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'.)
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- 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
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS