eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Pelvic Inflammatory Disease

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

Introduction

Background

Pelvic inflammatory disease (PID) is a spectrum of infections of the female genital tract that includes endometritis, salpingitis, tubo-ovarian abscess, and peritonitis.

Pathophysiology

Pelvic inflammatory disease is caused by organisms ascending to the upper female genital tract from the vagina and cervix. It most commonly is associated with Chlamydia trachomatis and Neisseria gonorrhoeae, but other organisms and, in many cases, multiple organisms, have been isolated.

Anaerobic bacteria, including those in the genera Peptococcus, Peptostreptococcus, and Bacteroides, appear to play an important role. The genital Mycoplasma and Ureaplasma organisms and the gut coliforms also have been isolated from the upper genital tract of women with pelvic inflammatory disease.

Frequency

United States

Pelvic inflammatory disease is the single most frequent serious infection encountered by women. The disease afflicts more than 1 million women each year and generates annual health care costs of approximately 4.2 billion dollars. It is responsible for nearly 250,000 hospitalizations per year.

Mortality/Morbidity

Several long-term sequelae have been clearly associated with pelvic inflammatory disease.

• Ectopic pregnancy rates are 12-15% higher in women who have had an episode of pelvic inflammatory disease.
• Tubal occlusion with infertility occurs at a rate of 12-50% in these patients, increasing with each episode of pelvic inflammatory disease.
• Chronic pelvic pain has been associated with pelvic inflammatory disease at an incidence as high as 18% after a single episode of the disease.

Sex

Pelvic inflammatory disease is a disease of the female upper genital tract.

Age

Sexually active women younger than 25 years are at greatest risk, although pelvic inflammatory disease can occur at any age.

Other risk factors include previous history of chlamydia or another sexually transmitted infection, prior episode of pelvic inflammatory disease, high number of sexual partners, inconsistent or no regular use of condoms, sexual intercourse at an early age, and women who exchange sex for money or drugs.

Screening recommendations
 
Based on published data, the US Preventive Services Task Force (USPSTF) recommends that all nonpregnant women younger than 24 years should be screened for chlamydia, regardless of their risk factors. Additionally, women older than 25 years should be screened if they are at increased risk (A level recommendation). Screening women older than 25 years who are not at increased risk carries a C level recommendation from the USPSTF. No data weigh the benefits and risks of screening men, and, thus, the USPSTF does not provide recommendations for chlamydia screening in men.

Clinical

History

• Most women with pelvic inflammatory disease typically report symptoms of bilateral lower abdominal pain.
• Vaginal discharge
• Low back pain
• Irregular vaginal bleeding
• Depending on the severity of the infection, patients with pelvic inflammatory disease may be minimally symptomatic or may present with toxic symptoms of fever, nausea, vomiting, and severe pain.
• Gonococcal pelvic inflammatory disease 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 the menstrual period.

Physical

Physical examination findings of pelvic inflammatory disease are described below.

• The lower abdomen is usually tender. This is a very sensitive but nonspecific finding.
• Pelvic examination
  • Mucopurulent cervical discharge
  • Cervical motion tenderness
  • Uterine tenderness
  • Adnexal tenderness (usually bilateral)
• An adnexal mass may be found in more extensive cases, suggesting a tubo-ovarian abscess, or peritonitis may be present, mimicking an acute surgical abdomen.
• The clinical diagnosis of pelvic inflammatory disease can be difficult and imprecise due to the nonspecific nature of the presenting signs and symptoms.
  • Diagnosis is also complicated because a subset of women with pelvic inflammatory disease appear to exhibit subtle symptoms that often are undiagnosed by a health care provider or are unappreciated by the patient.
  • Because of the serious potential complications of untreated pelvic inflammatory disease 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 pelvic inflammatory disease when a patient has all of the following minimal clinical criteria in the absence of an established cause other than pelvic inflammatory disease:
    • Lower abdominal tenderness on palpation
    • Adnexal tenderness
    • Cervical motion tenderness
• Data from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) trial shows that the presence of adnexal tenderness has a sensitivity of 95.5% for histologic endometritis. This trial supports the empiric treatment of all women at risk for pelvic inflammatory disease with adnexal tenderness and no other obvious cause. Based on data from the PEACH trial, the CDC recommends that all women at risk for pelvic inflammatory disease and who exhibit adnexal, uterine, or pelvic tenderness on bimanual examination, and no other explanation for these findings, be treated empirically for pelvic inflammatory disease.
• Additional criteria, especially in women with more severe clinical signs, can be used to increase the specificity of the diagnosis.
  • Oral temperature more than 38.3°C (101°F)
  • Abnormal cervical or vaginal discharge
  • Elevated erythrocyte sedimentation rate (ESR)
  • Elevated C-reactive protein level
  • White blood cells on saline wet mount of vaginal secretion
  • Laboratory documentation of cervical infection with N gonorrhoeae or C trachomatis

Causes

• N gonorrhoeae and C trachomatis traditionally have been considered the etiologic agents of pelvic inflammatory disease, alone or combined.
• A sexually transmitted disease (STD) organism is not recovered in a third of women with pelvic inflammatory disease.
• Facultative anaerobes consistent with the endogenous vaginal and perineal flora have also been identified as potential etiologic agents in pelvic inflammatory disease. These include the following flora:
  • Gardnerella vaginalis
  • Streptococcus agalactiae
  • Peptostreptococcus species
  • Bacteroides species (other than Bacteroides fragilis)
  • Genital Mycoplasma and Ureaplasma species, coliforms
• Other nongenital pathogens, such as Haemophilus influenzae and Haemophilus parainfluenzae, may be the causes of some pelvic inflammatory disease cases.
  • Actinomyces species have been linked to some pelvic inflammatory disease cases associated with intrauterine device (IUD) usage.
  • In less-developed countries, pelvic inflammatory disease may be due to a granulomatous salpingitis caused by Mycobacterium tuberculosis and Schistosoma species.

• Search for CME/CE on This Topic »

• Pelvic Inflammatory Disease (Obstetrics and Gynecology)
• Pelvic Inflammatory Disease/Tubo-ovarian Abscess (Radiology)
• Salpingitis (Obstetrics and Gynecology)
• Gonorrhea (Pediatrics: General Medicine)

• Female Sexual Problems Overview
• Pregnancy and Reproduction Center
• Birth Control Overview
• Birth Control FAQs
• Pelvic Inflammatory Disease Causes
• Pelvic Inflammatory Disease Symptoms
• Pelvic Inflammatory Disease Overview
• Pelvic Inflammatory Disease Treatment
• Sexually Transmitted Diseases Center

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