8.09 Pelvic Inflammatory Disease
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agk's Library of Common Simple Emergencies

Presentation
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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 exacer- 
    bating 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, sed- 
    imentation 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 polymorpho- 
    nuclear 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: 
     o temperature >38 C (100.4 F), 
     o leukocytosis >10,500 WBC/mm^3, 
     o inflammatory mass on pelvic examination 
         or ultrasound,
     o elevated C-reactive protein, 
     o erythrocyte sedimentation rate >15mm/h, 
     o or evidence of gonorrhea or chlamydia 
         in the endocervix (by positive antigen 
         test, Gram stain or mucopurulent cerv-
         icitis).
- Remove any intrauterine device (IUD).
- Treat suspected cases while awaiting diag- 
    nostic 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 antibiot- 
    ics, 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 clinda- 
    mycin 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
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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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 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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