eMedicine Specialties > Radiology > Obstetrics/Gynecology
Pelvic Inflammatory Disease/Tubo-ovarian Abscess
Updated: Aug 10, 2009
Introduction
Background
Pelvic inflammatory disease (PID) is one of the most serious complications of sexually transmitted diseases.1 It is an infection of the female upper genital tract that encompasses a broad category of diseases, including endometritis, salpingitis, salpingo-oophoritis, tubo-ovarian abscess (TOA), and pelvic peritonitis. Prompt diagnosis and treatment of this condition are critical because the complications of PID can be life and fertility threatening.2,3,4,5,6,7
Endovaginal sonogram. This image shows anechoic tubular structures in the adnexal area; the finding is compatible with a hydrosalpinx.
Transabdominal ultrasound scan. This image shows anechoic tubular structures in the adnexa; the finding is compatible with a hydrosalpinx.
Endovaginal ultrasound scan. This image shows anechoic tubular structures in the adnexa; the finding is compatible with a hydrosalpinx.
Recent studies
Bloom et al studied the rates of outpatient PID in women younger than 25 years who joined either the U.S. Army or U.S. Navy between January 1, 2001, and December 31, 2005. Individuals were followed for up to 60 months, either until a first outpatient PID diagnosis occurred or the individual left military service. There were 1276 diagnoses (in 58,088 individuals) of PID in the Army and 546 diagnoses (in 33,046 individuals) in the Navy. The crude incident rate was 64% higher in the Army (13.6/1000 person-years) than the Navy (8.3/1000 person-years). Risk for the Army personnel increased soon after beginning service, followed by a decline, while risk for the Navy remained comparatively uniform.8
Halperin et al studied 163 patients (42 with clinical and sonographic evidence of TOA and 121 with PID) to define the predictors discriminating between patients developing TOA and those with non-TOA acute PID on the day of admission to the hospital. A palpable adnexal mass in women older than 42 years and an erythrocyte sedimentation rate greater than 50 mm/h were the best predictors of TOA. There was no difference in the mean temperature or number of sick days prior to hospitalization.9
Pathophysiology
Pelvic inflammatory disease (PID) most commonly occurs as a result of Chlamydia trachomatis or Neisseria gonorrhoeae infection of the cervix or vagina that then spreads into the endometrium, fallopian tubes, ovaries, and adjacent structures. Less commonly, direct spread from a nearby infection such as appendicitis or diverticulitis may occur. Hematogenous infection is a rare cause of PID except in cases of tuberculous PID.10
Frequency
United States
Annually, there are approximately 1 million women who develop pelvic inflammatory disease (PID).11 An estimated 1 in 8 sexually active adolescent girls develop PID before reaching age 20. Because PID may be asymptomatic and this condition is frequently undiagnosed, the incidence rate is likely higher.11,12
Mortality/Morbidity
Serious lifelong sequelae may occur if pelvic inflammatory disease (PID) is not diagnosed and treated promptly. More than 25% of women with PID have at least 1 complication, which can include ectopic pregnancy, infertility, and/or chronic abdominal pain.
Sex
Pelvic inflammatory disease typically affects sexually active women.
