SIGNS AND SYMPTOMS 
History
- Lower abdominal pain is the most common symptom in PID, ranging from subtle to severe pain
- Abdominal pain that worsens during intercourse or onset of pain shortly after or during menses is suggestive of PID
- Abdominal pain is usually bilateral and usually present for ≤2 wk
- New vaginal discharge, urethritis, fever, and chills are common symptoms but are neither sensitive nor specific for the diagnosis
Pregnancy Considerations
PID is rare during pregnancy, but if present usually occurs during the 1st trimester before hormonal changes such as mucus plug formation can protect the uterus from ascending bacteria.
Physical Exam
- Only 50% of patients with PID have fever
- Abdominal exam reveals diffuse tenderness worse in the lower quadrants, usually but not always symmetric
- Rebound tenderness and decreased bowel sounds are commonly found
- Right upper quadrant tenderness is suggestive of perihepatitis (Fitz-Hugh–Curtis syndrome) in the setting of PID
- Pelvic exam can reveal a purulent endocervical discharge, cervical motion tenderness, or adnexal tenderness
- If uterine or adnexal tenderness is not prominent, one must consider other diagnoses
ESSENTIAL WORKUP
- History and physical exam including pelvic exam
- Pregnancy test to rule out ectopic pregnancy or complications of an intrauterine pregnancy
- Cervical culture for N. gonorrhea and C. trachomatis
- Minimum criteria for clinical diagnosis:
- Lower abdominal tenderness or
- Uterine/adnexal tenderness or
- Cervical motion tenderness
- Supportive criteria for diagnosis:
- Fever > 38.3°C (101°F)
- Abnormal cervical/vaginal discharge
- Intracellular gram-negative diplococci on endocervical Gram stain
- Leukocytosis > 10,000/mm3
- Elevated erythrocyte sedimentation rate (ESR) or C-reactive protein
- WBCs or bacteria in peritoneal fluid obtained by culdocentesis or laparoscopy
DIAGNOSIS TESTS & INTERPRETATION
Lab
- CBC
- Gram stain of endocervix
- Urine polymerase chain reaction tests for Chlamydia and Gonococcus
- Microscopic exam of vaginal discharge in saline
- Liver enzymes may be elevated in Fitz-Hugh–Curtis syndrome
- Positive urinalysis or occult blood in stool decreases the probability of PID
- ESR or C-reactive protein may be elevated, but not routinely recommended
Imaging
- Patients with adnexal fullness or an adnexal mass on exam should have a transvaginal US to exclude TOA
- Consider obtaining a pelvic US in patients who use an intrauterine device, fail outpatient antibiotic therapy for PID, or who have inadequate pelvic exams due to pain or obesity
Diagnostic Procedures/Surgery
Laparoscopy may be useful in confirming PID in a patient with a high suspicion of competing diagnosis or who failed outpatient treatment for PID
DIFFERENTIAL DIAGNOSIS
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PRE-HOSPITAL
- No specific pre-hospital considerations
- Appropriate pain management
INITIAL STABILIZATION/THERAPY
- Resuscitation rarely indicated
- Pain control
ED TREATMENT/PROCEDURES
Outpatient
- Ceftriaxone or cefoxitin/probenecid + doxycycline; with metronidazole when anaerobes are a particular concern
- Alternatives include ceftriaxone + azithromycin.
- Must evaluate and treat sex partner as appropriate
Inpatient
- Doxycycline + cefoxitin or cefotetan
- Alternatives include gentamicin + clindamycin; or ampicillin/sulbactam + doxycycline
- Continue parenteral antibiotic administration for 24 hr after clinical improvement, then switch to oral antibiotics to finish 14 day course
- Laparoscopy can be used to lyse adhesions in the acute and chronic stages of Fitz-Hugh–Curtis syndrome
- Add metronidazole when anaerobes are a particular concern
MEDICATION
- Ampicillin/sulbactam: 3 g IV q6h
- Azithromycin: 1 g PO once per week for 2 wk
- Cefotetan: 2 g IV q12h
- Cefoxitin: 2 g IM single dose (outpatient); 2 g IV q6h (inpatient)
- Ceftriaxone: 250 mg IM single dose
- Clindamycin: 450 mg PO QID for 14 days (outpatient); 900 mg IV q8h (inpatient)
- Doxycycline: 100 mg PO BID for 14 days (outpatient); 100 mg IV or PO q12h (inpatient)
- Oral doxycycline is preferred due to pain of IV infusion
- IV and oral doxycycline have similar bioavailability
- Gentamicin: 2 mg/kg loading dose followed by 1.5 mg/kg IV q8h. Single daily IV dosing of gentamicin may also be used.
- Metronidazole: 500 mg PO BID for 14 days (outpatient); 500 mg IV q8h (inpatient)
- Probenecid: 1 g PO single dose
First Line
- For outpatient:
- Ceftriaxone or cefoxitin/probenecid + doxycycline
- With metronidazole when anaerobes are a particular concern, in suspected Trichomonas vaginalis infection
- Or in women with recent history of pelvic instrumentation
- Of note, oral cephalosporins are no longer a recommended treatment for gonococcal infections (CDC recommends combination therapy with single IM dose of ceftriaxone + oral azithromycin or doxycycline)
- For inpatient:
- Doxycycline + cefoxitin or cefotetan
Second Line
- For outpatient:
- Ceftriaxone + azithromycin with or without metronidazole
- For inpatient:
- Gentamicin + clindamycin; or ampicillin/sulbactam + doxycycline
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DISPOSITION
Admission Criteria
- Uncertain diagnosis and toxic appearance
- Suspected pelvic abscess, including TOA
- Pregnancy
- Immunodeficiency
- Severe illness (e.g., vomiting or severe pain)
- Failure of outpatient therapy
- Probable noncompliance with outpatient therapy (e.g., adolescents)
- Consider admission if appropriate clinical follow-up cannot be arranged
Discharge Criteria
- Patients who do not meet admission criteria may be treated as outpatients
- Recent studies have shown that in women with mild to moderate PID, there was no difference in reproductive outcomes between women randomized to inpatient vs. outpatient treatment
Issues for Referral
TOAs may require drainage or surgical intervention in addition to antibiotics
FOLLOW-UP RECOMMENDATIONS
- If outpatient therapy is selected, it is important to have follow-up in 48–72 hr to assess for clinical improvement
- If the patient has not defervesced by 72 hr, inpatient treatment and further evaluation should be considered
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