Gynecology Topic 36. Pelvic inflammatory disease

I. Pelvic Inflammatory Disease (PID)

Definition

• PID: Acute infection and inflammation of the upper female genital tract.
• May include: Endometritis, salpingitis, pyosalpinx, tubo-ovarian abscess (TOA), pelvic peritonitis.
• Often polymicrobial and ascending from the vagina/cervix.
• Delayed/subclinical disease may later present as infertility or chronic pelvic pain.

Etiology

• Ascending infection is most common.
• STI pathogens:

• Neisseria gonorrhoeae.
• Chlamydia trachomatis.
• Mycoplasma genitalium.

• Vaginal/enteric flora and anaerobes:

• Gardnerella vaginalis / BV-associated organisms.
• E. coli, Peptostreptococcus, other anaerobes/enteric flora.

Risk Factors

• Multiple or new sex partners.
• Unprotected intercourse.
• Previous PID or STI.
• Recent IUD insertion → Risk mainly limited to first few weeks after insertion.
• Recent childbirth, abortion, D&C, hysteroscopy or other gynecologic procedures.

II. Clinical Features

Symptoms

• Lower abdominal/pelvic pain → Usually bilateral; often worse with coitus or movement.
• Fever, chills; temperature may be ≥38°C.
• Mucopurulent/purulent vaginal or cervical discharge.
• Abnormal uterine bleeding.
• Deep dyspareunia.
• Nausea/vomiting, malaise in more severe disease.
• RUQ pain → Fitz-Hugh-Curtis syndrome.

Physical Examination

• Lower abdominal tenderness.
• Pelvic examination minimal criteria:

• Cervical motion tenderness.
• Uterine tenderness.
• Adnexal tenderness.

• Cervicitis: Friable red cervix, mucopurulent discharge.
• Guarding/rebound tenderness → Peritonitis or ruptured abscess concern.
• Palpable tender adnexal mass → Tubo-ovarian abscess.

III. Complications

Acute Complications

• Tubo-ovarian abscess.
• Pelvic peritonitis.
• Sepsis, septic shock.
• Ruptured TOA → Surgical emergency.
• Fitz-Hugh-Curtis syndrome: Perihepatitis → RUQ pain + violin-string adhesions between liver capsule and abdominal wall/diaphragm.

Long-Term Sequelae

• Tubal scarring/adhesions → Tubal occlusion.
• Infertility.
• Ectopic pregnancy.
• Chronic pelvic pain.
• Recurrent PID.

IV. Diagnosis

Clinical Diagnosis

• Maintain low threshold because delayed treatment increases infertility and ectopic pregnancy risk.
• Presumptive treatment is indicated in sexually active women at STI risk with pelvic/lower abdominal pain when no other cause is found and ≥1 of:

• Cervical motion tenderness.
• Uterine tenderness.
• Adnexal tenderness.

Laboratory Tests

• Pregnancy test (β-hCG) → Exclude ectopic pregnancy.
• CBC → Leukocytosis may support diagnosis.
• CRP, ESR → May be elevated; nonspecific.
• LFTs if RUQ pain → Fitz-Hugh-Curtis differential.
• Urinalysis/urine culture → UTI differential.

Microbiology

• NAAT/PCR for N. gonorrhoeae and C. trachomatis from cervical/vaginal specimen or urine.
• Culture/wet mount may identify discharge, BV/trichomoniasis or alternate infection.
• Negative gonorrhea/chlamydia tests do not exclude PID → Treat empirically if clinical criteria fit.

Imaging

• Transvaginal US → Evaluate complications and differential diagnoses.
• Salpingitis signs:

• Thickened, fluid-filled fallopian tube.
• Cogwheel sign.
• Tubal hyperemia, free fluid.

• Tubo-ovarian abscess → Complex adnexal mass.

Laparoscopy

• Gold standard for visual diagnosis but not required before treatment.
• Use when diagnosis is unclear, severe disease, treatment failure, or surgical pathology suspected.

V. Treatment

Principles

• Start empiric broad-spectrum antibiotics early.
• Coverage must include N. gonorrhoeae, C. trachomatis, anaerobes, BV-associated flora, gram-negative rods and streptococci.
• Treatment duration: Complete 14 days.
• Abstain from intercourse until treatment is complete, symptoms resolve and partners are treated.

Outpatient Treatment: Mild-Moderate PID

• Ceftriaxone IM single dose + doxycycline PO for 14 days + metronidazole PO for 14 days.
• Reevaluate clinically within 72 hours.
• If no improvement within 72 hours → Hospitalize, reassess diagnosis, start IV therapy and evaluate for TOA/alternate pathology.

Hospitalization / Inpatient Treatment

• Indications:

• Pregnancy.
• Severe illness, high fever, nausea/vomiting, severe abdominal pain.
• Tubo-ovarian abscess.
• Possible surgical emergency or unclear diagnosis.
• Unable to tolerate oral therapy.
• No response to outpatient therapy within 72 hours.

Inpatient Regimens

• Recommended parenteral options:

• Cefoxitin IV + doxycycline.
• Clindamycin IV + gentamicin.

• Continue IV until clinical improvement, then switch to oral doxycycline + metronidazole to complete 14 days.
• TOA: Ensure anaerobic coverage and inpatient observation.

Surgical / Interventional Treatment

• Indications:

• Ruptured TOA.
• Non-resolving or enlarging TOA despite antibiotics.
• Peritonitis/sepsis or diagnostic uncertainty with surgical abdomen.

• Options: Image-guided percutaneous drainage, transvaginal drainage, laparoscopic drainage, laparotomy if unstable/rupture.

VI. Partner Management and Follow-Up

Partner Treatment

• Treat sexual partners for gonorrhea/chlamydia coverage, regardless of the woman's test results.
• Advise partner examination, STI testing and abstinence until both partners complete therapy.

Follow-Up

• Outpatients: Reevaluate within 72 hours.
• Expected improvement: Less fever, pain and cervical/uterine/adnexal tenderness.
• Educate about condom use, STI prevention and early evaluation of recurrent pelvic pain/discharge.