Pelvic Inflammatory Disease Clinical Presentation

  • Author: Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM; Chief Editor: Michel E Rivlin, MD   more...
 
Updated: May 17, 2011
 

History

The classic high-risk patient is a menstruating woman younger than 25 years who has multiple sex partners, does not use contraception, and lives in an area with a high prevalence of sexually transmitted infections (STIs).

Pelvic inflammatory disease (PID) is more prevalent among individuals who are young at first intercourse. Additionally, the IUD confers a relative risk of 2.0-3.0 for the first 4 months following insertion, but then it decreases to baseline thereafter. Women who are not sexually active have a very low incidence of upper genital tract infection, as do women who have undergone total abdominal hysterectomy. Bilateral tubal ligation (BTL) does not provide protection against PID; however, patients post BTL may have delayed and milder forms of the disease.

Depending on the severity of the infection, patients with PID may be minimally symptomatic or may present with toxic symptoms of fever, nausea, vomiting, and severe pelvic and abdominal pain.

Gonococcal PID is thought to have an abrupt onset with more toxic symptoms than nongonococcal disease. Gonorrhea- and chlamydia-associated infections are more likely to cause symptoms toward the end of menses and in the first 10 days following menstruation.

Lower abdominal pain is present. Usually, pain is described as dull, aching or crampy, bilateral, and constant; it begins a few days after the onset of the last menstrual period and tends to be accentuated by motion, exercise, or coitus. Pain from PID usually lasts less than 7 days; if pain lasts longer than 3 weeks, the likelihood that PID is the correct diagnosis declines substantially.

Abnormal vaginal discharge is present in approximately 75% of cases, and unanticipated vaginal bleeding, often postcoital, coexists in about 40% of cases.[26]

Temperature higher than 38°C (30% of cases), nausea, and vomiting manifest late in the clinical course of the disease.

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Physical Examination

Because of the serious potential complications of untreated PID and the endemic prevalence of the infection, the Centers for Disease Control and Prevention (CDC) has adopted an approach to maximize diagnosis by using minimal criteria and by urging providers to maintain a low threshold for diagnosis and empiric treatment. Institute empiric treatment of PID when a sexually active young woman who is at risk for STI has pelvic or lower abdominal pain, no identifiable cause for her illness other than PID, and, on pelvic examination, 1 or more of the following minimal criteria[27] :

  • Cervical motion tenderness
  • Uterine tenderness
  • Adnexal tenderness

The presence of temperature higher than 38.3° C (101° F) and abnormal cervical or vaginal mucopurulent discharge enhance the specificity of the minimum criteria, as do selected laboratory tests.

Rebound lower abdominal tenderness and involuntary guarding may be noted and suggest associated peritonitis. The positive predictive value (PPV) of these findings will vary depending on the prevalence of PID in a given population.

One large, multicenter trial found adnexal tenderness to be the most sensitive physical examination finding (95% sensitive; P < .001).[28] Mucopurulent cervicitis is common, and if absent, it provides a significant negative predictive value (NPV). Adnexal fullness or disproportionate unilateral adnexal tenderness may indicate the development of a tubo-ovarian abscess.

Molander et al found the following 3 variables to be significant predictors of the diagnosis, correctly classifying 65% of patients with laparoscopically documented PID (95% confidence interval, 61-99%)[29] :

  • Adnexal tenderness (P < .001)
  • Fever (P < .001)
  • Elevated sedimentation rate (ESR) (P < .001)

Right upper-quadrant tenderness, especially if associated with jaundice, may indicate associated Fitz-Hugh-Curtis syndrome. A prospective cohort study in 117 incarcerated adolescents documented a 4% incidence of Fitz-Hugh-Curtis syndrome in those with mild-to-moderate PID.[30]

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Contributor Information and Disclosures
Author

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM  Associate Professor, Education Officer, Department of Emergency Medicine, Hospital of the University of Pennsylvania; Director of Education and Research, PENN Travel Medicine

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Chief Editor

Michel E Rivlin, MD  Professor, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine

Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

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"Violin-string" adhesions of chronic Fitz-Hugh-Curtis syndrome.
Transabdominal ultrasonogram. This image shows anechoic tubular structures in the adnexa; the finding is compatible with a hydrosalpinx.
Endovaginal ultrasonogram. This image reveals a tubular structure with debris in the left adnexa; the finding is compatible with a pyosalpinx.
This ultrasonogram shows a markedly heterogeneous and thickened endometrium, a finding that is compatible with endometritis.
This ultrasonogram reveals bilateral complex masses in a patient who had pyometrium, a finding that is compatible with tubo-ovarian abscess.
Transabdominal ultrasonogram. This image demonstrates an echogenic region within the endometrium with dirty shadowing, a finding that is compatible with air in the endometrium and endometritis. Additionally, bilateral complex masses are present; this finding is compatible with tubo-ovarian masses.
 
 
 
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