Age
The peak incidence rate is in women aged 20-24 years.13 However, if the incidence rate is corrected for sexually active females, it is highest in adolescent girls aged 15-19 years.14
Presentation
Risk factors
The endocervical canal and the mucus plug are the major barriers to the ascent of the bacteria into the upper genital tract. Changes in the vaginal flora, composition of the mucus plug, and cervical cell type are believed to affect the risk of infection. Endometrial instrumentation also increases the risk of pelvic inflammatory disease (PID).4
The Centers for Disease Control and Prevention (CDC) criteria for the diagnosis of PID are as follows12 :
- Minimum criteria (1 or more):
- Lower abdominal tenderness
- Adnexal tenderness
- Tenderness with cervical motion
- Additional criteria: Patients with PID should have 1 or more of the following:
- Signs of lower genital tract inflammation
- Oral temperature higher than 101ºF
- Abnormal cervical and vaginal discharge
- Greatly increased numbers of white blood cells on saline microscopy of vaginal secretions
- Elevated erythrocyte sedimentation rate
- Elevated C-reactive protein level
- Laboratory documentation of cervical infection with C trachomatis or N gonorrhoeae
- Elaborate criteria (additional findings include the following):
- Histopathologic evidence of endometritis at endometrial biopsy
- Thickened fluid-filled tubes with or without free pelvic fluid or a tubo-ovarian complex on transvaginal sonograms or images from other modalities
- Laparoscopic abnormalities that are consistent with PID
Treatment
PID is commonly treated as an outpatient disease, with the use of oral antibiotics that cover both aerobic and anaerobic organisms, including C trachomatis and N gonorrhoeae. Treatment is usually started before the endocervical culture results are available (empiric therapy) because negative findings do not exclude a diagnosis of PID in the upper genital tract.12 Empiric treatment is recommended if the minimum criteria above (see Diagnosis) are fulfilled and if no other cause for the patient's symptoms is identified.12,15,16
The CDC recommends hospitalization and administration of intravenous antibiotics in patients with the following: uncertain diagnosis, pregnancy, failure to adhere to or respond to oral treatment, severe illness, TOA, immunodeficiency, or human immunodeficiency virus infection.12
Preferred Examination
Ultrasonography should be the first diagnostic imaging examination to be performed in cases of suspected pelvic inflammatory disease (PID) in which there are nondiagnostic clinical findings. This modality is readily available and noninvasive and can be performed at the patient's bedside.
Transvaginal sonography (TVS) allows detailed visualization of the uterus and adnexa, including the ovaries. The fallopian tubes are usually imaged only when they are abnormal and distended on physical examination, primarily from postinflammatory obstruction. Transabdominal sonography (TAS) is complementary to the endovaginal examination because it provides a more global view of the pelvic contents. Whether TAS (bladder filling required) or TVS (bladder filling not required) is performed first and whether the complementary examination is needed for a final diagnosis is a matter of individual clinical imaging practice.
Magnetic resonance imaging (MRI) serves as an excellent imaging modality in cases in which the ultrasonographic findings are equivocal. In a study by Tukeva et al, the authors compared findings from MRI with sonograms and found that MRI was more accurate than ultrasonography in the diagnosis of PID.17 However, the study was limited to a select group of patients.
Occasionally, computed tomography (CT) scanning may be used as the initial diagnostic study for the investigation of nonspecific pelvic pain in a female, and PID may be found incidentally. Most often, ultrasonography is preferred over CT scanning as the triaging tool in a female child or adolescent with right lower quadrant or pelvic pain, particularly because of concerns about radiation exposure. If the diagnosis of PID is still in question, confirmation with ultrasonography is suggested.
Limitations of Techniques
TVS may be limited by the patient's inability to tolerate the transvaginal examination (although this is not usual). In such cases, only transabdominal findings may be available. Occasionally, the higher frequency and the lower position of the transvaginal transducer limits penetration of the sound beam, and TVS imaging of an unusually high adnexa may not be possible. Sometimes, a patient's large body habitus or abdominal wall scarring limits penetration of the sound beam, adversely affecting TAS.
Differential Diagnoses
| Appendicitis | Nephrolithiasis/Urolithiasis |
| Ectopic Pregnancy | Ovarian Torsion |
| Endometrioma/Endometriosis | |
| Inflammatory Bowel Disease | |
| Mesenteric Adenitis |
Other Problems to Be Considered
Chronic Pelvic Pain
Hematoma
Hemorrhagic cyst or corpus luteum
Mittelschmerz
Necrotic pelvic neoplasm
More on Pelvic Inflammatory Disease/Tubo-ovarian Abscess |
 Overview: Pelvic Inflammatory Disease/Tubo-ovarian Abscess |
| Imaging: Pelvic Inflammatory Disease/Tubo-ovarian Abscess |
| Follow-up: Pelvic Inflammatory Disease/Tubo-ovarian Abscess |
| Multimedia: Pelvic Inflammatory Disease/Tubo-ovarian Abscess |
| References |
| Further Reading |
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References
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Haggerty CL, Ness RB. Newest approaches to treatment of pelvic inflammatory disease: a review of recent randomized clinical trials. Clin Infect Dis. Apr 1 2007;44(7):953-60. [Medline].
