PELVIC INFLAMMATORY DISEASE (PID) This presentation is prepared as a case based discussion. References include American Academy of Family Physicians AAFP I WOULD LIKE TO DEDICATE SPECIAL THANKS TO DR ALI AL KHALAF FOR REVISING THIS MATERIAL

1. DAWOOD AL NASSER
Saudi Board of Family Medicine Trainee

2.  Introduction
 Group discussion (CBD)
 MCQs
 Summary
 Home Massage

3.  Pelvic inflammatory disease (PID) is a polymicrobial infection
of the upper genital tract that primarily affects young, sexually
active women.

5. 20 years old newly married female, presents with moderate lower
abdominal pain for 1 day. There is history of unusual vaginal discharge
O/E: The patient is febrile (38.4°C).
Remaining physical examination was unremarkable except for adnexal
tenderness.
1- What are the diagnostic criteria if PID is suspected?
2- What is the single clinical finding that can lead to a diagnosis of PID?
3- Is this patient at increased risk of any complications?

6. 1- What are the diagnostic criteria
if PID is suspected?
One or more of the following minimum
criteria must be present on pelvic
examination to diagnose PID:
 Cervical motion tenderness
 Uterine tenderness
 Adnexal tenderness

7. 2- What is the single clinical finding that can lead to a diagnosis
of PID?
No single clinical finding or laboratory test is sensitive or specific
enough to definitively diagnose PID.

8. 3- Is this patient at increased risk of any complications?
 20 % chance of developing infertility from tubal scarring.
 9 % percent chance of having an ectopic pregnancy.
 18 % chance of developing chronic pelvic pain.

9. 20 years old newly married female ,presents with moderate lower abdominal pain for 1 day.
There is history of unsual vaginal discharge and the patient is febrile (38.4°C).
Remaining physical examination was unremarkable except for adnexal tenderness
… After reviewing the previous patient history you are still suspecting
PID as a primary diagnosis and planning to initiate management with
antibiotics.
1- How would we choose between outpatient or inpatient management?
2- What are the preferred outpatient treatment options?

10. 1-How would we choose between outpatient or inpatient management?
(Suggested Criteria for Hospitalization of Patients with Pelvic Inflammatory Disease):
 Inability to follow or tolerate an outpatient oral medication regimen
 No clinical response to oral antimicrobial therapy
 Pregnancy
 Severe illness, nausea and vomiting, or high fever
 Surgical emergencies (e.g., appendicitis) cannot be excluded
 Tubo-ovarian abscess

11. 2- What are the preferred
outpatient treatment options ?

12. Dr.Fatemah is a 27 years old GP who presents with a 2 days history of
cramping lower abdominal pain and nausea and vomiting.
The patient had inserted an IUD last week and have been using vaginal
douching daily.
On examination she has cervical motion tenderness and a mucopurulent
discharge.
1- Would you advice her to remove or keep the IUD?
2- Would you recommend antibiotics at time of insertion to prevent a similar
condition?
3- If she is 10 weeks pregnant, how would that affect the management?

13. 1- Would you advice her to remove or keep the IUD?
 Women with IUDs have an increased risk of PID only within the first
three weeks after insertion of the IUD.
 There is no evidence that suggests removal of the IUD is necessary in
patients with acute PID; however, close follow-up is recommended.
 Data indicate no difference in outcomes of PID in women with copper
IUDs versus the levonorgestrel-releasing intrauterine system (Mirena).

14. 2- Would you recommend antibiotics at time of insertion to
prevent a similar condition?
There are insufficient data to suggest that antibiotics should be given
to patients at the time of IUD insertion to decrease the risk of
developing infection

15. 3- If she is 10 weeks pregnant, how would that affect the
management plan?
 PID is uncommon during pregnancy, although if it occurs, it is usually
within the first 12 weeks before the mucous plug can act as an
adequate barrier.
 Pregnant women with suspected PID should be hospitalized and given
parenteral antibiotics.
 PID during pregnancy increases the risk of preterm delivery and
increases maternal morbidity.

