HWN Suggests

Pelvic Inflammatory Disease

Patients with PID are frequently misdiagnosed with a urinary tract infection because they may have urinary symptoms, but the urinalysis often shows sterile pyuria, which should raise your suspicion for PID.

And while the utility of the pelvic exam is constantly scrutinized and questioned in patients with vaginal bleeding, it is impossible to diagnose PID without it. Having said that, the clinical diagnosis is only 65-90% specific so even minimal symptoms with no other explanation warrant antibiotic therapy to reduce further complications.

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  Inpatient Regimen

Non-sexually acquired PID: Amoxycillin 2g IV Q6hrly + Gentamicin 5mg/kg IV OD + Metronidazole 500mg Q12hrly. Sexually acquired PID treat partners too: Doxycycline 100mg PO/IV Q12hrly + Metronidazole 500mg Q12hrly + Ceftriaxone 1g OD OR Gentamicin 5mg/kg IV OD + Clindamycin 600mg IV Q8hrly, if patient pregnant or breastfeeding -> substitute doxycycline for roxithromycin 300mg OD.

  Outpatient Regimen

Ceftriazone 500mg IM, Doxy 100mg BID X14days, +/- Flagyl 500mg BID x14days.

 Pelvic Inflammatory Disease – CDC Treatment Guidelines

Ceftriaxone 500 mg IM plus Doxycycline 100 mg po BID x 14 days with Metronidazole 500 mg po BID x 14 days.

 Pelvic Inflammatory Disease: Tricky Diagnosis

Despite historical opinion, modern IUDs do not cause any significant increased risk for PID. The risk of PID is limited to the first 3 weeks post-insertion, but beyond that, nope. What about removing an IUD in the ED if there is active infection? We strongly caution against this. First, this is 100% wrong on test questions. Exams never want you removing a woman’s birth control. Secondly, most guidelines note that leaving an IUD in place while treating PID is totally reasonable, with inpatient assessment versus outpatient follow up by gynecology to determine removal if there is no improvement.

Articles of Interest

Pelvic Inflammatory Disease: Pearls and Pitfalls

There is no specific lab value, physical examination finding, or imaging study that is diagnostic of PID. The diagnosis of PID is often presumptive based on clinical findings.

Pelvic Inflammatory Disease and Tubo-ovarian Abscess

The most common physical exam findings are bilateral adnexal tenderness and purulent cervical discharge. Cervical motion, uterine, and lower abdominal tenderness may also be present. Unilateral adnexal tenderness or fullness may suggest the presence of a tuboovarian abscess, while right upper quadrant tenderness may suggest Fitz-Hugh-Curtis syndrome where the infection extends to cause a perihepatitis with inflammation of the liver capsule and ‘violin string’ scar tissue formation.

Pelvic Inflammatory Disease: Current concepts in pathogenesis, diagnosis and treatment

Pelvic inflammatory disease (PID) is characterized by infection and inflammation of the upper genital tract in women: the uterus, fallopian tubes and/or ovaries. While a definitive diagnosis of PID can be made by laparoscopic visualization of inflamed, purulent fallopian tubes, PID is generally a clinical diagnosis and thus represents a diagnostic challenge.