Click here to view next page of this article

Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) is an ascending polymicrobial genital tract infection that occurs in sexually active females. Neisseria gonorrhoeae and Chlamydia trachomatis are usually the causative agents of PID. Consequences of PID include chronic pain, ectopic pregnancy, and infertility.

PID affects 1 million American women annually. Sexually active have a tenfold increase in risk compared with adults.

Clinical Characteristics

The most common presenting complaint of women who have PID is lower abdominal pain. Associated symptoms include vaginal discharge, irregular bleeding, dysmenorrhea, dyspareunia, dysuria, nausea, vomiting, and fever. Gonococcal infection may cause more acute inflammation (peritoneal signs, fever, leukocytosis) than nongonococcal infection. Most women who have acute PID present during the first half of the menstrual cycle.

PID caused by C trachomatis tends to be associated with less fever and pain and fewer systemic symptoms than gonococcal PID, but it also is associated with high rates of infertility.

The CDC recommends the use of three minimum criteria and eight optional, additional criteria for the diagnosis of PID (Table 1) . Empiric treatment should be undertaken.

lower abdominal tenderness, adnexal tenderness, and cervical motion tenderness are present on physical examination. Additional criteria supporting the diagnosis include an oral temperature of more than 38.3E°C (100.9E°F), abnormal cervical or vaginal discharge, elevated erythrocyte sedimentation rate or C-reactive protein, and laboratory evidence of cervical infection with N gonorrhoeae or C trachomatis. 

TABLE 1 -- CDC-recommended Criteria for the Diagnosis of Pelvic Inflammatory Disease

Diagnosis

If PID is suspected, a pelvic examination is paramount for diagnosis. In addition to the laboratory studies noted in the CDC recommendations, a urine pregnancy test is essential to exclude the possibility of uterine or ectopic pregnancy. If an abnormal vaginal discharge is present, a sample should be examined microscopically for trichomoniasis, candidiasis, and bacterial vaginosis. Most patients who have suspected PID also should be evaluated with urinalysis and urine culture for urinary tract infection and serologic test for syphilis. All patients who have STDs should be offered counseling and testing for HIV.

Endocervical samples should be collected and sent to the laboratory prior to initiating antibiotic therapy. These specimens should be examined for C trachomatis and N gonorrhoeae.

Four types of tests are used to detect C trachomatis. Cell culture detects fewer than 80% of chlamydial infections. Antigen detection tests, which include direct-smear fluorescent antibody (DFA) and enzyme-linked immunosorbent assay (ELISA), yield quicker results than culture but are less sensitive and specific. Nucleic acid hybridization or genetic probe tests detect 50% to 70% of infections. Genetic amplification, which includes polymerase chain reaction (PCR) and ligase chain reaction (LCR) has detection of C trachomatis. In addition to having detection rates of 95%, the tests can be performed on vaginal and urine samples as well as on cervical samples.

Although endocervical culture has been used traditionally for the detection of N gonorrhoeae, LCR now offers a readily available alternative. Its sensitivity and specificity for N gonorrhoeae exceeds 97%, and the same specimen can be used to test for both N gonorrhoeae and C trachomatis. The disadvantage of LCR is its high cost.

Pelvic ultrasonography can be very helpful in narrowing the differential diagnosis of PID and identifying complications of the disease. It always should be performed in the adolescent who has suspected PID and a positive pregnancy test. Beyond 6 weeks' gestation, the absence of an intrauterine sac on ultrasonography raises suspicion of an ectopic pregnancy. Ultrasonography, particularly if performed both transabdominally and transvaginally, can help in the diagnosis of appendicitis, appendiceal abscess, adnexal torsion, ovarian cyst, and TOA. Any adolescent who has suspected PID and does not respond promptly to antibiotic therapy should be evaluated by ultrasonography for the presence of TOA.

Laparoscopy rarely is necessary to establish the diagnosis of PID. It is indicated only when the diagnosis is in doubt or the patient has failed to respond to appropriate antibiotic therapy.

Management

Treatment regimens for PID must provide antimicrobial coverage for N gonorrhoeae, C trachomatis, anaerobes, streptococci, and gram-negative facultative bacteria.

Patients who have baseline laboratory documentation of N gonorrhoeae or C trachomatis should be screened again for these organisms following completion of therapy. Sexual partners of women who have PID should be treated for N gonorrhoeae and C trachomatis, even if neither patient nor partner has laboratory evidence of infection by these organisms. The likelihood of both asymptomatic infection in males and reinfection in treated females is sufficiently high to warrant empiric treatment of all male sexual contacts of females.