Pelvic Inflammatory Disease (PID)

Symptoms

• Lower abdominal or pelvic pain (often on both sides, ranging from mild to severe)
• Abnormal vaginal discharge (which may have an unpleasant odor)
• Abnormal uterine bleeding (such as bleeding between periods, after sex, or heavier periods)
• Deep pain during sexual intercourse (dyspareunia)
• Fever and chills
• Nausea and vomiting
• Painful urination (dysuria)
• Back pain
• Many cases of PID are asymptomatic or have only mild, non-specific symptoms ('silent' PID)
• Severe lower abdominal pain (emergency symptom)
• High fever (>101°F or >38.3°C) (emergency symptom)
• Signs of peritonitis (e.g., rebound tenderness, guarding) (emergency symptom)
• Nausea and vomiting preventing oral intake (emergency symptom)
• Suspicion of a surgical emergency (e.g., appendicitis, ectopic pregnancy) (emergency symptom)
• Right upper quadrant pain (suggestive of Fitz-Hugh-Curtis syndrome) (emergency symptom)

Causes & Risk Factors

• Polymicrobial infection (involving a mix of pathogens)
• Neisseria gonorrhoeae (gonorrhea)
• Chlamydia trachomatis (chlamydia)
• Mycoplasma genitalium
• Anaerobes (e.g., Prevotella spp., Peptostreptococcus spp.)
• Facultative bacteria associated with bacterial vaginosis (e.g., Gardnerella vaginalis, Atopobium vaginae)
• Haemophilus influenzae
• Enteric Gram-negative rods (e.g., Escherichia coli)
• Streptococcus spp.
• Multiple sexual partners
• New sexual partner (within last 3 months)
• Inconsistent condom use
• History of sexually transmitted infections (STIs), particularly Chlamydia trachomatis or Neisseria gonorrhoeae
• Bacterial vaginosis (BV)
• Uterine instrumentation (e.g., IUD insertion, termination of pregnancy, hysteroscopy) without appropriate STI screening/prophylaxis
• Vaginal douching
• Young age, particularly adolescents and young women (<25 years)
• Previous episode of PID
• Lack of consistent use of condoms (protective factor)
• Use of combined oral contraceptives (may decrease risk of symptomatic PID, but does not prevent cervical infection)

Diagnosis

• A low threshold for empirical treatment is recommended due to the potential for serious complications and diagnostic difficulty.
• Sexual history (new/multiple partners, condom use)
• Menstrual history
• Contraceptive history
• History of STIs or PID
• Recent gynecological procedures
• Abdominal examination (assess for tenderness, guarding, rebound tenderness)
• Pelvic (bimanual) examination to assess for cervical motion tenderness (CMT or 'Chandelier sign'), uterine tenderness, and adnexal tenderness
• Speculum examination to observe cervix for inflammation (cervicitis) and collect samples
• Minimum Clinical Criteria (CDC 2021): Cervical motion tenderness OR Uterine tenderness OR Adnexal tenderness (in sexually active young women and others at risk for STIs with pelvic/lower abdominal pain, if no other cause is identified)
• Additional Criteria (enhance specificity): Oral temperature >101°F (>38.3°C), abnormal cervical or vaginal mucopurulent discharge, abundant white blood cells on saline microscopy of vaginal fluid, elevated erythrocyte sedimentation rate (ESR), elevated C-reactive protein (CRP), laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis
• More Specific Criteria: Endometrial biopsy with histopathologic evidence of endometritis, transvaginal sonography or MRI showing thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex, laparoscopic findings consistent with PID
• Nucleic Acid Amplification Tests (NAATs) for N. gonorrhoeae, C. trachomatis, and M. genitalium from vaginal, cervical, or urine samples
• Pregnancy test (to exclude ectopic pregnancy)
• Microscopy of vaginal discharge (to look for white blood cells and evidence of co-infections)
• Inflammatory markers (C-reactive protein (CRP) and Erythrocyte Sedimentation Rate (ESR))
• Transvaginal Ultrasound (TVS) to identify tubo-ovarian abscesses (TOA), pyosalpinx, or exclude other pathologies
• Magnetic Resonance Imaging (MRI) for complex cases
• Laparoscopy (diagnostic gold standard, reserved for uncertain diagnosis or failure to respond to therapy)
• Differential Diagnosis: Ectopic pregnancy, appendicitis, endometriosis, ovarian cyst rupture or torsion, urinary tract infection / pyelonephritis, irritable bowel syndrome, diverticulitis

Treatment Options

• Treatment should be initiated empirically as soon as the presumptive diagnosis is made.
• Regimens must provide broad-spectrum coverage of likely pathogens, including N. gonorrhoeae, C. trachomatis, anaerobes, and Gram-negative bacteria.
• Outpatient Medical Treatment (CDC 2021): Ceftriaxone 500 mg IM in a single dose PLUS Doxycycline 100 mg orally twice a day for 14 days WITH Metronidazole 500 mg orally twice a day for 14 days.
• Outpatient Medical Treatment (NICE UK, 2017): Ceftriaxone 1g IM in a single dose PLUS Doxycycline 100 mg orally twice a day for 14 days PLUS Metronidazole 400 mg orally twice a day for 14 days.
• Indications for Hospitalization: Surgical emergencies cannot be excluded, tubo-ovarian abscess (TOA), pregnancy, severe illness, nausea and vomiting, high fever, inability to follow or tolerate an outpatient oral regimen, no clinical response to oral antimicrobial therapy.
• Inpatient Parenteral Regimen 1 (CDC): Ceftriaxone 1 g IV every 24 hours PLUS Doxycycline 100 mg orally or IV every 12 hours PLUS Metronidazole 500 mg orally or IV every 12 hours.
• Inpatient Parenteral Regimen 2 (CDC): Cefotetan 2 g IV every 12 hours PLUS Doxycycline 100 mg orally or IV every 12 hours.
• Inpatient Parenteral Regimen 3 (CDC): Cefoxitin 2 g IV every 6 hours PLUS Doxycycline 100 mg orally or IV every 12 hours.
• Surgical treatment is generally reserved for complications, primarily for management of a tubo-ovarian abscess (TOA) that does not respond to antibiotics, or if rupture is suspected.
• Surgical procedures may include laparoscopic or ultrasound-guided drainage of abscess; in severe cases, salpingectomy, oophorectomy, or hysterectomy may be required.
• Patients treated as outpatients should be clinically re-evaluated within 72 hours.
• If no clinical improvement, hospitalization for parenteral therapy and further diagnostic evaluation is recommended.
• Repeat testing for chlamydia, gonorrhea, and M. genitalium is recommended 3 months after treatment.
• Male sex partners of women with PID from the preceding 60 days should be evaluated and treated empirically for chlamydia and gonorrhea, regardless of their symptoms or test results.
• Patients should be instructed to abstain from sexual intercourse until they and their partner(s) have completed treatment.

Frequently Asked Questions