Pelvic inflammatory disease (PID) is infection and inflammation of the female upper genital tract (including uterus, fallopian tubes, ovaries, and/or pelvic peritoneum) unrelated to pregnancy or surgical intervention. PID can be classified as acute (≤30 days’ duration), subclinical, or chronic (>30 days’ duration).

• PID
• Endometritis
• Salpingitis
• Oophoritis
• Adnexitis
• Pelvic peritonitis
• Pyosalpinx
• Tuboovarian abscess
• TOA

^* Indicates nonbillable codes.

• •Pelvic or lower abdominal pain
• •Abnormal vaginal discharge
• •Abnormal uterine bleeding
• •Postcoital bleeding
• •Dysuria
• •Dyspareunia
• •Fever
• •Nausea and vomiting (suggestive of peritonitis)
• •Cervical friability
• •Cervical motion tenderness
• •Uterine tenderness
• •Adnexal tenderness
• •Adnexal mass
• •Right upper quadrant tenderness (perihepatitis, Fitz-Hugh-Curtis syndrome [Fig. E1]): 5% to 10% of PID cases may develop right upper quadrant pain, pleuritic pain, and tenderness in the right upper quadrant when the liver is palpated. The pain may radiate to the shoulder or into the back. Liver transaminase levels may be elevated.

NOTE: Women with PID may be asymptomatic and/or have a benign physical examination.

PID occurs as a result of ascending infection from the lower genital tract. Infections are often polymicrobial, and although gonorrheal and chlamydial infections are commonly implicated in the development of PID, fewer than 50% of women test positive for these organisms. This is likely due in part to increased STI screening efforts. PID may also arise in the setting of organisms associated with normal vaginal flora such as:

• •Bacteroides fragilis
• •Escherichia coli and other enteric gram-negative rods
• •Gardnerella vaginalis
• •Haemophilus influenzae
• •Streptococcus agalactiae

Less common infectious causes include the following: Trichomonas vaginalis, Mycoplasma hominis, Ureaplasma urealyticum, Mycoplasma genitalium (a concern because of antibiotic resistance), Mycobacterium tuberculosis (an important cause in developing countries), and cytomegalovirus (CMV).

• •Appendicitis
• •Ectopic pregnancy
• •Intrauterine/other pregnancy
• •Ovarian cyst
• •Adnexal torsion
• •Endometriosis
• •Urinary tract infection (cystitis or pyelonephritis)
• •Diverticulitis

• •History: See "Risk Factors" and "Physical Findings & Clinical Presentation"
• •Physical examination: See "Physical Findings & Clinical Presentation"

• •Wet mount: Clue cells, increased WBCs
• •Gram stain of endocervical exudate: >30 polymorphonuclear cells per high-power field correlates with chlamydial or gonococcal infection
• •Endocervical cultures for N. gonorrhoeae and C. trachomatis
• •CBC: Leukocytosis
• •Human chorionic gonadotropin to rule out intrauterine or ectopic pregnancy
• •Elevated acute phase reactants: ESR >15 mm/h, C-reactive protein
• •HIV and rapid plasma reagin, with consideration for other STI screening such as hepatitis B surface antigen, hepatitis C Ab (HIV increases incidence of tuboovarian abscess [TOA])
• •Fallopian tube aspirate or peritoneal exudate culture if laparoscopy or drainage of TOA performed
• •Endometritis on endometrial biopsy if performed

Ultrasonography is commonly used to assess for PID and can be used to determine inpatient vs. outpatient treatment by presence or absence of TOA. Ultrasonographic findings include:

• •Thick-walled adnexal mass with heterogenous or cystic contents suggestive of abscess
• •Dilated fallopian tubes (note that normal fallopian tubes are rarely identified on ultrasonography)
• •"Cogwheel sign" indicating thickened fallopian tube walls
• •Heterogenous fluid within the endometrium

Computed tomography or MRI scan may be useful to better characterize adnexal masses and/or rule out other pathology, such as appendicitis or renal calculus. Choice of imaging modality will depend on clinical suspicion, logistic access, and associated cost.

Endometrial biopsy that reveals endometritis may support a diagnosis of PID. Laparoscopy has been utilized as a gold standard for diagnosing PID, but due to the invasive nature of this procedure and the risks and costs associated, it is rarely indicated as a diagnostic tool.

Inpatient regimens consist of intravenous (IV) and oral antibiotics. See Table 1 for treatment regimens.