16. Dr Fatemah is a 27 years old GP who presents with a 2 days history of cramping lower abdominal pain and
nausea and vomiting.
The patient had inserted and IUD last week and have been using vaginal douching daily.
On examination she has Cervical motion tenderness and a mucopurulent discharge.
You decide to send C/S sample which confirms positive sensitivity to
ciprofloxacin (as an effective choice).
However Dr Fatemah argues that fluoroquinolones are not the 1st line for PID !
1- How would you counsel Dr Fatemah regarding treatment options?
2- When do you expect the clinical improvement (how many hours?)
3- Should we treat her husband?
4- Should they be advised to abstain from intercourse?

17. 1- How would you counsel Dr Fatemah regarding treatment
options?
Unless there is proven sensitivity, fluoroquinolones should not be
used in women with PID because of widespread resistance in
Neisseria gonorrhoeae;
A parenteral cephalosporin is recommended instead.

18. 2- When do you expect the clinical improvement (how many hours?)
 Follow-up is important to ensure that the patient is responding to
outpatient treatment.
 Clinical symptoms should improve within 72 hours of treatment, and if
not, further evaluation is advised.
 Some patients may require additional testing to rule out other diagnoses,
such as a tubo-ovarian abscess, and assessment is needed for additional
antimicrobial therapy, parenteral antimicrobials, and hospitalization.

19. 3- Should we treat her husband?
 Male partners of women with PID should be evaluated and treated
if they have had sexual contact within 60 days of a diagnosis of PID.
 Men are often asymptomatic even when their partners are
positive for chlamydia or gonorrhea.

20. 4- Should they be advised to abstain from intercourse?
To decrease the chance of recurrence, women and their partners
should abstain from sexual intercourse until they have completed
the course of treatment.

21. Diagnosis
 The diagnosis of PID is based primarily on clinical evaluation.

22.  Physicians must consider PID in the differential diagnosis in
women 15 to 44 years of age who present with lower
abdominal or pelvic pain and cervical motion or pelvic
tenderness, even if these symptoms are mild.

23.  However, there is no single symptom, physical finding, or
laboratory test that is sensitive or specific enough to
definitively diagnose PID; clinical diagnosis alone is 87 %
sensitive and 50 % specific.

24. One or more of the following minimum criteria must be
present on pelvic examination to diagnose PID:
 Cervical motion tenderness
 Uterine tenderness
 Adnexal tenderness

25. The following criteria can improve the specificity of the diagnosis:
 Oral temperature > 101°F (> 38.3°C)
 Abnormal cervical or vaginal mucopurulent discharge
 Presence of abundant numbers WBCs on saline microscopy of
vaginal fluid
 Elevated ESR
 Elevated C-reactive protein level
 Laboratory documentation of cervical infection with gonorrhea or
chlamydia

26. The following test results are the MOST SPECIFIC criteria for
diagnosing PID:
 Endometrial biopsy with histopathologic evidence of
endometritis.
 Transvaginal sonography or MRI showing thickened, fluid-
filled tubes with or without free pelvic fluid or tubo-ovarian
complex, or Doppler studies suggesting pelvic infection (e.g.,
tubal hyperemia).
 Laparoscopic abnormalities consistent with PID.

27.  Age <25 years.
 Young age at first sexual encounter (younger than 15 years).
 Use of non-barrier contraception, especially IUD or OCP.
 New, multiple, or symptomatic sex partners.
 History of PID or STD.
 Recent IUD insertion.
 Black women may be at higher risk of PID.
 Vaginal douching also may be a risk factor.

28.  Lower abdominal or pelvic pain, although it may be mild.
 New or abnormal vaginal discharge,
 Fever or chills,
 Cramping, dyspareunia, dysuria,
 and abnormal or postcoital bleeding.
 Some women also may have low back pain, nausea, and
vomiting.

29.  It is less common for women to have no symptoms or atypical
symptoms, such as right upper quadrant pain from perihepatitis
(i.e., Fitz-Hugh–Curtis syndrome)

31. Female patient with a 2-day history of severe abdominal pain. She is a 24-year-old G1 P1
whose LMP was 1 week ago.
She is on OCP for birth control. Her pain is across her lower abdomen and a little more on
the right side than the left. She has felt feverish. She has had some nausea but no
vomiting. She denies bowel or bladder problems. Her pain is improves with
acetaminophen and worsens with activity.
On examination, she appears uncomfortable but not toxic. Her temperature is 38°C, but
the rest of her vitals are normal.
Her abdominal examination reveals decreased bowel sounds, with tenderness to palpation
primarily across the lower quadrants. She has initial guarding and no rebound tenderness.
Her pelvic examination is remarkable for cervical motion tenderness. The uterus is of
normal size and consistency with no masses.

