8.09 Pelvic Inflammatory Disease

agk’s Library of Common Simple Emergencies

Presentation

A woman aged 15-30, possibly with a new sex partner, complains of lower abdominal pain. There may be associated vaginal discharge, malodor, dysuria, dyspareunia, menorrhagia or intermenstrual bleeding. Patients with more severe infections may develop fever, chills, malaise, nausea and vomiting. Women with severe pelvic pain tend to walk slightly bent over, holding their lower abdomen and shuffling their feet. Abdominal examination reveals lower quadrant tenderness, sometimes with rebound, and occasionally there will be right upper quadrant tenderness due to perihepatitis (Fitz-Hugh-Curtis syndrome). Pelvic examination demonstrates bilateral adnexal tenderness as well a uterine fundal and cervical motion tenderness.

What to do:

• Always perform a pelvic examination on women with lower abdominal complaints or lower abdominal tenderness. The examination should be thorough, yet performed as gently and briefly as possible to avoid exacerbating a very painful condition.
• Obtain endocervical cultures for Neisseria gonorrhoeae and Chlamydia trachomatis.
• Obtain blood for syphilis serology and recommend HIV testing.
• Obtain urine for urinalysis and blood or urine for pregnancy testing.
• Consider obtaining a leukocyte count, sedimentation rate and C-reactive protein. These are indicators of clinical severity, but normal results do not rule out PID.
• Determine pH of any vaginal discharge and make wet mount examinations and Gram stains of endocervical secretions, looking for Candida, Trichomonas, clue cells and any gram-negative diplococci inside polymorphonuclear neutrophils (almost diagnostic of gonorrhea).
• Perform pelvic ultrasound if there is a suspected mass, severe pain, or a positive pregnancy test.
• Because no laboratory tests are diagnostic for PID, assume a diagnosis when there are lower abdominal pain with tenderness on examination, bilateral adnexal tenderness and cervical motion tenderness plus one of:temperature > 38 C (100.4 F), leukocytosis > 10,500 WBC/mm³, inflammatory mass on pelvic examination or ultrasound, elevated C-reactive protein, erythrocyte sedimentation rate > 15mm/h, or evidence of gonorrhea or chlamydia in the endocervix (by positive antigen test, Gram stain or mucopurulent cervicitis).
• Remove any intrauterine device (IUD).
• Treat suspected cases while awaiting diagnostic confirmation.
• Hospitalize adolescents with salphingitis and all patients with pelvic or tubo-ovarian abscess, pregnancy, fever >38.5 C, nausea and vomiting that preclude oral antibiotics, current use of an IUD, septicemia or other serious disease, high risk of poor compliance, failed follow up and failure on 48 hours of the outpatient therapy below.
• Treat mild to moderate cases as outpatients with one dose of ceftriaxone (Rocephin) 250mg im or cefoxitin (Mefoxin) 2000mg im plus probenecid 1000mg po concurrently, followed by a prescription for doxycycline 100mg bid for 14 days. For more severe cases with a high probability of resistant anerobic infection, add metronidazole 1000mg po bid or clindamycin 450mg po qid. A completely oral alternative is ofloxacin (Floxin) 400mg bid x14d plus either clindamycin 450mg qid or metronidazole 500mg qid, also for 14 days.
• Provide for follow up examination in three days.
• Provide analgesics as needed.
• Instruct the patient to abstain from sexual intercourse for at least two weeks.
• Unless sexual acquisition can be excluded with certainty, treat the partner for presumptive gonorrhea and chamydia with ceftriaxone 125mg im once or ciprofloxacin 500mg po once plus doxycycline 100mg po bid x7d or azithromycin 1000mg po once.
• Counsel the patient about the sexually transmitted nature of PID and its risks for infertility (15-30% per episode) and ectopic pregnancy. Barrier methods of contraception (condoms and diaphragms) reduce the risk. Vaginal spermicides are also bactericidal.

What not to do:

• Do not use ofloxacin in pregnant women or patients under 18.
• Do not miss the more unilateral disorders like ectopic pregnancy, appendicitis, ovarian cyst or torsion and diverticulitis. Early consultation by both general surgeon and obstetrician/gynecologist are sometimes necessary.
• Do not diagnose PID in a patient with a positive pregnancy test without rulling out ectopic pregnancy, usually with a sonogram.
• Do not ignore pelvic symptoms if the patient has perihepatic inflammation.

Discussion

Pelvic inflammatory disease (PID) is defined as salpingitis, often accompanied by endometritis or secondary pelvic peritonitis, that results from ascending genital infection. PID related to N. gonorrhoeae and C. trachomatis is more common within the first one or two weeks after the onset of menstuation. There is increased risk for this disease in sexually active adolescents compared with women over twenty years old. There is also increased risk with multiple sex partners, use of an interuterine device (IUD), previous history of PID and vaginal douching. The incubation period for PID varies from 1-2 days to weeks or months. Laparoscopy is indicated in severe cases, if diagnosis is uncertain or if there is inadequate response to initial antibiotic therapy. A diagnosis of PID in children or young adolescents should prompt an evaluation for possible child abuse.

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