Simms I, Stephenson JM, Mallinson H, et al. Risk factors associated with pelvic inflammatory disease. Sex Transm Infect. Dec 2006;82(6):452-7. [Medline].
Ibarrola Vidaurre M, Benito J, Azcona B, Zubeldía N. [Infectious pathology: vulvovaginitis, sexually transmitted diseases, pelvic inflammatory disease, tubo-ovarian abscesses]. An Sist Sanit Navar. 2009;32 Suppl 1:29-38. [Medline].
Judlin P, Thiebaugeorges O. Levofloxacin plus metronidazole in uncomplicated pelvic inflammatory disease: a preliminary study. Eur J Obstet Gynecol Reprod Biol. Aug 2009;145(2):177-9. [Medline].
Sweet RL. Treatment strategies for pelvic inflammatory disease. Expert Opin Pharmacother. Apr 2009;10(5):823-37. [Medline].
Bloom MS, Hu Z, Gaydos JC, Brundage JF, Tobler SK. Incidence rates of pelvic inflammatory disease diagnoses among Army and Navy recruits potential impacts of Chlamydia screening policies. Am J Prev Med. Jun 2008;34(6):471-7. [Medline].
Halperin R, Svirsky R, Vaknin Z, Ben-Ami I, Schneider D, Pansky M. Predictors of tuboovarian abscess in acute pelvic inflammatory disease. J Reprod Med. Jan 2008;53(1):40-4. [Medline].
Morishita K, Gushimiyagi M, Hashiguchi M, Stein GH, Tokuda Y. Clinical prediction rule to distinguish pelvic inflammatory disease from acute appendicitis in women of childbearing age. Am J Emerg Med. Feb 2007;25(2):152-7. [Medline].
US National Library of Medicine, National Institutes of Health. Pelvic inflammatory disease (PID). Updated 9/19/2006. MedlinePlus. Available at http://www.nlm.nih.gov/medlineplus/ency/article/000888.htm. Accessed August 10, 2007.
Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. Aug 4 2006;55(RR-11):1-94. [Medline]. [Full Text].
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Savaris RF, Teixeira LM, Torres TG, et al. Comparing ceftriaxone plus azithromycin or doxycycline for pelvic inflammatory disease: a randomized controlled trial. Obstet Gynecol. Jul 2007;110(1):53-60. [Medline].
Smith KJ, Ness RB, Wiesenfeld HC, Roberts MS. Cost-effectiveness of alternative outpatient pelvic inflammatory disease treatment strategies. Sex Transm Dis. Jul 13 2007;epub ahead of print. [Medline].
Tukeva TA, Aronen HJ, Karjalainen PT, et al. MR imaging in pelvic inflammatory disease: comparison with laparoscopy and US. Radiology. Jan 1999;210(1):209-16. [Medline]. [Full Text].
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Further Reading
Related eMedicine topics
Pelvic Inflammatory Disease (Emergency Medicine)
Pelvic Inflammatory Disease (Obstetrics and Gynecology)
Clinical guidelines
Pelvic inflammatory disease. Sexually transmitted diseases treatment guidelines 2006. Centers for Disease Control and Prevention - Federal Government Agency [U.S.]. 1993 (revised 2006 Aug 4). 6 pages. NGC:005189
United Kingdom national guideline for the management of pelvic inflammatory disease. British Association for Sexual Health and HIV - Medical Specialty Society. 1999 Aug (revised 2005). Various pagings. NGC:004512
Clinical trials
A Trial Comparing Moxifloxacin Versus Levofloxacin Plus Metronidazole In Uncomplicated Pelvic Inflammatory Disease
Keywords
pelvic inflammatory disease, tubo-ovarian abscess, sexually transmitted disease, endometritis, salpingitis, endometrioma, tuboovarian abscess, peritonitis, PID, TOA abscess, Chlamydia trachomatis, C trachomatis, Neisseria gonorrhoeae, N gonorrhoeae
