Pelvic inflammatory disease: Clinical sciences
Introduction0:00–0:56
Pelvic inflammatory disease, or PID for short, is an inflammatory condition that can affect the uterus, fallopian tubes, ovaries, and peritoneum.
PID is often caused by infection with sexually transmitted organisms such as gonorrhea and chlamydia. However, it may also be caused by microorganisms normally found in the vaginal flora.
Inflammation of the fallopian tubes, also known as salpingitis, increases the risk of infertility and ectopic pregnancy, while peritonitis can lead to pelvic adhesions and chronic pelvic pain.
Even very mild cases of PID can lead to these sequelae. Finally, based on the severity, the clinical presentation of PID can range from asymptomatic or only mild symptoms to severe pelvic pain or even sepsis.
Your first step in evaluating a patient presenting with a chief concern suggesting PID is to perform a CABCDE assessment in order to determine if they are stable or unstable, which in most cases would indicate they’ve developed sepsis.If the patient is unstable, stabilize their airway, breathing, and circulation right away.
Unstable patient0:56–3:41
This means that you might have to intubate the patient, obtain IV access and continuously monitor their vital signs. In addition, you should immediately obtain an HCG pregnancy test!
Once you have initiated acute management, your next step is to take a focused history and physical exam. Patients typically report fever, nausea and vomiting, lower abdominal and pelvic pain, abnormal vaginal discharge, and intermenstrual or post-coital spotting.
Here’s a high-yield fact! If this patient reports upper abdominal pain, you should consider perihepatitis, also known as Fitz-Hugh-Curtis syndrome.
Perihepatitis develops when the pathogenic microorganisms causing PID spill from the fimbriae and settle in the space surrounding the liver and diaphragm.
This leads to inflammation of the liver capsule, without involvement of the liver parenchyma, as well as to the formation of the so-called “violin string” adhesions between the liver and the peritoneum, resulting in right upper quadrant pain that can mimic gallbladder disease.
Okay, back to the physical exam. Here, you might find signs of sepsis, such as elevated temperature, hypotension, and tachycardia.
Be sure to assess the abdomen for diffuse tenderness, which may include rebound pain or guarding. In addition, the pelvic exam may reveal signs of cervicitis, such as swelling, inflammation, and mucopurulent cervical discharge, as well as cervical motion tenderness, uterine and adnexal tenderness.
Finally, you might find an adnexal mass, which should get you to think about a tubo-ovarian abscess.Based on these findings, you should suspect PID with sepsis.
If this is the case, initiate IV fluids and targeted IV antibiotics. In addition, obtain appropriate labs, including CBC, chemistries, and lactate to monitor your patient’s progression, as well as blood cultures and nucleic acid amplification testing, or NAAT, to identify the causative infections.
Lastly, obtain a gynecologic surgery consultation for possible exploration. Alright, now that unstable patients are taken care of, let’s talk about stable patients.
Stable patient3:41–7:11
Your first step in managing a stable patient is a focused history and physical exam as well as labs including microscopy of the vaginal discharge, an ESR, CRP, and a NAAT for gonorrhea and chlamydia.Here’s another high-yield fact!
Although many cases of PID are associated with gonorrhea and chlamydia, other organisms such as Trichomonas vaginalis, bacterial vaginosis, Mycoplasma genitalium, cytomegalovirus, and bacteria that comprise the normal vaginal flora can be involved.
So, consider also obtaining a NAAT for these organisms.Alright, the history might reveal systemic symptoms of fever, nausea, and vomiting.
Additionally, as stated earlier, the patient may report lower abdominal and pelvic pain, dysuria, dyspareunia, abnormal vaginal discharge, and intermenstrual or post-coital spotting.When obtaining the history, be sure to discuss sexual activity, particularly recent sexual activity or new partners, as well as douching.
A private, confidential discussion is important for all patients, including young patients like adolescents. Although it may be difficult, you should ask caregivers of young patients to step out of the room for this discussion.
Additionally, always consider sexual assault or abuse whenever a young patient has a positive sexual activity history, especially if the patient is a child.
If there is abuse going on, you will need to follow up with allegations of abuse in accordance with your State’s law. Finally, review the patient's contraceptive history.
Keep in mind that non-barrier methods of pregnancy prevention, such as oral contraceptive pills, do not prevent transmission of diseases such as gonorrhea or chlamydia.Here is a high-yield fact!
The presence of an intrauterine device, or IUD does not increase the risk of developing PID except within the first 3 weeks of insertion.
Also, keep in mind that IUDs typically do not need to be removed while treating PID, unless treatment fails after 48 to 72 hours.
When it comes to the physical exam, the three minimum criteria to diagnose PID include cervical motion tenderness, uterine tenderness, and adnexal tenderness.
In fact, in a patient with a clinical picture consistent with PID, any one of those three minimum criteria can be considered clinically diagnostic.
