Pelvic inflammatory disease
Pelvic inflammatory disease is an ascending polymicrobial infection of the upper female genital tract, most often caused by Neisseria gonorrhoeae, Chlamydia trachomatis, or Mycoplasma genitalium, diagnosed clinically on uterine, adnexal, or cervical motion tenderness. Most women are treated as outpatients with a single dose of ceftriaxone plus 14 days of doxycycline, while parenteral cefotetan or cefoxitin plus doxycycline, or clindamycin plus gentamicin, is reserved for hospitalized patients, with tubo-ovarian abscess and infertility among the major complications of delayed treatment.
- Topic reviewThe full article, organized the way the exam asks it.
- ABIM-format MCQsVignettes with an explanation for every wrong answer.
- Key factsThe numbers and thresholds worth memorizing, up front.
- AI tutorMedBrain answers the question you're stuck on.
What this article covers
- Overview
Pelvic inflammatory disease (PID) is an infection of the upper female genital tract (endometrium, fallopian tubes, ovaries, and adjacent peritoneum) arising from ascending spread of organisms from the vagina and endocervix.
- Epidemiology
PID is a common cause of preventable infertility and ectopic pregnancy in women of reproductive age, and unrecognized disease accounts for a substantial share of this burden.
- Risk factors
Age younger than 25 years, the strongest demographic risk factor, paralleling gonorrhea and chlamydia risk.
- Pathophysiology
Infection begins as cervicitis, with Neisseria gonorrhoeae or Chlamydia trachomatis colonizing the endocervix, or with disruption of the normal cervical mucus barrier from bacterial vaginosis.
- Clinical features
Lower abdominal or pelvic pain is the presenting symptom in most patients, typically bilateral, worse with intercourse (dyspareunia), and often beginning during or shortly after menses.
- Differential diagnosis
Ectopic pregnancy: abdominal pain with a positive pregnancy test, often with vaginal bleeding; a quantitative hCG and transvaginal ultrasound distinguish it and must be excluded before treatment.
- Diagnosis
PID is a clinical diagnosis: the presence of uterine tenderness, adnexal tenderness, or cervical motion tenderness on bimanual examination is sufficient to establish the diagnosis in a sexually…
- Management
First, decide on site of care: most women with PID can be managed safely as outpatients on oral antibiotics; hospitalization for parenteral antibiotics is required when any of the following is…
- Complications
Tubo-ovarian abscess, the most severe acute complication, presenting as a palpable adnexal mass with high fever and requiring parenteral antibiotics with drainage if refractory.
- Prognosis
Prompt initiation of antibiotic therapy at the first clinical suspicion substantially reduces long-term sequelae, which is why treatment is started before laboratory confirmation.
- Prevention
Screen all sexually active women younger than 25 years for chlamydia and gonorrhea annually, and screen women 25 years and older who have STI risk factors, since asymptomatic cervical infection is the precursor to most PID.
Read the whole article
Subscribing to Internal Medicine opens every article, the full question bank and MedBrain, on the web, iPhone and Android.
Related articles
- Chlamydia trachomatis infection
Chlamydia trachomatis is the most commonly reported bacterial sexually transmitted infection in the United States, frequently asymptomatic, and diagnosed by nucleic acid amplification testing of urine or genital/rectal/oropharyngeal swabs. Uncomplicated genital infection is treated with a single dose of azithromycin or a course of doxycycline, complications include pelvic inflammatory disease and epididymitis, and LGV serovars require a 21-day course and are an increasing cause of proctitis.
- Mycoplasma genitalium infection
Mycoplasma genitalium is an emerging sexually transmitted pathogen and a leading cause of nongonococcal, nonchlamydial urethritis in men and of cervicitis and pelvic inflammatory disease in women. Diagnosis requires nucleic acid amplification testing, and treatment is resistance-guided, with doxycycline lead-in therapy followed by extended azithromycin or moxifloxacin because macrolide resistance is increasingly common.
- Trichomonas vaginalis infection
Trichomonas vaginalis is a flagellated protozoan sexually transmitted infection that presents with malodorous frothy yellow-green discharge and a strawberry cervix but is frequently asymptomatic, especially in men. Diagnosis rests on nucleic acid amplification testing of vaginal secretions, and treatment is a single 2 g oral dose of metronidazole or tinidazole with partner treatment and retesting in 3 months for high reinfection rates.
- Infectious genital ulcers
Infectious genital ulcers are caused chiefly by herpes simplex virus and syphilis in the United States, with chancroid, lymphogranuloma venereum, and granuloma inguinale as less common causes, distinguished by ulcer pain, number, and associated lymphadenopathy, and worked up with an ordered panel of HSV NAAT, syphilis serology or darkfield, and targeted testing since a substantial minority of ulcers have no identified cause and empiric therapy is often required.
- Bacteremia
Bacteremia is the presence of viable bacteria in the blood, confirmed by positive blood cultures, that ranges from transient and clinically silent to the trigger for sepsis and septic shock requiring urgent source identification and antimicrobial therapy.