PELVIC INFLAMMATORY DISEASE- From Diagnosis to Prevention

Jorma Paavonen MD

Dermatologic Clinics Vol.16 No.4 Oct.1998

Reviewed by Peter Fontana, MD

Definition  infection of uterus, fallopian tubes and adjacent pelvic structures not associated with surgery or pregnancy

Risk Factors  young age, ‘ sexual partners, IUD, douching, smoking, GC, chlamydia, BV; OC may be protective against severe disease

Recent Trends  chlamydia>GC   outpatient>inpatient 

Pathogenesis  ascending infection from vagina’cervix’genital tract (endometritis’ salpingitis’ pyosalpinx/TOA); most cases begin soon after menstrual period (hormonal)

Etiology  C. trachomatis (~30% of patients with chlamydial cervicitis develop PID), N. gonorrhea (rates are dropping), BV (#1 cause of vag d/c, role in PID underestimated)

Clinical Picture  bilateral lower abd. pain, abnormal vag d/c, metorrhagia, postcoital bleeding, abnormal uterine bleeding, dysuria, fever, nausea, vomiting

Silent/atypical/subclinical disease  cervicitis w/o other sxs; may still lead to infertility 

Severe disease  peritonitis, perihepatitis (Fitzhugh-Curtis)

Dx  Major criteria (need all): lower abd. pain/tenderness, adnexal tenderness, CMT

Additional criteria (specificity of dx): fever, d/c, +GC/Chlam, ‘CRP or ESR, ‘WBC

Clinical criteria  are insensitive and nonspecific; when compared to laparoscopy (gold standard for dx), pelvic examination is ~60-70% sensitive

Definitive diagnosis via laparoscopy, endometrial biopsy, endovaginal U/S, MRI

Treatment  antibiotics are very effective for short-term clinical cure but prevention of long-term sequelae is not known; IUDs should be removed; contraceptive counseling

Inpatient treatment

A: Cefotetan 2g IV q12 or Cefoxitin 2g IV q6 + Doxycycline 100 mg IV/PO  q12

B: Clindamycin 900 mg IV q8 + Gentamycin loading dose (2 mg/kg) IV/IM then

     maintenance (1.5 mg/kg) q8

Outpatient treatment

A: Ceftriaxone 250 IM or Cefoxitin 2g IM (with Probenicid 1g PO) + Doxycycline

     100mg PO bid x 14 days

B: Ofloxacin 400mg PO bid x 14 days + Metronidazole 500mg PO bid x 14 days

Hospitalization recommended for: uncertain dx, pelvic abscess, pregnancy, adolescent age, other severe illness (HIV), failed outpatient treatment, poor follow-up

Outcome  worldwide increase in PID over the last few decades has led to secondary epidemics in infertility and ectopics

1 episode of PID’ 7% relative risk of infertility; 2 episodes’16.2%; e3 episodes’28%  

Women with a history of PID have 7-10fold increased risk for tubal pregnancy, are 10 times more likely to be admitted for abd. pain, and hysterectomy rates are 8 times higher

Prevention  STD education and screening for cervicitis (especially chlamydia)