Pelvic inflammatory disease: Clinical manifestations and diagnosis
- Jonathan Ross, MD
Jonathan Ross, MD
- Professor of Sexual Health and HIV
- Department of Sexual Health and HIV
- University Hospitals Birmingham NHS Foundation Trust
- Mariam R Chacko, MD
Mariam R Chacko, MD
- Professor of Pediatrics/Adolescent & Sports Medicine
- Baylor College of Medicine
Pelvic inflammatory disease (PID) refers to acute and subclinical infection of the upper genital tract in women, involving any or all of the uterus, fallopian tubes, and ovaries; this is often accompanied by involvement of the neighboring pelvic organs. It results in endometritis, salpingitis, oophoritis, peritonitis, perihepatitis, and/or tubo-ovarian abscess.
The majority of PID cases (85 percent) are caused by sexually transmitted pathogens or bacterial vaginosis-associated pathogens. Fewer than 15 percent of acute PID cases are not sexually transmitted and instead are associated with enteric (eg, Escherichia coli, Bacteroides fragilis, Group B streptococci, and Campylobacter spp) or respiratory pathogens (eg, Haemophilus influenzae, Streptococcus pneumoniae, Group A streptococci, and Staphylococcus aureus) that have colonized the lower genital tract . Post-operative pelvic cellulitis and abscess, pregnancy-related pelvic infection, injury or trauma-related pelvic infection, and pelvic infection secondary to spread of another infection (eg, appendicitis, diverticulitis, tumor) can also produce a very similar clinical picture. However, the etiologic differences among these processes, principally in that they are not caused by a sexually transmitted infection (STI), have significant implications for treatment and prevention. Infectious complications of gynecologic surgery and pregnancy are discussed elsewhere. (See "Posthysterectomy pelvic abscess" and "Septic pelvic thrombophlebitis" and "Postpartum endometritis".)
PID represents a spectrum of infection and there is no single diagnostic gold standard. Clinical diagnosis remains the most important practical approach. Several expert guidelines discuss the clinical approach to the diagnosis of PID. These include the United States Centers for Disease Control and Prevention guidelines on the management of STIs, the International Union against STI European guidelines for the management of PID, and the British Association for Sexual Health and HIV guidelines on the management of PID [2-4]. The discussion in this topic is generally consistent with these guidelines.
The clinical features and diagnosis of sexually transmitted PID will be reviewed here. The pathogenesis, microbiology, risk factors for acquisition, treatment, and sequelae associated with this disorder are discussed separately. (See "Pelvic inflammatory disease: Pathogenesis, microbiology, and risk factors" and "Pelvic inflammatory disease: Treatment".)
Patients at risk — Any sexually active female is at risk for sexually transmitted infection (STI) associated pelvic inflammatory disease (PID), but those with multiple sexual partners are at the highest risk. Additionally, age younger than 25, a partner with a sexually transmitted infection, and a history of prior PID or a sexually transmitted infection are important risk factors. The use of barrier contraception is protective. These are discussed in detail elsewhere. (See "Pelvic inflammatory disease: Pathogenesis, microbiology, and risk factors", section on 'Risk factors'.)
- Brunham RC, Gottlieb SL, Paavonen J. Pelvic inflammatory disease. N Engl J Med 2015; 372:2039.
- Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections. 2012 European guideline for the management of pelvic inflammatory disease. Int J STD AIDS 2014; 25:1.
- Ross JDC, McCarthy J. UK National Guideline for the Management of PID. 2011. http://www.bashh.org/guidelines (Accessed on June 18, 2015).
- Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015; 64:1.
- Korn AP, Hessol NA, Padian NS, et al. Risk factors for plasma cell endometritis among women with cervical Neisseria gonorrhoeae, cervical Chlamydia trachomatis, or bacterial vaginosis. Am J Obstet Gynecol 1998; 178:987.
- Jacobson L, Weström L. Objectivized diagnosis of acute pelvic inflammatory disease. Diagnostic and prognostic value of routine laparoscopy. Am J Obstet Gynecol 1969; 105:1088.
- Wiesenfeld HC, Sweet RL, Ness RB, et al. Comparison of acute and subclinical pelvic inflammatory disease. Sex Transm Dis 2005; 32:400.
- Peipert JF, Ness RB, Blume J, et al. Clinical predictors of endometritis in women with symptoms and signs of pelvic inflammatory disease. Am J Obstet Gynecol 2001; 184:856.
