Pelvic Inflammatory Disease: Diagnosis, Management, and Prevention

 

Pelvic inflammatory disease (PID) is an infection of the upper genital tract occurring predominantly in sexually active young women. Chlamydia trachomatis and Neisseria gonorrhoeae are common causes; however, other cervical, enteric, bacterial vaginosis–associated, and respiratory pathogens, including Mycobacterium tuberculosis, may be involved. PID can be acute, chronic, or subclinical and is often underdiagnosed. Untreated PID can lead to chronic pelvic pain, infertility, ectopic pregnancy, and intra-abdominal infections. The diagnosis is made primarily on clinical suspicion, and empiric treatment is recommended in sexually active young women or women at risk for sexually transmitted infections who have unexplained lower abdominal or pelvic pain and cervical motion, uterine, or adnexal tenderness on examination. Mild to moderate disease can be treated in an outpatient setting with a single intramuscular injection of a recommended cephalosporin followed by oral doxycycline for 14 days. Additionally, metronidazole is recommended for 14 days in the setting of bacterial vaginosis, trichomoniasis, or recent uterine instrumentation. Hospitalization for parenteral antibiotics is recommended in patients who are pregnant or severely ill, in whom outpatient treatment has failed, those with tubo-ovarian abscess, or if surgical emergencies cannot be excluded. Treatment does not change in patients with intrauterine devices or those with HIV. Sex partner treatment is recommended; expedited partner treatment is recommended where legal. Prevention of PID includes screening for C. trachomatis and N. gonorrhoeae in all women younger than 25 years and those who are at risk or pregnant, plus intensive behavioral counseling for all adolescents and adults at increased risk of sexually transmitted infections.

Pelvic inflammatory disease (PID) includes an array of infectious processes that damage the endometrium, fallopian tubes, ovaries, and pelvic peritoneum. Sexually transmitted infections (STIs) cause most PID cases, but organisms associated with bacterial vaginosis (BV) have also been implicated. Approximately 15% of untreated chlamydial infections progress to PID; this percentage may be higher with gonococcal infections.1 Delayed diagnosis contributes to inflammatory sequelae, including infertility, ectopic pregnancy, and chronic pelvic pain.2,3 Approximately one in six women with salpingitis develops infertility.2,3 The cost of having PID has previously been estimated at $1,995 per patient, not including expenses for future evaluation and treatment of complications.4 Based on the National Health and Nutrition Examination Survey 2013–2014 data, 4.4% of women (2.5 million) 18 to 44 years of age in the United States reported a history of PID.5 Although studies suggest an overall decline in rates of PID, cases of gonorrhea and chlamydia are increasing.6 This is especially worrisome with the rise of antibiotic-resistant Neisseria gonorrhoeae.

WHAT IS NEW ON THIS TOPIC:

Because of emerging resistance, routine use of quinolones is no longer recommended for pelvic inflammatory disease to provide empiric coverage for gonorrhea.

Intrauterine devices pose no increased risk of pelvic inflammatory disease beyond the first 20 days postinsertion.

Intrauterine devices do not need to be removed if the patient with pelvic inflammatory disease is clinically improving within 48 to 72 hours of initiation of antibiotics.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

The diagnosis of PID should be made clinically in the absence of other obvious causes in an at-risk woman with unexplained pelvic pain and cervical motion, uterine, or adnexal tenderness.8

C

Consensus guideline from the Centers for Disease Control and Prevention

Empiric antibiotic treatment should be offered at the time of presentation to patients with PID symptoms.8

C

Consensus guideline

Women with mild to moderate PID may be treated in an outpatient setting without increased risk of sequelae.3,26

B

Multicenter RCT showing no differences in reproductive outcomes between inpatient and outpatient treatment in mild to moderate PID

Patient-delivered or expedited partner therapy for STIs should be offered where legal to decrease rates of reinfection.8,32

B

Consensus guideline and RCT of expedited therapy showing reduction in rates of STI

Annual screening for chlamydia and gonorrhea is recommended in all sexually active women younger than 25 years and any women who are at increased risk of STIs.8,34

B

Consensus guideline and U.S. Preventive Services Task Force guideline with B recommendation


PID = pelvic inflammatory disease; RCT = randomized controlled trial; STI = sexually transmitted infection.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual pr

The Authors

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AMY CURRY, MD, is an associate director of the University of Kansas School of Medicine Family Medicine Program at Via Christi Health and a clinical associate professor in the Department of Family and Community Medicine at the University of Kansas School of Medicine in Wichita....

TRACY WILLIAMS, MD, is an associate director of the University of Kansas School of Medicine Family Medicine Program at Via Christi Health and an associate professor in the Department of Family and Community Medicine at the University of Kansas School of Medicine.

MELISSA L. PENNY, DO, is the director of osteopathic education and an associate director of the University of Kansas School of Medicine Family Medicine Program at Via Christi Health and a clinical instructor in the Department of Family and Community Medicine at the University of Kansas School of Medicine.

Address correspondence to Amy Curry, MD, 707 N. Emporia, Wichita, KS 67214 (email: amy.curry@ascension.org). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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