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 with endocervical infections and PID may be asymptomatic. Uncomplicated endocervical infections with C trachomatis and N gonorrhoeae are underdiagnosed and tend to be undertreated.^[63]Bjartling et al reported less symptomatic urethral infection and decreased lower abdominal findings produced by a less virulent variant strain of C trachomatis.^[25]

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%.

Because of the relatively poor specificity and sensitivity of clinical findings, the Centers for Disease Control and Prevention (CDC) has established minimal criteria for the diagnosis of PID. According to these criteria, empiric treatment of PID is indicated 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^[6]:

Cervical motion tenderness
Uterine tenderness
Adnexal tenderness

The differential diagnosis includes appendicitis, cervicitis, urinary tract infection, endometriosis, ovarian torsion, interstitial cystitis, 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 the patient has PID declines substantially.

Most patients show clinical response within 48-72 hours after initiation of 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

Adnexal Tumors
Appendicitis
Ectopic Pregnancy
Endometriosis
Interstitial Cystitis
Ovarian Cysts
Ovarian Torsion

Workup

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Media Gallery

"Violin-string" adhesions of chronic Fitz-Hugh-Curtis syndrome.
Transabdominal ultrasonogram shows anechoic tubular structures in adnexa; finding is compatible with hydrosalpinx.
Endovaginal ultrasonogram reveals tubular structure with debris in left adnexa; finding is compatible with pyosalpinx.
Ultrasonogram shows markedly heterogeneous and thickened endometrium; finding is compatible with endometritis.
Ultrasonogram reveals bilateral complex masses in patient who had pyometrium; finding is compatible with tubo-ovarian abscess.
Transabdominal ultrasonogram demonstrates echogenic region within endometrium with dirty shadowing; finding is compatible with air in endometrium and endometritis. Additionally, bilateral complex masses are present; finding is compatible with tubo-ovarian masses.

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Pelvic Inflammatory Disease Differential Diagnoses

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