Recommended intramuscular (IM)/oral (PO) regimens:

• •Ceftriaxone 500 mg IM in a single dose PLUS doxycycline 100 mg PO bid for 14 days PLUS metronidazole 500 mg PO bid for 14 days OR
• •Cefoxitin 2 g IM in a single dose and probenecid 1 g PO administered concurrently in a single dose PLUS doxycycline 100 mg PO bid for 14 days PLUS metronidazole 500 mg PO bid for 14 days OR
• •Other third-generation cephalosporin (ceftizoxime or cefotaxime) PLUS doxycycline 100 mg PO bid for 14 days PLUS metronidazole 500 mg PO bid for 14 days

Alternative intramuscular/oral regimen if the patient has a cephalosporin allergy:

• •Levofloxacin 500 mg PO daily PLUS metronidazole 500 mg PO bid for 14 days
• •Moxifloxacin 400 mg PO daily for 14 days (preferred if M. genitalium)
• •Azithromycin 500 mg IV daily for 1 to 2 doses followed by 250 mg PO daily for 7 days or in combination with metronidazole 500 mg PO tid for 12 to 14 days

Due to quinolone-resistant N. gonorrhoeae, antimicrobial susceptibility testing should be performed if a culture is positive for gonorrhea in a patient with a cephalosporin allergy. If the isolate is quinolone-resistant, consultation with an infectious disease specialist is recommended.

• •Antimicrobials should include coverage against N. gonorrhoeae and C. trachomatis even if these organisms are not identified on culture.
• •Women should avoid sexual activity until they and their sexual partners have been adequately treated and symptoms have resolved.
• •TOA may require drainage, which may be accomplished by interventional radiology via aspiration or placement of a drain, or by a gynecologist via vaginal or laparoscopic means. Recurrent/persistent TOAs may be managed by total hysterectomy with bilateral salpingo-oophorectomy after acute treatment of infection.
• •Treatment of PID in women with intrauterine devices (IUDs) does not include/require removal of the device unless there is no clinical improvement after 48 to 72 h of treatment with an approved regimen. IUDs rarely serve as a source for PID, especially >3 wk after insertion.
• •Sexual partners of patients diagnosed with PID or other STIs should be evaluated and treated appropriately. In the setting of PID, treat all sexual partners within 60 days of onset of symptoms. Some states allow for expedited partner therapy (EPT), such that a woman’s provider is able to supply her with enough medication to treat herself and her partner(s).³
• •Treatment of chronic PID may be aimed at a different spectrum of microbes and should be tailored appropriately.

When clinical improvement is apparent based on symptoms, physical exam, and laboratory criteria, antibiotics may be transitioned from IV to PO with doxycycline PO and metronidazole PO or clindamycin PO (depending on the regimen selected) administered to complete 14 days of total antibiotic therapy. If a patient does not improve despite use of a recommended antibiotic regimen, further workup and potential procedural intervention are warranted.

• •Given the risk of reinfection, all women should be retested for gonorrhea and Chlamydia 3 mo after treatment.
• •Follow-up includes confirmation of partner treatment, education on use of barrier contraception, and risks of PID and long-term sequelae, including:
  1. 1.Recurrent PID
  2. 2.Chronic pelvic pain
  3. 3.Fallopian tube damage that leads to infertility and/or ectopic pregnancy
  4. 4.Fitz-Hugh-Curtis syndrome
  5. 5.Potential risk for cancer: Limited studies have suggested a small association between PID and ovarian, endometrial, and colon cancer

• •Maintain a low threshold for the diagnosis and treatment of PID given the risks for progression to severe infection and to significant and chronic medical and reproductive complications.
• •Most patients are candidates for outpatient therapy, but inpatient hospitalization is recommended in select cases.
• •Use only CDC-recommended treatment regimens unless contraindicated due to severe patient allergy; in such cases, check local susceptibilities of suspected pathogen.
• •Offer HIV and other STI screening to all women with suspected or diagnosed PID.
• •IUDs may be retained unless women have failed to improve with 48 to 72 h of treatment.
• •Treat sexual partners of women with PID, with EPT if possible.
• •Counsel patients on abstinence until they and their partners have completed treatment.
• •Test for reinfection with gonorrhea and Chlamydia 3 mo after treatment.

Women aged <25 yr and/or participating in high-risk sexual behavior should be screened annually for gonorrhea and Chlamydia; studies have shown such screening to reduce cases of PID by >50%. The importance of minimizing partner exposures and using barrier contraception (either alone or in conjunction with another method) should also be emphasized.

• Pelvic Inflammatory Disease (Patient Information)
• Chlamydia Genital Infections (Related Key Topic)
• Gonorrhea (Related Key Topic)
• Pelvic Abscess (Related Key Topic)