Pelvic Inflammatory Disease Clinical Presentation

Updated: Aug 16, 2021
  • Author: Kristi A Tough DeSapri, MD; Chief Editor: Nicole W Karjane, MD  more...
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The classic patient at high risk for pelvic inflammatory disease (PID) 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). Young age at first intercourse is also a risk factor for PID. Use of an intrauterine device (IUD) for contraception confers a relative risk of 2.0-3.0 for the first 4 months following insertion, but risk subsequently decreases to baseline. Follow-up is recommended within the first month after IUD insertion.

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 who have had 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 (temperature 38° C [100.4° F] or higher), 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 usually present. The pain is typically 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 the 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. Unanticipated vaginal bleeding, often postcoital, is reported in about 40% of cases. [58] Temperature higher than 38°C (found in 30% of cases), nausea, and vomiting manifest late in the clinical course of the disease. Abnormal uterine bleeding is present in more than one-third of patients. [59]


Physical Examination

Because of the potential serious complications of untreated PID and the endemic prevalence of the infection, the Centers for Disease Control and Prevention (CDC) has adopted an approach designed to maximize diagnosis by using minimal criteria. The CDC also urges clinicians to maintain a low threshold for diagnosis and empiric treatment.

The CDC recommends instituting 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)

AND, on pelvic examination, 1 or more of the following minimal criteria [6] :

  • Cervical motion tenderness
  • Uterine tenderness
  • Adnexal tenderness

A temperature higher than 38.3° C (101° F) and the presence of an 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 of these findings will vary, depending on the prevalence of PID in a given population.

A large multicenter trial found adnexal tenderness to be the most sensitive physical examination finding (sensitivity, 95%). [60] Mucopurulent cervicitis is common and, if absent, has substantial negative predictive value. Adnexal fullness or disproportionate unilateral adnexal tenderness may indicate the development of a tubo-ovarian abscess (TOA).

Molander et al found the following 3 variables to be significant predictors of the diagnosis, correctly classifying 65% of patients with laparoscopically documented PID [61] :

  • Adnexal tenderness

  • Fever

  • Elevated erythrocyte sedimentation rate (ESR)

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. [62]