Pelvic Inflammatory Disease Differential Diagnoses

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

Diagnostic Considerations

The diagnosis of acute pelvic inflammatory disease (PID) is primarily based on historical and clinical findings. The diagnostic process is imprecise, with no single piece of historical, physical, or laboratory information found to be highly specific or sensitive for the disease.

Patients may be asymptomatic with endocervical infections and PID. Uncomplicated endocervical infections with C trachomatis and N gonorrhoeae are underdiagnosed and tend to be undertreated.[31] Bjartling et al have found less symptomatic urethral infection and decreased lower abdominal findings produced by a less virulent variant strain of C trachomatis.[11]

Although many patients with PID have atypical presentations and exhibit no or few symptoms, more than 25% of these patients meet objective criteria for upper tract infection on laparoscopic examination. The sensitivity of the pelvic examination is only 60%.

Due to the relatively poor specificity and sensitivity of clinical findings, the CDC has established minimal criteria for the diagnosis of PID. Institute empiric treatment of PID when a patient who is at risk for sexually transmitted disease (STD) 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 differential diagnosis includes appendicitis, cervicitis, urinary tract infection, endometriosis, and, less commonly, adnexal tumors. A delay in diagnosis or treatment can result in long-term sequelae, such as chronic pelvic pain and tubal infertility.

All female patients of childbearing age with lower abdominal pain require a pregnancy test. PID is the most common incorrect diagnosis in missed ectopic pregnancy.

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.

Most patients show clinical response within 48-72 hours after medical therapy. If the patient continues to have fever, chills, uterine tenderness, adnexal tenderness, and cervical motion tenderness, consider other possible causes and a diagnostic laparoscopy.

Differential Diagnoses

Proceed to Workup
 
 
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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