Infectious Diseases

Infections of the Female Pelvis

OVERVIEW: What every practitioner needs to know

Are you sure your patient has pelvic inflammatory disease? What should you expect to find?

  • The usual clinical manifestations of acute pelvic inflammatory disease (PID) are fever, moderate to severe bilateral pelvic pain, and a purulent vaginal discharge. The discharge is actually emanating from the cervix but is perceived by the patient as coming from the vagina. Patients may also note irregular vaginal bleeding.

  • On physical examination, patients are tachycardic and mildly tachypneic. They will have direct lower abdominal tenderness and rebound tenderness. A mucopurulent exudate is evident in the exocervix, and the uterus and adnexa are tender to palpation. Some patients with acute PID have a palpable tuboovarian abscess, and they may well become critically ill.

  • In addition, some patients with gonococcal-initiated PID have manifestations of disseminated gonococcal infection, including arthritis, dermatitis, endocarditis, pericarditis, and meningitis. Fitz-Hugh Curtis syndrome (perihepatitis) may also occur in association with gonococcal or chlamydia infection, and affected patients experience moderate to severe right upper quadrant pain and tenderness.

  • In women who engage in receptive anal intercourse, an inflammatory proctitis may be apparent.

  • Similarly, in women who engage in oral sex, gonococcal infection can cause a severe purulent pharyngitis.

How did the patient develop pelvic inflammatory disease? What was the primary source from which the infection spread?

Acute PID is a common and very serious disorder. Approximately 250,000 women are hospitalized each year for treatment of PID, and three to four times that many are treated as outpatients. The Centers for Disease Control and Prevention (CDC) estimate that the annual direct cost of treating PID is in the range of $2-3 billion. PID is usually sexually transmitted, although it can develop as a result of instrumentation of the upper genital tract (e.g., insertion of an intrauterine contraceptive device or performance of an endometrial biopsy).

Which individuals are of greater risk of developing pelvic inflammatory disease?

Younger patients with multiple sexual partners and a prior history of lower genital tract infections (e.g., gonorrhea or chlamydia infection) are at particular risk for developing PID. Patients with untreated bacterial vaginosis are also at increased risk for developing upper tract infection. Following an initial acute episode of PID, patients remain at risk for recurrent episodes of infection.

Beware: there are other diseases that can mimic pelvic inflammatory disease:

The differential diagnosis of acute PID includes the following disorders:

  • Appendicitis

  • Ectopic pregnancy

  • Diverticulitis

  • Adnexal torsion

  • Rupture or hemorrhage of an ovarian cyst

  • Nephrolithiasis

  • Pancreatitis

  • Perforated viscus

What laboratory studies should you order and what should you expect to find?

Results consistent with the diagnosis

  • In patients with acute PID, the peripheral white blood cell (WBC) count is usually elevated, and a left shift is evident. Nucleic acid amplification tests for gonorrhea and/or chlamydia will usually be positive, especially in initial episodes of PID. In patients with recurrent PID, chlamydia is still a common pathogen, but gonococcal organisms are less commonly identified. Specimens for nucleic acid amplification tests may be obtained from either the urine or cervix. A serum hCG test should be negative, and is very helpful in excluding the diagnosis of ectopic pregnancy. Pelvic ultrasound can be of great value in excluding the diagnosis of ectopic pregnancy and confirming the presence of a tuboovarian abscess. In problematic cases, diagnostic laparoscopy may be necessary to confirm the diagnosis. Key findings that may be evident at the time of laparoscopy include: marked erythema of the tubal serosa, purulent exudate emanating from the tubal os, clubbing of the distal portion of the tube, and an actual tuboovarian abscess.

Results that confirm the diagnosis

The diagnosis of acute PID is usually made on the basis of clinical criteria: fever, pelvic pain, purulent endocervical discharge, and uterine/adnexal tenderness. Positive tests for gonorrhea and/or chlamydia are of great value in confirming the diagnosis, as is identification of a tuboovarian abscess on ultrasound examination. Direct observation of pelvic inflammation by laparoscopy, of course, is the ultimate proof of diagnosis, but this procedure is usually not necessary.

What imaging studies will be helpful in making or excluding the diagnosis?

The most useful imaging modality for evaluation of a patient with suspected PID is pelvic ultrasound. This procedure should be performed by someone who is skilled in doing endovaginal sonography in gynecologic patients. In most centers, the cost of pelvic sonography should be less than $500, and the test is significantly less expensive than computed tomography (CT) or magnetic resonance imaging (MRI). Pelvic sonography is of great value in excluding the diagnosis of ectopic pregnancy and in identifying unilateral or bilateral tuboovarian abscesses. The presence of a tuboovarian abscess greatly increases the likelihood that the patient will require surgery for management of complications.

What consult service or services would be helpful for making the diagnosis and assisting with treatment?

If you decide the patient haspelvic inflammatory disease, what therapies should you initiate immediately?

When the diagnosis of pelvic inflammatory disease is suspected, consultation should be obtained from an experienced obstetrician-gynecologist. PID is a polymicrobial, mixed aerobic-anaerobic infection. The initial infection is usually incited by either gonococci or chlamydia or both, and the organisms are introduced into the female from an infected sexual partner. Although these two organisms are of great importance, other key pathogens include anaerobes (both gram-positive and gram-negative), aerobic gram-negative bacilli, gram-positive aerobic cocci., and genital mycoplasmas. Unlike gonococci and chlamydia, these latter organisms are part of the normal vaginal flora, and they are introduced into the upper genital tract, coincident with intercourse or surgical manipulation.

