Pelvic Inflammatory Disease (PID)

CHAPTER 93

Pelvic Inflammatory Disease (PID)

Presentation

A sexually active woman (commonly 15 to 35 years of age), possibly with a new sex partner or multiple sex partners, complains of lower abdominal pain beginning with or soon after her last menstrual period. There may be associated vaginal discharge, malodor, dysuria, dyspareunia, menorrhagia, or intermenstrual bleeding. In patients with more severe infections, fever, chills, malaise, nausea, and vomiting may develop.

Women with severe pelvic pain tend to walk in a slightly bent-over position, holding their lower abdomen and shuffling their feet. Abdominal examination reveals lower quadrant tenderness, sometimes with rebound, and occasionally, there will be right upper quadrant tenderness resulting from gonococcal perihepatitis (Fitz-Hugh–Curtis syndrome). Pelvic examination demonstrates bilateral adnexal tenderness as well as uterine fundal and cervical motion tenderness.

Many women with pelvic inflammatory disease (PID) exhibit subtle or mild symptoms with absence of fever and leukocytosis as well as minimal cervical motion tenderness and adnexal tenderness.

What To Do:

Always perform a pelvic examination on women with lower abdominal complaints or lower abdominal tenderness. The examination should be thorough, yet performed as gently and briefly as possible to avoid exacerbating a very painful condition. When the pain is intolerable, provide IV narcotic analgesia.

Obtain urine for urinalysis and blood or urine for pregnancy testing. A catheterized urine specimen will be required when a vaginal discharge or bleeding is present.

Obtain endocervical cultures for Neisseria gonorrhoeae and Chlamydia trachomatis. Under ideal transport conditions, gonorrheal culture is inexpensive, excellent, and, in some cases, as sensitive as nucleic acid amplification testing. However, when the maintenance of appropriate transport conditions is not possible, nonculture nucleic acid amplified testing is superior. Testing for Chlamydia has been revolutionized by the emergence of these nucleic acid amplification techniques, which has improved the sensitivity of disease detection by 25% to 30% compared with cultures. Older nonculture techniques, such as direct fluorescent antibody, enzyme immunoassay, and nonamplified nucleic acid hybridization, are even less sensitive than a culture.

When PID is strongly suspected, obtain blood for syphilis serology and hepatitis B, and recommend human immunodeficiency virus (HIV) testing, because these infections may be contracted simultaneously.

Consider obtaining a leukocyte count, sedimentation rate, and C-reactive protein level. These are indicators of clinical severity, but normal results do not rule out PID.

Determine the pH of any vaginal discharge, and make wet-mount examinations and Gram stains of endocervical secretions, looking for Candida organisms, Trichomonas organisms, leukocytes, and clue cells (see Chapter 95). Gram stain of the cervical specimen is not adequate for diagnosing gonorrhea in women.

Perform pelvic ultrasonography if there is a suspected mass, severe pain, or a positive pregnancy test. One of the most specific criteria for diagnosing PID is the finding of thickened, fluid-filled tubes, with or without free pelvic fluid, on transvaginal sonography.

Maintain a low threshold for diagnosing PID. No laboratory tests are diagnostic for PID, and the clinical diagnosis is also imprecise. In addition, the long-term sequelae of missing PID are significant and include infertility, tubo-ovarian abscess (TOA), perihepatitis, chronic pelvic pain, and ectopic pregnancy.

Initiate empirical treatment of PID in sexually active young women and other women at risk for sexually transmitted diseases (STDs), if the following minimum criteria are present and no other causes for the illness can be identified:

Uterine/adnexal tenderness

Cervical motion tenderness

Base treatment on a patient’s risk profile. More elaborate diagnostic evaluation often is needed. These additional criteria may be used to enhance the specificity of the minimum criteria and further support a diagnosis of PID:

Oral temperature greater than 101° F (>38.3° C)

Abnormal cervical or vaginal mucopurulent discharge

Presence of white blood cells (WBCs) on saline microscopy of vaginal secretions

Elevated erythrocyte sedimentation rate

Elevated C-reactive protein level

Laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis

Investigate alternative causes for pain if the cervical discharge appears normal and no WBCs are found on the wet-mount preparation. Consider transvaginal sonography and spiral CT scanning to help rule out other potential gynecologic, gastrointestinal (especially appendicitis), or urologic causes.