- Eschenbach DA, Buchanan TM, Pollock HM, et al. Polymicrobial etiology of acute pelvic inflammatory disease. N Engl J Med 1975; 293:166.
- Piton S, Marie E, Parmentier JL. [Chlamydia trachomatis perihepatitis (Fitz Hugh-Curtis syndrome). Apropos of 20 cases]. J Gynecol Obstet Biol Reprod (Paris) 1990; 19:447.
- Litt IF, Cohen MI. Perihepatitis associated with salpingitis in adolescents. JAMA 1978; 240:1253.
- Bolton JP, Darougar S. Perihepatitis. Br Med Bull 1983; 39:159.
- Stajano C. La reaccio'n frenich en ginecologia. Semana Méd 1920; 27:243.
- Wang SP, Eschenbach DA, Holmes KK, et al. Chlamydia trachomatis infection in Fitz-Hugh-Curtis syndrome. Am J Obstet Gynecol 1980; 138:1034.
- Paavonen J, Saikku P, von Knorring J, et al. Association of infection with Chlamydia trachomatis with Fitz-Hugh-Curtis syndrome. J Infect Dis 1981; 144:176.
- Moore DE, Spadoni LR, Foy HM, et al. Increased frequency of serum antibodies to Chlamydia trachomatis in infertility due to distal tubal disease. Lancet 1982; 2:574.
- Punnonen R, Terho P, Nikkanen V, Meurman O. Chlamydial serology in infertile women by immunofluorescence. Fertil Steril 1979; 31:656.
- Wølner-Hanssen P. Silent pelvic inflammatory disease: is it overstated? Obstet Gynecol 1995; 86:321.
- Wiesenfeld HC, Hillier SL, Krohn MA, et al. Lower genital tract infection and endometritis: insight into subclinical pelvic inflammatory disease. Obstet Gynecol 2002; 100:456.
- Washington AE, Gove S, Schachter J, Sweet RL. Oral contraceptives, Chlamydia trachomatis infection, and pelvic inflammatory disease. A word of caution about protection. JAMA 1985; 253:2246.
- Ness RB, Keder LM, Soper DE, et al. Oral contraception and the recognition of endometritis. Am J Obstet Gynecol 1997; 176:580.
- Nishino M, Hayakawa K, Iwasaku K, Takasu K. Magnetic resonance imaging findings in gynecologic emergencies. J Comput Assist Tomogr 2003; 27:564.
- Bennett GL, Slywotzky CM, Giovanniello G. Gynecologic causes of acute pelvic pain: spectrum of CT findings. Radiographics 2002; 22:785.
- Tukeva TA, Aronen HJ, Karjalainen PT, et al. MR imaging in pelvic inflammatory disease: comparison with laparoscopy and US. Radiology 1999; 210:209.
- Romosan G, Valentin L. The sensitivity and specificity of transvaginal ultrasound with regard to acute pelvic inflammatory disease: a review of the literature. Arch Gynecol Obstet 2014; 289:705.
- Sellors J, Mahony J, Goldsmith C, et al. The accuracy of clinical findings and laparoscopy in pelvic inflammatory disease. Am J Obstet Gynecol 1991; 164:113.
- Livengood CH 3rd, Hill GB, Addison WA. Pelvic inflammatory disease: findings during inpatient treatment of clinically severe, laparoscopy-documented disease. Am J Obstet Gynecol 1992; 166:519.
- Peipert JF, Boardman LA, Sung CJ. Performance of clinical and laparoscopic criteria for the diagnosis of upper genital tract infection. Infect Dis Obstet Gynecol 1997; 5:291.
- Miettinen AK, Heinonen PK, Laippala P, Paavonen J. Test performance of erythrocyte sedimentation rate and C-reactive protein in assessing the severity of acute pelvic inflammatory disease. Am J Obstet Gynecol 1993; 169:1143.
- CLINICAL FEATURES
- Patients at risk
- Spectrum of disease
- Acute symptomatic PID
- - Symptoms
- - Examination findings
- - Laboratory findings
- - Perihepatitis
- - Tubo-ovarian abscess
- Subclinical PID
- Chronic PID
- Initial evaluation
- - History
- - Physical and pelvic exam
- - Point-of-care and laboratory tests
- Additional evaluation for diagnostic uncertainty
- - Imaging techniques
- - Other studies
- DIFFERENTIAL DIAGNOSIS
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS