Definition: Pelvic inflammatory disease is an inflammatory disorder of the female upper reproductive

tract (the endometrium, fallopian tubes, ovaries, or pelvic peritoneum) caused by an infection.

Pathophysiology and Microbial Causes

The majority of acute and subacute PID are due to sexually transmitted pathogens (Neisseria
gonorrhoease, chlamydia tachomatis, mycoplasma genitalium) or bacterial vaginosis-associated
microbes (peptostreptococcus, bacteroides, etc). less commonly respiratory and enteric pathogens.
These microbes ascend from the cervix or vagina to upper reproductive tract. Chronic PID is due to
chronic infection with Mycobacterium tuberculosis or actinomyces species. Some prospective studies
suggest about 15% of untreated chlamydial infections progress to clinically diagnosed PID.16-18 Ascending
infection leads to inflammatory damage of the upper genital tract (including the peritoneal surface)
leads to scarring adhesions with possible obstruction of the fallopian tubes. This can result in infertility,
ectopic pregnancy, and pelvic pain (cilaitaed epithelial cell impairment along the fallopian tubes).

Clinical Manifestations and Diagnosis

Epidemiologically, PID is common among sexually active young women. Characteristic symptoms include
the acute onset of severe lower abdominal pain during or shortly after menses. (Pelvic tenderness has
high sensitivity and low specificity, increased specificity with lower genital tract findings). This is classic,
but it is now recognized that the onset and severity of symptoms may be more subtle/ill-defined. Other
symptoms include abnormal vaginal discharge, intermenstrual or postcoital bleeding, dyspareunia, and
dysuria. Fever may be present, but systemic manifestations do not always occur. Occasionally right
upper quadrant pain is present, which suggests Fitz-Hugh-Curtis syndrome (inflammation and adhesion
formation of the liver capsule). It is possible for infection and inflammation of the upper genital tract to
occur in the absence of symptoms (called subclinical PID).1,4,12 Studies have shown strong associations
between infertility and serologic evidence of previous C. trachomatis or N. gonorrhoeae infection (no hx
of diagnosis of PID).36,37 Need a low threshold for considering diagnosis. Diagnosis is made by findings of
pelvic organ tenderness (cervical motion tenderness, adnexal tenderness, or uterine compression
tenderness). Lower genital tract signs include cervical mucopus, cervical friability, or increased white
cells on wet mount. Laparoscopy is the gold standard, although not routinely used. Transcefvical
endometrial aspiration with histopathological findings of increased numbers of plasma cells and
neutrophils can help confirm the diagnosis (but again is somewhat invasive and can delay diagnosis).
Transvaginal ultrasound and MRI showing thickened fluid filled tubes are highly specific for
salpingitis.46,47 (US sensitivity is only fair, MRI is expensive). Power doppler studies showing increased
fallopian-tube flood flow are also highly suggestive of infection.46,48 Imaging studes can also help with
alternative diagnoses (ovarian cyst, TOA endometriosis, ectopic, appendicitis). All patients should
undergo cervical or vaginal nucleic acid amplification tests for N. gonorrhoeae and C. trachomatis
infection (positive increases likelihood of PID). Vaginal fluid should be evaluated for increased numbers
of white cells and signs of BV (clue cells, elevated pH, amine odor with KOH).” Rule out pregnancy and
HIV. ESR or CRP elevation can help support diagnosis too.

Treatment
Treatment is empirical and should cover the common pathogens (N. gonorrhoeae and C. trachomatis)
regardless of testing results. Anaerobic coverage is also recommended due to BV commonly being found
in women with PID. CDC first-line treat recommendations for outpatient management of mild-to-
moderate PID include doxycycline (100 mg orally BID for 2 weeks) with or without metronidazole (500
mg orally BID for 2 weeks) plus one of the following: ceftriaxone (250 mg IM single dose), cefoxitin (2 g
IM with probenecid (1 go orally) concurrently in a single dose, or other parenteral 3rd generation
cephalosporins (cefotaxime or ceftizoxime). For inpatient management of moderate to severe disease
with or without tubo-ovarian abscess one of the following is recommended: cefotetan (2 g IV Q12hrs)
plus doxycycline (100 mg orally or IV Q12hrs), cefoitin (2g IV Q6hrs) plus doxycycline (100 mg orally or IV
Q12hrs), or clincamycin (900 mg IV Q8hrs) plus gentamicin (3 to 5 mg per kg IV QD) (this last regimen
may be particularly helpful for TOA). For inpatient management transition to oral therapy can usually
happen within 24 to 48 hours after clinical improvement, and oral therapy should be continued to
complete 2 weeks of therapy. The PEACH (Pelvic INflammtory Disease Evaluation and Clinical Health)
study showed that among women with mild-moderte PID the efficacy of cefoxitin-doxycycline therapy
was similar in inpatient and outpatient settings.52 Reasons for hospitalization include pregnancy, concern
for other diagnosis, inability to take oral medications, or tubal abscess. NSAIDs do not help, neither does
removal of IUD.

Long term outcomes

Long term outcomes remain suboptimal with incrased risk of intertility, ectopic pregnancy, and chronic
pelvic pain. It is important to trat early.

Prevention

The USPTF recommends C. trachomatis screening for all sexually active women younger than 25 years of
age and older women at increased risk for infection.33,35This task force also recommends testing for N.
gonorrhoeae among women at increased risk for infection. Sex education and promotion of condem
usage helps. Empiriacal treatment of male sex partners helps reduce reinfection risk.