eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Pelvic Inflammatory Disease: Differential Diagnoses & Workup

Author: Iris Reyes, MD, Advisory Dean; Director of Quality Improvement, Associate Professor, Department of Emergency Medicine, University of Pennsylvania
Coauthor(s): Ritu Kumar, MD, Resident, Department of Emergency Medicine, Hospital of the University of Pennsylvania; Stephanie Abbuhl, MD, Vice Chair, Associate Professor, Department of Emergency Medicine, University of Pennsylvania School of Medicine; Attending Physician in Emergency Services, Hospital of the University of Pennsylvania
Contributor Information and Disclosures

Updated: Feb 4, 2009

Differential Diagnoses

Abortion, Threatened
Ovarian Cysts
Appendicitis, Acute
Ovarian Torsion
Diverticular Disease
Pregnancy, Ectopic
Endometriosis
Urinary Tract Infection, Female
Gastroenteritis

Workup

Laboratory Studies

  • All female patients of childbearing age with lower abdominal pain require a pregnancy test. Pelvic inflammatory disease (PID) is the most common incorrect diagnosis in missed ectopic pregnancies. Although it is rare to have pelvic inflammatory disease in pregnancy, the disease can occur in the first 12 weeks of gestation before the decidua seals off the uterus from ascending bacteria.
  • Complete blood cell count
    • Fewer than 50% of women with acute pelvic inflammatory disease have a white blood cell (WBC) count more than 10,000.
    • An elevated WBC count is not a CDC criterion for diagnosing pelvic inflammatory disease.
  • The erythrocyte sedimentation rate (ESR) is included in the CDC's additional criteria for pelvic inflammatory disease. However, ESR may not be particularly helpful in the ED where other diagnoses that also may elevate ESR are present or under consideration.
  • Perform a urinalysis on all patients with lower abdominal pain to exclude cystitis or pyelonephritis.
  • Obtain gonorrhea and chlamydia cultures or other detection assays, (eg, enzyme-linked immunosorbent assay [ELISA], fluorescent antibody tests, DNA probes) on all patients during the pelvic examination.

Imaging Studies

  • Pelvic ultrasonography
    • On transvaginal ultrasonography, acute pelvic inflammatory disease can present as tubal wall thickness greater than 5 mm, incomplete septae within the tube, fluid in the cul-de-sac, and the cogwheel sign (a cogwheel appearance on the cross-section tubal view). One study found that using color flow Doppler in conjunction with transvaginal ultrasonography was 100% sensitive for diagnosing pelvic inflammatory disease.1 Further studies are needed to confirm this result.
    • Although pelvic ultrasonography is not used in the routine diagnosis of uncomplicated pelvic inflammatory disease, it is a valuable adjunct in the diagnosis of tubo-ovarian abscess.
    • Ultrasonography can also help diagnose other entities on the differential, including ovarian cyst and ovarian torsion.
  • Magnetic resonance imaging is useful in diagnosing pelvic inflammatory disease, but it is not a practical tool due to its limited availability and significant cost. Although the cost of MRI is prohibitive, it is a more sensitive and specific imaging modality compared with ultrasonography in diagnosing pelvic inflammatory disease. On MRI, pelvic inflammatory disease can present as a fluid-filled fallopian tube or free fluid in the pelvis with polycysticlike ovaries.

Other Tests

  • Venereal Disease Research Laboratory (VDRL) test
  • Rapid plasma reagent test
  • HIV test

Procedures

  • Some experts believe that pelvic inflammatory disease is rare without a coexisting purulent endocervical infection and recommend a wet-mount examination from the os to look for numerous WBCs.

More on Pelvic Inflammatory Disease

Overview: Pelvic Inflammatory Disease
Differential Diagnoses & Workup: Pelvic Inflammatory Disease
Treatment & Medication: Pelvic Inflammatory Disease
Follow-up: Pelvic Inflammatory Disease
References
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References

  1. Molander P, Sjoberg J, Paavonen J, Cacciatore B. Transvaginal power Doppler findings in laparoscopically proven acute pelvic inflammatory disease. Ultrasound Obstet Gynecol. Mar 2001;17(3):233-8. [Medline].

  2. CDC. Sexually transmitted diseases treatment guidelines 2002. Centers for Disease Control and Prevention. MMWR Recomm Rep. May 10 2002;51(RR-6):1-78. [Medline].

  3. CDC. Update to CDC's sexually transmitted diseases treatment guidelines, 2006: Fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR Morb Mortal Wkly Rep. April 13 2007;56(14):332-336.

