pelvic inflammatory disease (PID)
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Etiology
- etiologic agents
- risk factors:
- young age
- multiple sexual partners
- intrauterine contraceptive devices
Pathology
- polymicrobial infection[4]
- an inflammatory process due to ascending microorganisms into the upper genital tract causing endometritis, oophoritis, parametritis, salpingitis, tubo-ovarian abscess & pelvic peritonitis
- inflammation spreads from the vagina or cervix to the upper genital tract, with endometritis as an intermediate stage[9]
Clinical manifestations
- clinical manifestations variable
- chronic, mild lower abdominal & pelvic pain/discomfort usually in the week following menstruation
- acute peritonitis with rebound tenderness
- subclinical pelvic inflammatory disease is common[9]
- vaginal discharge, mucopurulent cervical discharge
- postcoital bleeding
- gastrointestinal (GI) symptoms
- fever/chills (temperature > 38.3 C, 101 F)
- dysuria
- dyspareunia
- cervical motion tenderness/ chandelier sign
- adnexal fullness & tenderness may be present
Laboratory
- pregnancy test to rule out ectopic pregnancy
- complete blood count (CBC) may show leukocytosis
- antigen test for Chlamydia is positive < 50% of time
- Gram stain for Neisseria gonorrhea positive < 50% of time
- GenProbe for Neisseria gonorrhoeae & Chlamydia trachomatis
- Neisseria gonorrhoeae DNA (urine, vaginal, endocervical)
- Chlamydia trachomatis DNA (urine, vaginal, endocervical)
- endometrial biopsy to rule out endometriosis
- microscopy of vaginal discharge shows leukocytes
- serum aminotransferases if right upper quadrant pain (perihepatitis Neisseria gonorrhea, Chlamydia trachomatis)
- elevated inflammatory markers (non-specific)
- increased serum CRP
- increased ESR
- increased serum acute phase reactants
- screen for other sexually transmitted diseases
Diagnostic procedures
- laparoscopy
- 'gold standard' for diagnosis
- indications
- peritonitis or sepsis from ruptured tubo-ovarian abscess
- lack of response to antibiotics within 48-72 hours
Radiology
- pelvic ultrasound to rule out tubo-ovarian abscess
Complications
- infertility
- 10% risk for single episode of PID in women 15-24 years of age
- risk of infertility doubles with each episode of PID
- subclinical PID associated with loss of fertility[7]
- ectopic pregnancy
- chronic pelvic pain
- repeated pelvic infections
- tubo-ovarian abscess
Differential diagnosis
- ectopic pregnancy
- appendicitis
- chronic pelvic pain
- chronic adhesive disease
- endometriosis
- ovarian torsion
- ovarian cyst(s)
- irritable bowel syndrome
- somatization disorder
- interstitial cystitis
Management
- pharmacologic agents
- broad spectrum antibiotic coverage for
- outpatient[4][6]
- ceftriaxone (Rocephin) 250 mg IM single dose or other 3rd generation cephalosporin plus doxycycline 100 mg BID for 14 days with or without metronidazole or clindamycin for 14 days
- addition of metronidazole results in fewer anaerobes in the uterus[10]
- cefoxitin (Mefoxin) 2 g IM plus probenecid 1 g PO plus doxycyline with or without metronidazole for 14 days
- oral fluoroquinolone (ofloxacin 400 mg BID) for 14 days plus either clindamycin 450 mg PO QID or metronidazole 500 mg PO BID for 14 days
- ceftriaxone (Rocephin) 250 mg IM single dose or other 3rd generation cephalosporin plus doxycycline 100 mg BID for 14 days with or without metronidazole or clindamycin for 14 days
- inpatient
- cefoxitin 2 g IV every 6 hours or cefotetan 2 g IV every 12 hours, plus doxycycline 100 mg IV/PO every 12 hours; continue at least 48 hours after clinical improvement, followed by doxycycline 100 mg PO BID for a total of 14 days of treatment
- clindamycin 900 mg IV every 8 hours plus gentamicin 2 mg/kg IV loading dose followed by 1.5 mg/kg IV every 8 hours; continue at least 48 hours after clinical improvement, followed by doxycycline 100 mg PO BID or clindamycin 450 mg PO QID for a total of 14 days of treatment
- hospitalize if
- pelvic abscess
- pregnant
- adolescent
- severe or systemic illness
- diagnosis uncertain
- no response to therapy (after 48-72 hours)
- possiblilty of surgical emergency (ectopic pregnancy or appendicitis) cannot be excluded
- clinical follow-up cannot be arranged within 2 hours
- patient is known to be infected with HIV
- vomiting precludes oral antibiotics
- general
- evaluate for other sexually transmitted disease, including HIV
- treat sexual partner
- abstain from sex until treatment complete
- limit number of sexual partners
More general terms
More specific terms
References
- ↑ Diagnostic History & Physical Examination in Medicine, Chan & Winkle, Current Clinical Strategies, Laguna Hills, CA 1996
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 394-397, 440-41
- ↑ The Sanford Guide to Antimicrobial Therapy, 29th ed., Gilbert, DN et al (editors), Antimicrobial Therapy, Inc., Hyde Park VT, 1999
- ↑ 4.0 4.1 4.2 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 16, 17. American College of Physicians, Philadelphia 1998, 2006, 2012, 2015
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 544
- ↑ 6.0 6.1 Ness RB, Trautmann G, Richter HE, Randall H, Peipert JF, Nelson DB, Schubeck D, McNeeley SG, Trout W, Bass DC, Soper DE. Effectiveness of Treatment Strategies of Some Women With Pelvic Inflammatory Disease: A Randomized Trial. Obstet Gynecol. 2005 Sep;106(3):573-580. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16135590
- ↑ 7.0 7.1 Wiesenfeld HC et al. Subclinical pelvic inflammatory disease and infertility. Obstet Gynecol 2012 Jul; 120:37 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22678036
- ↑ Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010 Dec 17;59(RR-12):1-110. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21160459 many of these guidelines withdrawn from NGC Jan 2016
- ↑ 9.0 9.1 9.2 Brunham RC, Gottlieb SL, Paavonen J Pelvic Inflammatory Disease. N Engl J Med 2015; 372:2039-2048. May 21, 2015 (review) PMID: https://www.ncbi.nlm.nih.gov/pubmed/25992748
- ↑ 10.0 10.1 Wiesenfeld HC, Meyn LA, Darville T, Macio IS, Hillier SL. A randomized controlled trial of ceftriaxone and doxycycline, with or without metronidazole, for the treatment of acute pelvic inflammatory disease. Clin Infect Dis 2020 Feb 13 PMID: https://www.ncbi.nlm.nih.gov/pubmed/32052831 https://academic.oup.com/cid/advance-article-abstract/doi/10.1093/cid/ciaa101/5735325?redirectedFrom=fulltext
- ↑ 11.0 11.1 NEJM Knowledge+ Nephrology/Urology