The first step in treating the patient is deciding whether or not hospitalization is indicated. Patients with milder infections can usually be treated on an outpatient basis. However, patients who meet any of the following criteria should be hospitalized and treated with parenteral antibiotics:

  • Concurrent pregnancy

  • Intrauterine device (IUD) in place

  • Patient is non-compliant

  • Pelvic mass is present

  • Patient appears seriously ill

  • Patient has failed to respond promptly to outpatient therapy

1. Anti-infective agents

Several possible antibiotic regimens have been recommended by the CDC for outpatient treatment of PID. One convenient regimen is ceftriaxone (250mg i.m once) plus doxycylcine (100mg orally twice daily x 14 days) plus metronidazole (500mg orally twice daily x 14 days). An alternative is cefoxitin (2g i.m in a single dose) plus probenecid (1g orally) plus doxycycline (100mg orally twice daily x 14 days) plus metronidazole (500mg orally twice daily x 14 days).

The CDC also has made several recommendations for inpatient therapy of PID. One suggested regimen is intravenous clindamycin (900mg every 8 hours) plus gentamicin (administered as a single dose based on patient weight every 24 hours). Another is intravenous cefotetan (2g every 12 hours) or cefoxitin (2g every 6 hours) plus doxycycline (100mg orally or intravenously every 12 hours). A third recommendation is ampicillin/sulbactam (3g i.v. every 6 hours) plus doxycycline (100mg orally or i.v. every 12 hours). Patients should be treated with parenteral antibiotics until they have been afebrile and relatively asymptomatic for a minimum of 24 hours. At this point, they can be changed to oral antibiotics to complete a 10-14 day course of therapy.

2. Other key therapeutic modalities.

  • Patients with acute PID should receive oral or parenteral analgesics, depending on their ability to tolerate oral feedings. They should also receive antipyretics to reduce their fever. Patients who have a tuboovarian abscess who fail to respond to antibiotic therapy may require a surgical procedure to drain the abscess. In some instances, drainage can be accomplished with a CT- or ultrasound-guided catheter insertion. In other instances, laparoscopy or laparotomy may be necessary to effect adequate drainage. In extremely severe infections, removal of the infected pelvic organs may be necessary.

What should you tell the family about the patient's prognosis?

  • PID is one of the two most important causes of infertility in women. Prior PID is the single most important risk factor for ectopic pregnancy. PID can also lead to chronic pelvic pain.

  • Mortality from PID is rare and occurs almost exclusively in patients who have a ruptured tuboovarian abscess. With prompt diagnosis and treatment and careful monitoring of the patient's clinical progress, full recovery is the norm.

How do you contract pelvic inflammatory disease and how frequent is this disease?

Acute PID is a common and very serious disorder. Approximately 250,000 women are hospitalized each year for treatment of PID, and three to four times that many are treated as outpatients. The CDC estimates that the annual direct cost of treating PID is in the range of $2-3 billion. PID is usually sexually transmitted, although it can develop as a result of instrumentation of the upper genital tract (e.g., insertion of an intrauterine contraceptive device or performance of an endometrial biopsy).

What other clinical manifestations may help me to diagnose and manage pelvic inflammatory disease?

  • The usual clinical manifestations of acute PID are fever, moderate to severe bilateral pelvic pain, and a purulent vaginal discharge. The discharge is actually emanating from the cervix but is perceived by the patient as coming from the vagina. Patients may also note irregular vaginal bleeding.

  • On physical examination, patients are tachycardic and mildly tachypneic. They have direct lower abdominal tenderness and rebound tenderness. A mucopurulent exudate is evident in the exocervix, and the uterus and adnexa are tender to palpation. Some patients with acute PID have a palpable tuboovarian abscess.

  • In addition, some patients with gonococcal-initiated PID have manifestations of disseminated gonococcal infection, including arthritis, dermatitis, endocarditis, pericarditis, and meningitis. Fitz-Hugh Curtis syndrome (perihepatitis) may also occur in association with gonococcal or chlamydia infection, and affected patients experience moderate to severe right upper quadrant pain and tenderness.

  • In women who engage in receptive anal intercourse, an inflammatory proctitis may be apparent.

  • Similarly, in women who engage in oral sex, gonococcal infection can cause a severe purulent pharyngitis.

How can pelvic inflammatory disease be prevented?

The two most important steps a woman can take to prevent PID are:

  • Be circumspect in selection of sexual partner

  • Use barrier methods of contraception (i.e., male and/or female condoms) to prevent transmission of infection

WHAT'S THE EVIDENCE for specific management and treatment recommendations?

"Sexually transmitted diseases treatment guidelines, 2010". MMWR. vol. 59. 2010. pp. 1-111.

Soper, DE. "Pelvic inflammatory disease". Obstet Gynecol. vol. 116. 2010. pp. 419-28.

DRG CODES and expected length of stay

For patients who require hospitalization, the usual length of stay is 3-5 days. Patients who have a tuboovarian abscess that requires drainage may remain in the hospital for 7-10 days.

Whether treated as an inpatient or outpatient, women usually receive antibiotics for 10-14 days. At this point, the majority of patients have returned to their usual state of activity.

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