32. Which of the following diagnoses can be absolutely excluded from your
differential at this point?
A) Ectopic pregnancy
B) Appendicitis
C) Pelvic inflammatory disease (PID)
D) Pyelonephritis
E) None of the above diagnoses should be excluded based on the
information available.

33. You obtain cultures/PCR for chlamydia and gonorrhea. The urine pregnancy test
is negative. The urinalysis is negative for nitrites and leukocytes, and the WBC is
15,600/mm3 with an increase in bands.
She reports that she’s had an appendectomy.
What is the most appropriate next step?
A) Consult surgery and gynecology to confirm your findings.
B) Admit for IV antibiotics and IV hydration.
C) Treat as an outpatient with antibiotics and schedule follow-up for 36 to 48 hours.
D) Treat with IV antibiotics on an outpatient basis utilizing visiting nurse care.
E) Obtain cultures, discharge the patient, and treat based on culture results.

34. For empiric antibiotic therapy for PID in this patient, you prescribe:
A) Amoxicillin 500 mg PO ID or 14 days.
B) Ceftriaxone 250 mg IM once PLUS azithromycin 1 g.
C) Ceftriaxone 250 mg IM once PLUS doxycycline 100 mg PO BID or 14 days.
D) A and B.
E) B and C.

35. Which of the following is NOT a potential consequence of PID?
A) Infertility
B) Chronic pelvic pain
C) Increased risk for ectopic pregnancy
D) Recurrent PID
E) None of the above

36. A 24-year-old woman is noted to have lower abdominal tenderness,
cervical motion tenderness, and a vaginal discharge. She has a low
grade fever of 100.5oC (38.0oC).
Which of the following is the best therapy for her condition?
A) Ceftriaxone intramuscularly and doxycycline orally
B) Ampicillin orally and azithromycin orally
C) Metronidazole orally as a single dose
D) Ciprofloxacin orally as a single dose

37. A 28-year-old woman with a recent new sexual partner presents
with pelvic pain, fever, vaginal discharge, and nausea with
vomiting. Examination shows a significant cervical motion
tenderness.
The most likely diagnosis is:
A) Ectopic pregnancy
B) Pyelonephritis
C) PID
D) BV
E) Yeast vaginitis

38. Which of the following physical findings would most strongly
support diagnosis of PID?
A) Courvoisier’s sign
B) Chandelier sign
C) Cullen’s sign
D) Grey-Turner’s sign
E) Positive Murphy’s sign
Cervical motion tenderness (positive Chandelier sign).

39. An 18-year-old woman presents to your office complaining of pelvic pain,
dysuria, and a purulent yellowish-green vaginal discharge. A Gram’s stain of
cervical secretions shows gram-negative diplococci.
The most appropriate medication is:
A) Ceftriaxone + azithromycin
B) Penicillin G + azithromycin
C) Cefuroxime + tetracycline
D) Cefoxitin + doxycycline
E) Metronidazole + doxycycline
For patients with a severe allergy to cephalosporins, CDC recommends a single 2-g dose of
azithromycin orally.

40. A 32-year-old woman presents to the emergency room complaining of
severe lower abdominal pain. She says she was diagnosed with pelvic
inflammatory disease by her gynecologist last month, but did not take
the medicine that she was prescribed because it made her throw up.
She has had fevers on and off for the past 2 weeks.
In the emergency room, the patient has a temperature of 38.3°C
(101°F). Her abdomen is diffusely tender, but more so in the lower
quadrants. She has diminished bowel sounds. On bimanual pelvic
examination, bilateral adnexal masses are palpated. The patient is sent
to the ultrasound department, and a transvaginal pelvic ultrasound
demonstrates bilateral tuboovarian abscesses.

41. Which of the following is the most appropriate next step in the
management of this patient?
A) Admit the patient for emergent laparoscopic drainage of the abscesses.
B) Consult interventional radiology to perform CT-guided percutaneous
drainage of the abscesses.
C) Send the patient home and arrange for intravenous antibiotics to be
administered by a home health agency.
D) Admit the patient for intravenous antibiotic therapy.
E) Admit the patient for exploratory laparotomy, TAH/BSO.