Pelvic inflammatory disease: Clinical sciences

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. 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. 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.