A Synopsis of AFP's "Pelvic Inflammatory Disease"

A synopsis of
Pelvic Inflammatory Disease, MARGARET GRADISON, MD, MHS-CL, Duke University Medical Center, Durham, North Carolina
Am Fam Physician. 2012 Apr 15;85(8):791-796.
http://www.aafp.org/afp/2012/0415/p791.pdf

     PID is an infection of the upper genital tract in women. It can lead to infertility (from tubal scarring) and  ectopic pregnancy. The patient may present with lower abdominal pain, pelvic pain, vaginal discharge, fever, chills, cramping, dyspareunia, nausea and vomiting. On pelvic exam, the patient may have cervical motion, uterine, or adnexal tenderness. There are no specific clinical finding to diagnosis PID definitively. There is no specific bug that causes PID. The most common bugs are Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas, Gardnerella, Mycoplasma genitalium, and others! There are no specific lab tests for diagnosing PID, thus, clinical judgement should lead the way to treatment. Treatment should be done empirically.
     As far as testing is concerned, there are some tests that can be done (but should not delay treatment). PCR and other nucleic acid tests of vaginal or endocervical samples can be done for chlamydia and gonorrhea. Saline microscopy of vaginal discharge may reveal Trichomonas or bacterial vaginosis. PID is less likely without the presence of WBC's in the microscopy. Other diagnostic tests that are available include transvaginal ultrasonography, MRI, endometrial biopsy, laparoscopy, and CT.
     Treatment is empiric. Chlamydia and gonorrhea treatment is part of the regiment regardless of culture results. Treatment for Gardnerella is controversial and recommendations state treating for it only if the studies are inconclusive. Treatment is not directed against Mycoplasma, which has been associated with treatment failure.  There are many different treatment regimens depending on local resistance patterns (including fluoroquinolone resistant N. gonorrhoeae). According to this article, the first line therapy is IM ceftriaxone with 14 days of PO doxycycline. Cefoxitin or another third generation cephalosporin can be used instead of ceftriaxone. Metronidazole may be added to the therapy as well. Parental treatment and hospitalization may be needed if the patient cannot tolerate PO meds, if there is no response from the outpatient treatment, if they are pregnant, or if they have severe symptoms. Patients may need extended hospitalization if a tubo-ovarian abscess is found.
     Patients should improve within three days of treatment initiation. Male partners within the last 60 days may need evaluation. Patients should be checked for reinfection after 3-6 months. HIV and syphilis should be checked as well. Patient with an IUD have an increased risk of PID for three weeks following device insertion. Screening is recommended for all sexually active women younger than 25 and for those above 25 with increased risk.