Pelvic inflammatory disease is a subacute or chronic infection of the upper female reproductive tract and/or peritoneum. The most common causative organisms are Chlamydia trachomatis and Neisseria gonorrhoeae, but most cases are polymicrobial, involving anaerobes.
Clinical criteria for diagnosis
- Cervical motion tendernes or,
- Uterine tenderness, or
- Adnexal tenderness
Additional criteria may include oral temperature > 38.3 degrees Celsius, abnormal cervical or vaginal mucopurulent discharge, abundant WBCs on microscopy of vaginal secretions, elevated ESR or CRP, and documented chlamydial or gonorrhoeal infection
- Risk factors
- Multiple sex partners or new sexual partner
- Age <25 years
- Unprotected sex
- History of sexually tranmitted infection
- Younger age at first intercourse
- Substance abuse
- Lower socioeconomic status
- Intrauterine contraceptive device (IUD) use
- Instrumentation of the uterus such as surgical termination of pregnancy
- Post-partum endometritis.
- Protective factors
- Barrier contraception
- Combined oral contraceptive pill
- Patient history
- Young woman of reproductive age
- Unprotected intercourse with multiple partners
- Signs and symptoms
- Lower abdominal pain
- Acute and constant
- Dull and crampy
- Usually non-severe
- Bilateral
- Associated with menstruation (begins a few days after menses)
- Mucopurulent vaginal discharge
- Deep dyspareunia
- Post-coital vaginal bleeding (inflammation makes tissue more friable)
- Fever
- Nausea and vomiting
- Irregular and/or more painful menses.
- Lower abdominal pain
- Physical examination
- Cervical motion tenderness
- Uterine tenderness
- Global uterine or adnexal tenderness (most sensitive finding)
- Mucopurulent discharge
- Erythematous inflammed cervix
- Fever +/- other systemic symptoms
- RUQ pain/ tenderness (Fitz-Hugh-Curtis syndrome)
- Rebound tenderness and guarding (in tubo-ovarian abscess or generalized peritonitis)
- Differentials
- Ectopic pregnancy
- Endometriosis
- Ovarian torsion
- Ovarian cysts
- Tubo-ovarian abscess
- Urinary tract infection
- Interstitial cystitis
- Appendicitis
- Investigations
- Qualitative B-hCG to rule out ectopic pregnancy
- Culture and microscopy of vaginal secretions
- NAAT for gonorrhoea and chlamydia.
- Transvaginal ultrasound or CT-scan to rule out tubo-ovarian abscess, particularly in more ill-appearing patients and those who do not respond to outpatient treatment
- Liver Function Test if there is RUQ pain
- Indications for inpatient treatment
- Adolescent
- Cannot complete a course of oral antibiotics (including nausea or vomiting that precludes oral treatment)
- Failed outpatient treatment
- Pregnant patient
- Tubo-ovarian abscess (large abscesses will need to be drained)
- Severe disease (high fever, toxic appearing)
- Generalized peritonitis
- Drug abuse
- Recent intrauterine instrumentation
- WBCs > 15,000
- Treatment
- Outpatient
- Ceftriaxone and doxycicline
- Metronidazole may be added to target anaerobes
- Azithromycin can be used in place of ceftriaxone in case of allergy to cephalosporins
- Inpatient (intravenous antibiotics)
- Cefoxitin/cefotetan + doxycycline or clindamycin + gentamicin
- Clindamycin or metronidazole may be added for anaerobic coverage
- Transition to oral antibiotics and discharge 24-48 hours after clinical improvement
- If treatment fails, imaging can be performed to rule out a tubo-ovarian abscess
- Treatment of a tubo-ovarian abscess
- IV antibiotics for abscesses 4-6 cm
- Percutaneous drainage for large abscess (especially those > 10 cm)
- Surgical drainage with salpingo-oophorectomy for:
- Sepsis
- Percutaneous drainage is unfeasable
- Patients who fail to improve with antibiotics
- Rupture of an abscess
- Outpatient
- Complications of pelvic inflammatory disease
- Ectopic pregnancy
- Infertility
- Fitz-Hugh-Curtis syndrome when the infection spreads to the peritoneum and peri-hepatic structures
- Chronic pelvic pain
- Tubo-ovarian abscess