When in doubt, always treat. Subtle findings may include only a history of abnormal uterine bleeding, dyspareunia, vaginal discharge, or cervical purulence.

Remove any intrauterine device (IUD).

Treat suspected cases while awaiting diagnostic confirmation. Prevention of long-term sequelae has been linked directly with immediate administration of appropriate antibiotics. When selecting a treatment regimen, consider availability, cost, patient compliance, and antimicrobial susceptibility.

Hospitalize all patients with pelvic or tubo-ovarian abscess, pregnancy, high fever (38.5° C), nausea and vomiting that preclude oral antibiotics, or current use of an IUD, as well as when surgical emergencies (e.g., appendicitis) cannot be excluded. Also hospitalize when there is severe illness with septicemia or other serious disease, high risk for poor compliance, failed follow-up, or failure after 48 hours of the outpatient therapy outlined later. No data are available suggesting that adolescent women, women over 35 years of age, or HIV-infected women benefit from hospitalization for treatment of PID unless they meet the criteria as noted above.

Whether inpatient or outpatient, the Centers for Disease Control and Prevention (CDC), as of 2007, no longer recommends fluoroquinolones as therapy for N. gonorrhoeae as a suspected or proven pathogen in PID. Local resistance patterns may allow use, if less than 5% of isolates are resistant; however, one must have a culture that demonstrates sensitivity, not just a positive nucleic acid amplified test (NAAT). If the NAAT is positive, one must use a cephalosporin to cover N. gonorrhoeae.

Inpatient treatment, with or without TOA, consists of IV antibiotics. Give cefotetan, 2 g IV every 12 hours, or cefoxitin, 2 g IV every 6 hours, plus doxycycline, 100 mg orally every 12 hours. (Because of pain associated with infusion, doxycycline should be administered orally when possible, even when the patient is hospitalized.) Alternatively, clindamycin, 900 mg every 8 hours IV, plus gentamycin at a loading dose of 2 g/kg, followed by 1.5 mg/kg every 8 hours. A single daily dose of gentamycin can be substituted. Yet another alternative is ampicillin-sulbactam (3 g every 6 hours IV) with doxycycline (100 mg oral preferred). Transition to oral therapy from parenteral can start after 24 hours, with demonstrated clinical improvement.

Treat mild to moderate cases on an outpatient basis. Give ceftriaxone (Rocephin), 250 mg IM in a single dose, plus doxycycline, 100 mg PO bid for 14 days, with or without metronidazole (Flagyl), 500 mg PO bid for 14 days. (Coverage of anaerobes may require the addition of metronidazole, which will also effectively treat bacterial vaginosis and trichomoniasis, frequently associated with PID, as well as provide coverage for a patient who recently had a gynecologic instrumentation within the preceding 2 to 3 weeks).

Arrange for follow-up examination within 72 hours. Patients should demonstrate substantial clinical improvement (e.g., defervescence, reduction in direct or rebound abdominal tenderness, and reduction in uterine, adnexal, and cervical motion tenderness) within 3 days of initiation of therapy. Patients who do not improve within this period usually require hospitalization, additional diagnostic tests, and possible surgical intervention.

Provide analgesics as needed.

Instruct the patient to abstain from sexual intercourse for at least 2 weeks.

Unless sexual acquisition can be excluded with certainty, treat the partner for presumptive gonorrhea and chlamydia if he or she had sexual contact with the patient during the 60 days preceding the patient’s onset of symptoms. Use ceftriaxone (Rocephin), 125 mg IM once, or ciprofloxacin (Cipro) 500 mg PO once (based on local resistance patterns), 500 mg PO once, PLUS either doxycycline (Vibramycin), 100 mg PO bid × 7 days, or azithromycin (Zithromax), 1000 mg PO once.

Male partners of women who have PID caused by C. trachomatis and/or N. gonorrhoeae often are asymptomatic. Sex partners should be treated empirically with regimens that are effective against both of these infections, regardless of the pathogens isolated from the infected woman. Patient-delivered treatment of sex partners was associated with a reduced risk for recurrent gonorrhea and/or chlamydia in a University of Washington (Seattle) study.