  4. Ness RB, Hillier SL, Kip KE, et al. Douching, pelvic inflammatory disease, and incident gonococcal and chlamydial genital infection in a cohort of high-risk women. Am J Epidemiol. Jan 15 2005;161(2):186-95. [Medline].

  5. CDC. 1998 guidelines for treatment of sexually transmitted diseases. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. Jan 23 1998;47(RR-1):1-111. [Medline].

  6. FDA. Center for Drug Evaluation and Research. Drugs to be discontinued. Available at www.fda.gov/cder/drug/shortages/#disc. Accessed May 2, 2007.

  7. Hillis SD, Joesoef R, Marchbanks PA. Delayed care of pelvic inflammatory disease as a risk factor for impaired fertility. Am J Obstet Gynecol. May 1993;168(5):1503-9. [Medline].

  8. Hollier LM, Workowski K. Treatment of sexually transmitted diseases in women. Obstet Gynecol Clin North Am. Dec 2003;30(4):751-75, vii-viii. [Medline].

  9. McCormack WM. Pelvic inflammatory disease. N Engl J Med. Jan 13 1994;330(2):115-9. [Medline].

  10. Meyers DS, Halvorson H, Luckhaupt S. Screening for chlamydial infection: an evidence update for the U.S. Preventive Services Task Force. Ann Intern Med. Jul 17 2007;147(2):135-42. [Medline].

  11. Ness RB, Hillier SL, Kip KE. Bacterial vaginosis and risk of pelvic inflammatory disease. Obstet Gynecol. Oct 2004;104(4):761-9. [Medline].

  12. Ness RB, Trautmann G, Richter HE, et al. Effectiveness of treatment strategies of some women with pelvic inflammatory disease: a randomized trial. Obstet Gynecol. Sep 2005;106(3):573-80. [Medline].

  13. Rice R, Schwartz D, Knapp J, et al. Pelvic inflammatory disease. In: Morse, Moreland, Holmes, eds. Atlas of Sexually Transmitted Diseases and AIDS. 1996:134-47.

  14. Sam JW, Jacobs JE, Birnbaum BA. Spectrum of CT findings in acute pyogenic pelvic inflammatory disease. Radiographics. Nov-Dec 2002;22(6):1327-34. [Medline].

  15. Soper DE. Pelvic inflammatory disease. Infect Dis Clin North Am. Dec 1994;8(4):821-40. [Medline].

  16. Suss AL, Homel P, Hammerschlag M, Bromberg K. Risk factors for pelvic inflammatory disease in inner-city adolescents. Sex Transm Dis. May 2000;27(5):289-91. [Medline].

  17. Walker CK, Wiesenfeld HC. Antibiotic therapy for acute pelvic inflammatory disease: the 2006 Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines. Clin Infect Dis. Apr 1 2007;44 Suppl 3:S111-22. [Medline].

  18. Westrom L, Joesoef R, Reynolds G, Hagdu A, Thompson SE. Pelvic inflammatory disease and fertility. A cohort study of 1,844 women with laparoscopically verified disease and 657 control women with normal laparoscopic results. Sex Transm Dis. Jul-Aug 1992;19(4):185-92. [Medline].

  19. Wiesenfeld HC, Sweet RL, Ness RB, Krohn MA, Amortegui AJ, Hillier SL. Comparison of acute and subclinical pelvic inflammatory disease. Sex Transm Dis. Jul 2005;32(7):400-5. [Medline].

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Further Reading

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Contributor Information and Disclosures

Author

Iris Reyes, MD, Advisory Dean; Director of Quality Improvement, Associate Professor, Department of Emergency Medicine, University of Pennsylvania
Iris Reyes, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Ritu Kumar, MD, Resident, Department of Emergency Medicine, Hospital of the University of Pennsylvania
Ritu Kumar, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Student Association/Foundation, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Stephanie Abbuhl, MD, Vice Chair, Associate Professor, Department of Emergency Medicine, University of Pennsylvania School of Medicine; Attending Physician in Emergency Services, Hospital of the University of Pennsylvania
Stephanie Abbuhl, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

David S Howes, MD, Residency Program Director, Professor of Medicine, Section of Emergency Medicine, University of Chicago/Pritzker School of Medicine
David S Howes, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Physicians-American Society of Internal Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Mark Zwanger, MD, MBA, Assistant Professor, Department of Emergency Medicine, Thomas Jefferson University
Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD, Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center
Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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