex Transm Dis, 2005) [MEDLINE]
    • Significant Lateralization of Adnexal Tenderness is Uncommon in PID
    • Adnexal Tenderness is the Exam Finding Which Correlates Best with the Presence of Endometritis on Endometrial Biopsy (Am J Obstet Gynecol, 2001) [MEDLINE]

Subclinical Pelvic Inflammatory Disease

  • Epidemiology
    • Associated with Specific Pathogens
    • Subclinical PID is Common (Sex Transm Dis, 2005) [MEDLINE]
    • Subclinical PID is More Common in Patients with Lower Genital Tract Infection (with Gonorrhea, Chlamydia, or Bacterial Vaginosis) (Obstet Gynecol, 2002)
    • Subclinical PID Occurs More Commonly in Orla Contraceptive Users (JAMA, 1985) [MEDLINE] (Am J Obstet Gynecol, 1997) [MEDLINE]
    • Patients with Tubal Factor Infertility Due to Probable PID Frequently Do Not Give a History of PID
      • Approximately 30.6% of Patients with Adhesions/Distal Tubal Occlusion Have a History of PID, But 80.6% of These Patients Have a History of Lower Abdominal Pain (Obstet Gynecol, 1995) [MEDLINE]
      • Only 11% of Patients with Adhesions/Distal Tubal Occlusion Have No History of PID or Lower Abdominal Pain (or Laparoscopic Evidence of Endometriosis), Suggesting This Subset Could Be Classified as Having Silent PID (Obstet Gynecol, 1995) [MEDLINE]
  • Diagnosis
    • Previously Undiagnosed PID Has Been Identified in Patients with a History of Only Mild Symptoms, But an Endometrial Biopsy Demonstrating Neutrophilia and Plasma Cells Consistent with PID
      • In Patients at Risk for PID But without Clinical Findings of PID, 13% Have Endometritis on Endometrial Biopsy (and Rates of Cervical Chlamydia Trachomatis Isolation were Similar to Women with Clinically Diagnosed PID) (Sex Transm Dis, 2005) [MEDLINE]
  • Clinical
    • Symptoms May Be Subtle Enough for Patient Not to Seek Medical Attention
    • Infertility

Chronic Pelvic Inflammatory Disease

  • Epidemiology
    • Associated with Specific Pathogens
      • Actinomyces (see Actinomycosis, [[Actinomycosis]])
        • IUD Use May Be a Risk Factor
      • Mycobacterium Tuberculosis (see Tuberculosis, [[Tuberculosis]])
  • Clinical
    • Indolent Presentation

Treatment

Antibiotics

  • Azithromycin (Zithromax) (see Azithromycin, [[Azithromycin]])

References

Background

  • Vaginal flora and its role in disease entities. Clin Obstet Gynecol. 1976;19(1):61 [MEDLINE]
  • Bacterial communities in women with bacterial vaginosis: high resolution phylogenetic analyses reveal relationships of microbiota to clinical criteria. PLoS One. 2012;7(6):e37818 [MEDLINE]

General

  • Pelvic inflammatory disease. N Engl J Med. 2015 May;372(21):2039-48 [MEDLINE]

Epidemiology

  • Oral contraceptives, Chlamydia trachomatis infection, and pelvic inflammatory disease. A word of caution about protection. JAMA. 1985;253(15):2246 [MEDLINE]
  • Oral contraception and the recognition of endometritis. Am J Obstet Gynecol. 1997;176(3):580 [MEDLINE]

Etiology

  • Economic consequences of gonorrhea in women: experience from an Urban hospital. J Am Vener Dis Assoc. 1974;1(1):40 [MEDLINE]
  • The bacteriology of acute pelvic inflammatory disease. Am J Obstet Gynecol. 1975;122(7):876 [MEDLINE]
  • Polymicrobial etiology of acute pelvic inflammatory disease. N Engl J Med. 1975;293(4):166 [MEDLINE]
  • Changes in the incidence of acute gonococcal and nongonococcal salpingitis. A five-year study from an urban area of central Sweden. Br J Vener Dis. 1978;54(4):247 [MEDLINE]
  • Use of laparoscopy to determine the microbiologic etiology of acute salpingitis. Am J Obstet Gynecol. 1979;134(1):68 [MEDLINE]
  • The microbiology and therapy of acute pelvic inflammatory disease in hospitalized patients. Am J Obstet Gynecol. 1980;136(2):179 [MEDLINE]
  • Etiology of acute salpingitis: influence of episode number and duration of symptoms. Obstet Gynecol. 1981;58(1):62 [MEDLINE]
  • Observations concerning the microbial etiology of acute salpingitis. Am J Obstet Gynecol. 1994;170(4):1008 [MEDLINE]
  • 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 [MEDLINE]
  • Mycoplasma genitalium infection and female reproductive tract disease: a meta-analysis. Clin Infect Dis. 2015;61(3):418 [MEDLINE]
  • Pelvic inflammatory disease. N Engl J Med. 2015 May;372(21):2039-48 [MEDLINE]
  • Risk of Pelvic Inflammatory Disease in Relation to Chlamydia and Gonorrhea Testing, Repeat Testing, and Positivity: A Population-Based Cohort Study. Clin Infect Dis. 2018;66(3):437 [MEDLINE]

