Pelvic Inflammatory Disease (PID)

Background

• PID describes an infection of the upper female genital tract which is often polymicrobial and commonly involves sexually transmitted organisms.
• PID most commonly results from ascending infection of microorganisms from the vagina and endocervix into the upper genital tract.

Evaluation

• PID is usually diagnosed clinically based on 1 or more of the following physical exam findings: uterine tenderness, adnexal tenderness, and cervical motion tenderness (Strong recommendation).
• Test for Neisseria gonorrhoeae and Chlamydia trachomatis in a patient with clinical findings suggestive of PID (Strong recommendation). If either test is positive, it strongly supports the diagnosis. However, negative test results do not rule out the diagnosis.
• If pelvic imaging is needed to further evaluate the upper genital tract, a transvaginal ultrasound is recommended as the initial imaging modality. Computed tomography or magnetic resonance imaging may also be used if ultrasound is indeterminate.
• Additional diagnostic testing includes microscopic examination of vaginal secretions (wet mount). Increased numbers of white blood cells (> 1 neutrophil per epithelial cell) and signs of bacterial vaginosis, including clue cells, elevated pH, and positive whiff test, supports the clinical diagnosis of PID. However, the presence of rods consistent with lactobacilli does not support a diagnosis of PID, and other alternative diagnoses should be considered.
• Diagnostic laparoscopy:
  • Laparoscopy is an invasive procedure that may be associated with complications and may not always be readily available; therefore, it is not routinely used in patients with mild-to-moderate symptoms.
  • Laparoscopy may be needed in patients with PID unresponsive to medical therapy and those for whom diagnosis remains unclear after a comprehensive evaluation or if there is a need to exclude a surgical emergency, such as ectopic pregnancy or acute appendicitis.

Management

• Treatment of PID may be started based on clinical findings alone in most cases (Strong recommendation).
• For outpatient treatment, use a cephalosporin (ceftriaxone 500 mg intramuscularly once, or cefoxitin 2 g intramuscularly plus probenecid 1 g orally once) PLUS doxycycline 100 mg orally twice daily for 14 days with metronidazole 500 mg orally twice daily for 14 days.
• For inpatient treatment:
  • Start with any of the following:
    • ceftriaxone 1 g every 24 hours PLUS doxycycline 100 mg orally or IV every 12 hours PLUS metronidazole 500 mg orally or IV every 12 hours
    • cefotetan 2 g IV every 12 hours PLUS doxycycline 100 mg orally or IV every 12 hours
    • cefoxitin 2 g IV every 6 hours PLUS doxycycline 100 mg orally or IV every 12 hours
  • Continue initial regimen until at least 24 hours after clinical improvement, and then continue therapy to complete 14 days with doxycycline 100 mg orally twice daily PLUS metronidazole 500 mg orally twice daily.
• Early treatment is important as delayed treatment increases risk of subsequent chronic pelvic pain, infertility, and ectopic pregnancy (Strong recommendation).
• Outpatient treatment is as effective as inpatient treatment for women with uncomplicated mild-to-moderate PID.
• In women with an intrauterine device (IUD) who present with acute PID:
  • There is insufficient evidence to recommend IUD removal; however, close clinical follow-up is required if the IUD remains in place (Strong recommendation).
  • Consider IUD removal if there is no clinical improvement within 48-72 hours of treatment initiation.
• Male sexual partners should be treated empirically with regimens effective against gonorrhea and chlamydia regardless of the pathogen isolated from the patient with PID (Strong recommendation).
• Repeat testing of all women diagnosed with gonorrhea or chlamydia should occur 3-6 months after treatment regardless of partner's treatment status (Strong recommendation).