Stacie Zelman
EPIDEMIOLOGY
Pelvic inflammatory disease (PID) is the most common gynecological complaint presenting to the ED, accounting for over 25,000 visits per year by women aged 15 to 44 years.
Ten to 20% of untreated gonococcal or chlamydial cervicitis may progress to PID.
Risk factors include multiple sexual partners, sexual abuse, young age, HIV-1 infection, bacterial vagino-sis, history of other STDs, frequent vaginal douching, and use of intrauterine devices (IUDs).
Risk is reduced with use of barrier contraception and pregnancy; however, PID can occur during the first trimester and may cause fetal loss.
Bilateral tubal ligation does not confer protection from PID, but disease severity may be less.
PATHOPHYSIOLOGY
PID represents an ascending infection from the lower genital tract. The spectrum of disease includes salpin-gitis, endometritis, tubo-ovarian abscess (TOA), and peritonitis.
Neisseria gonorrhoeae and/or Chlamydia trachomatis are isolated in many cases, but not all.
At least 30% to 40% of infections are polymicrobial and include anaerobes, such as Bacteroides species, aerobes such as Gardnerella vaginalis, enteric gram-negative rods, Haemophilus influenzae, and Streptococcus agalactiae, and endogenous genital tract mycoplasma such as Mycoplasma hominis and Ureaplasma urealyticum.
Neisseria gonorrhoeae and C. trachomatis may be instrumental in the initial infection of the upper genital tract, whereas other bacterial species and anaerobes are isolated increasingly as inflammation increases and abscesses form.
Infection may extend beyond the pelvis via direct or lymphatic spread to involve the hepatic capsule, resulting in perihepatitis and focal peritonitis (Fitz-Hugh–Curtis syndrome).
CLINICAL FEATURES
Lower abdominal pain is the most common presenting complaint.
Other common symptoms include abnormal vaginal discharge, vaginal bleeding, postcoital bleeding, irritative voiding symptoms, fever, malaise, nausea, and vomiting. However, severity of symptoms varies by individual.
Physical examination findings include lower abdominal tenderness, mucopurulent cervicitis, cervical motion tenderness, and uterine and/or adnexal tenderness. Peritoneal signs may be present.
Unilateral adnexal tenderness and palpable fullness or mass may indicate TOA.
Right upper quadrant tenderness, especially with jaundice, suggests Fitz-Hugh–Curtis syndrome.
DIAGNOSIS AND DIFFERENTIAL
PID is a clinical diagnosis (Table 66-1).
Laboratory evaluation should include a pregnancy test, wet prep, and endocervical swabs for gonorrhea and chlamydia. Elevations in white blood cell count, erythrocyte sedimentation rate, and C-reactive protein help support the diagnosis of PID.
Transvaginal pelvic ultrasound is used to detect TOA, which appears as a complex adnexal mass with multiple internal echoes.
Procedures such as endometrial biopsy, culdocentesis, and laparoscopy may help to facilitate or confirm the diagnosis; however, their utility in the emergency department setting is limited.
The differential diagnosis includes cervicitis, ectopic pregnancy, endometriosis, ovarian cyst, ovarian torsion, spontaneous abortion, septic abortion, cholecystitis, gastroenteritis, appendicitis, diverticulitis, pyelonephritis, and renal colic.
TABLE 66-1 Diagnostic Criteria for PID
TABLE 66–2 Parenteral Treatment Regimens for Pelvic Inflammatory Disease
EMERGENCY DEPARTMENT CARE AND DISPOSITION
Analgesia and IV hydration should be provided as needed.
Immediate initiation of broad-spectrum antibiotics improves long-term outcomes. See Tables 66-2 and 66–3 for treatment options as recommended by the Centers for Disease Control and Prevention.
Any IUD must be removed after antibiotics are started.
Sixty percent to 80% of TOAs resolve with antibiotics alone. The remainder requires drainage.
TABLE 66-3 Oral and Outpatient Treatment Regimens for Pelvic Inflammatory Disease
The decision for hospitalization should be made based on severity of illness, inability to tolerate PO medications/fluids, likelihood of anaerobic infection (IUD use, suspected abscess, recent instrumentation), uncertainty of diagnosis, immunosuppression, pregnancy, patient age, fertility issues, or concerns for compliance.
Patients started on IV antibiotics may be switched to oral treatment 24 hours after clinical improvement. With outpatient treatment, patients should be followed up within 72 hours to assess substantial response to antibiotic therapy and compliance.
Patients should be educated regarding prevention, compliance, and the need to have all sexual partners treated. Appropriate referrals for further STD testing including HIV and syphilis should be provided.
For further reading in Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th ed., see Chapter 107, “Pelvic Inflammatory Disease,” by Amy J. Behrman, William H. Shoff, and Suzanne M. Shepherd.