In addition, your patient may have an elevated temperature and lower abdominal tenderness. There may be evidence of cervicitis such as swelling and inflammation, as well as a friable cervix, and mucopurulent cervical discharge.
Lastly, an adnexal mass may be present, which could indicate a tubo-ovarian abscess.Now, even though the diagnosis of PID can often be made by history and physical exam alone, laboratory testing might be useful.
Labs that would support your diagnosis of PID include elevated white blood cells on saline microscopy, an elevated ESR or CRP, and positive NAAT for gonorrhea or chlamydia support the diagnosis.
So, once you have made the diagnosis of pelvic inflammatory disease, the next step is to assess for pregnancy with the HCG test you obtained previously.
Pelvic inflammatory Disease7:11–7:13
Negative HCG7:13–10:37
If the HCG test is negative, it is time to determine if the patient can be treated as an outpatient or needs admission to the hospital.
The first step is to order a pelvic ultrasound to look for a tubo-ovarian abscess. If the ultrasound is normal, the patient’s oral temperature is lower than 38.5 degrees Celsius, and they do not have nausea or vomiting, you can treat them as an outpatient with antibiotics, such as intramuscular ceftriaxone, which is given once, plus oral doxycycline and metronidazole, both of which are continued for total of 14 days.
These patients should follow up in 72 hours to make sure there’s clinical improvement. Here is a clinical pearl!
Instruct all patients with a diagnosis of PID, regardless of the severity of the illness, to abstain from intercourse until treatment is complete and symptoms resolve.
Now, if the ultrasound is normal but the patient is very ill, they may require admission to the hospital. Admission criteria include a temperature higher than 38.5 degrees Celsius, nausea and vomiting, as well as the failure of outpatient treatment.
When it comes to treatment, start with IV fluids and IV antibiotics such as ceftriaxone, doxycycline, and metronidazole.
Treat any additional symptoms as needed with antiemetics and antipyretics. Now, let’s discuss abnormal ultrasound findings.
If the ultrasound shows a multiloculated fluid collection with internal debris and increased surrounding vascularity, the patient likely has a tubo-ovarian abscess.
They may have an oral temperature higher than 38.5 degrees Celsius, as well as nausea and vomiting, but keep in mind that not all patients will present with a fever.
Based on these findings, these patients should be admitted to the hospital. Again, treat with IV fluids and IV antibiotics, as well as antiemetics and antipyretics.
Most patients will show clinical response to IV antibiotics in 72 hours. However, if your patient doesn’t respond to IV antibiotics over 72 hours, you may need to consult an experienced gynecologic surgeon for surgical exploration or definitive treatment, such as image-guided drainage or even surgical intervention.
Okay, time for a final clinical pearl! Postmenopausal patients who present with a tubo-ovarian abscess are at high risk for an underlying malignancy, so surgical exploration should be performed by an experienced gynecologic surgeon.Alright, this completes the management of non-pregnant patients.
Positive HCG10:37–11:39
This fusion of these two membranes, along with the thickened cervical mucus, serves to seal off the uterine cavity preventing entry and ascent of pathogens.
The treatment is pretty similar to before, so admit them to the hospital and treat them with IV fluids, IV antibiotics, antiemetics, and antipyretics.
There’s just one catch! Prior to use of any antibiotics, an obstetrician or infectious disease specialist should be consulted to ensure fetal safety, avoid using teratogenic antibiotics, such as doxycycline and fluoroquinolones, and be cautious when considering surgical interventions.
Finally, don't forget that pregnant patients with PID in the first trimester have a high risk of spontaneous abortion and of subsequent preterm labor, so keep a close eye.
Alright, as a quick recap… Patients with PID who are unstable likely have developed sepsis, and need hospital admission for acute management.
Review11:39–12:51
Immediately obtain an HCG pregnancy test, start IV fluids, IV antibiotics, and consult for possible gynecologic surgical exploration.
For stable patients, assess for pregnancy before starting the treatment. Nonpregnant patients with normal ultrasound without fever, nausea and vomiting can get outpatient treatment with antibiotics.
On the other hand, admit to the hospital patients with normal ultrasound but temperature higher than 38.5 degrees Celsius, nausea and vomiting, or failure of outpatient treatment, as well as those with ultrasound evidence of tubo-ovarian abscess.
Inpatient management includes IV fluids, IV antibiotics, antipyretics, and antiemetics. Additionally, for patients who have a tubo-ovarian abscess, consult a gynecologic surgeon for exploration or definitive treatment.
Finally, all pregnant patients with PID need hospital admission for IV fluids, IV antibiotics, antiemetics, and antipyretics.
Finally all pregnant patients with pid need hospital admission for IV fluids IV
- "Sexually transmitted infections treatment guidelines, 2021" MMWR Recomm Rep (2021)
- "Pelvic Inflammatory Disease" Obstet Gynecol (2010)
No notes for this video yet
Try adding a note below