Diagnosis

  • Objectivized diagnosis of acute pelvic inflammatory disease. Diagnostic and prognostic value of routine laparoscopy. Am J Obstet Gynecol. 1969;105(7):1088 [MEDLINE]
  • The accuracy of clinical findings and laparoscopy in pelvic inflammatory disease. Am J Obstet Gynecol. 1991;164(1 Pt 1):113 [MEDLINE]
  • Test performance of erythrocyte sedimentation rate and C-reactive protein in assessing the severity of acute pelvic inflammatory disease. Am J Obstet Gynecol. 1993 Nov;169(5):1143-9 [MEDLINE]
  • Performance of clinical and laparoscopic criteria for the diagnosis of upper genital tract infection. Infect Dis Obstet Gynecol. 1997;5(4):291 [MEDLINE]
  • MR imaging in pelvic inflammatory disease: comparison with laparoscopy and US. Radiology. 1999 Jan;210(1):209-16 [MEDLINE]
  • Gynecologic causes of acute pelvic pain: spectrum of CT findings. Radiographics. 2002;22(4):785 [MEDLINE]
  • Accuracy of five different diagnostic techniques in mild-to-moderate pelvic inflammatory disease. Infect Dis Obstet Gynecol. 2002;10(4):171-80 [MEDLINE]
  • Magnetic resonance imaging findings in gynecologic emergencies. J Comput Assist Tomogr. 2003 Jul-Aug;27(4):564-70 [MEDLINE]
  • Observer agreement with laparoscopic diagnosis of pelvic inflammatory disease using photographs. Obstet Gynecol. 2003 May;101(5 Pt 1):875-80 [MEDLINE]
  • The sensitivity and specificity of transvaginal ultrasound with regard to acute pelvic inflammatory disease: a review of the literature. Arch Gynecol Obstet. 2014 Apr;289(4):705-14 [MEDLINE]
  • Pelvic inflammatory disease. N Engl J Med. 2015 May;372(21):2039-48 [MEDLINE]

Clinical

  • Perihepatitis associated with salpingitis in adolescents. JAMA. 1978;240(12):1253 [MEDLINE]
  • Chlamydial serology in infertile women by immunofluorescence. Fertil Steril. 1979;31(6):656 [MEDLINE]
  • Increased frequency of serum antibodies to Chlamydia trachomatis in infertility due to distal tubal disease. Lancet. 1982;2(8298):574 [MEDLINE]
  • Perihepatitis. Br Med Bull. 1983 Apr;39(2):159-62 [MEDLINE]
  • Chlamydia trachomatis infection in Fitz-Hugh-Curtis syndrome. Am J Obstet Gynecol. 1980;138(7 Pt 2):1034 [MEDLINE]
  • Association of infection with Chlamydia trachomatis with Fitz-Hugh-Curtis syndrome. J Infect Dis. 1981;144(2):176 [MEDLINE]
  • [Chlamydia trachomatis perihepatitis (Fitz Hugh-Curtis syndrome). Apropos of 20 cases]. J Gynecol Obstet Biol Reprod (Paris). 1990;19(4):447 [MEDLINE]
  • Pelvic inflammatory disease: findings during inpatient treatment of clinically severe, laparoscopy-documented disease. Am J Obstet Gynecol. 1992;166(2):519 [MEDLINE]
  • Silent pelvic inflammatory disease: is it overstated? Obstet Gynecol. 1995;86(3):321 [MEDLINE]
  • Performance of clinical and laparoscopic criteria for the diagnosis of upper genital tract infection. Infect Dis Obstet Gynecol. 1997;5(4):291 [MEDLINE]
  • Clinical predictors of endometritis in women with symptoms and signs of pelvic inflammatory disease. Am J Obstet Gynecol. 2001;184(5):856 [MEDLINE]
  • Comparison of acute and subclinical pelvic inflammatory disease. Sex Transm Dis. 2005;32(7):400 [MEDLINE]

Treatment

  • 2012 European guideline for the management of pelvic inflammatory disease. Int J STD AIDS. 2014 Jan;25(1):1-7 [MEDLINE]
  • Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(RR-03):1 [MEDLINE]
  • Pelvic inflammatory disease. N Engl J Med. 2015 May;372(21):2039-48 [MEDLINE]
  • 2017 European guideline for the management of pelvic inflammatory disease. Int J STD AIDS. 2018;29(2):108 [MEDLINE]