Counsel the patient about the sexually transmitted nature of PID and its risks for infertility (8% of women after a single case, 19.5% after two episodes, and 40% in those women who had three or more episodes) and ectopic pregnancy, which is increased sixfold to tenfold. Women should also be made aware that as many as 23% of women who develop PID will be troubled with chronic pelvic pain, which is associated with a lower quality of physical and mental health. Barrier methods of contraception (condoms and diaphragms) reduce the risk. Vaginal spermicides are also bactericidal.

Rescreen the patient in 3 to 4 months, because reinfection is common. This can be done with consideration of your population and local pattern of prevalence of disease. In one study, 15% to 23% of patients had one or more new infections, and 66% were asymptomatic.

What Not To Do:

Do not miss the more unilateral disorders, such as ectopic pregnancy, appendicitis, ovarian cyst or torsion, and diverticulitis. Early consultation by both a general surgeon and an obstetrician/gynecologist is sometimes necessary.

Do not diagnose PID in a patient with a positive pregnancy test without ruling out ectopic pregnancy, usually with a sonogram.

Do not ignore pelvic symptoms if the patient has gonococcal perihepatic inflammation.

Do not presume to treat for urinary tract infection (UTI) in a patient with lower abdominal pain and when a urine dip demonstrates leukocyte esterase. Do the pelvic exam, because the leukocytes may be from the vaginal discharge of PID.

Do not assume sexual activity based on age.

Do not talk above the educational/comprehension level of the preteen and teenage patient. Their definition of sexual activity and yours may be different.

Discussion

The clinical diagnosis of acute PID is imprecise. The positive predictive value (PPV) of a clinical diagnosis of acute PID differs, depending on epidemiologic characteristics and the clinical setting. There is a higher PPV among sexually active young women (particularly adolescents) and among patients attending STD clinics or from settings in which rates of gonorrhea or chlamydia are high. In all settings, however, no single historical, physical, or laboratory finding is both sensitive and specific for the diagnosis of acute PID (i.e., can be used both to detect all cases of PID and to exclude all women without PID).

In spite of this, prompt diagnosis and early presumptive treatment are crucial to maintaining fertility and avoiding the other complications of PID. It should be kept in mind that the diagnosis and management of other common causes of lower abdominal pain (e.g., ectopic pregnancy, acute appendicitis, and functional pain) are unlikely to be impaired by initiating empirical antimicrobial therapy for PID.

PID is defined as salpingitis, often accompanied by endometritis or secondary pelvic peritonitis, which results from an ascending genital infection. In the United States, there is an increased risk for PID with multiple sex partners, nonbarrier contraceptive use, instrumentation of the cervix, smoking, minority race, use of an IUD, previous history of PID, and vaginal douching. The incubation period for PID varies from 1 to 2 days to weeks or months.

Gonorrheal and chlamydial infections are thought to initiate conditions that allow organisms from the lower genital tract to ascend into the upper genital tract. The resulting polymicrobial infection includes facultative and anaerobic organisms. A variety of gram-positive and gram-negative aerobic and anaerobic pathogens, such as aerobic streptococci, Escherichia coli, Bacteroides fragilis, Proteus spp., and Peptostreptococcus spp. can be recovered from the uterus, fallopian tubes, and peritoneal cavity. Gonococcal and chlamydial PID often occur within a week of the onset of menses. The absence of a positive test for N. gonorrhoeae or C. trachomatis does not rule out PID, because these microbes are only found in 25% to 40% of patients. A mixed aerobic and anaerobic infection is found in 25% to 60% of cases. PID associated with gonorrhea produces relatively rapid and more severe symptoms than chlamydia, whereas the latter is associated with more severe scarring.

Tubo-ovarian abscess (TOA) should be suspected in the setting of PID with persistent fever, despite adequate antibiotics, continued lower abdominal pain, or adnexal mass. Pelvic ultrasonography is highly sensitive (90% to 95%) in diagnosing TOA. It is usually amenable to medical therapy but requires surgical intervention in up to 25% of cases. Surgical intervention for TOA should be considered if there is an increase in the size of the abscess, persistent fever spikes, suspected abscess rupture, or lack of clinical improvement in 48 to 72 hours.

Although all of the gonorrheal isolates in the United States are susceptible to cephalosporins, resistance to quinolones has developed. Fluoroquinolones are no longer recommended for the treatment of PID. Laparoscopy is indicated in severe cases, if diagnosis is uncertain or there is inadequate response to initial antibiotic therapy.