Inflammatory disease of pelvic organs (gynaecology)
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Pelvic Inflammatory Disease (PID)
Definition
PID refers to infection that ascends from the cervix or vagina to involve the endometrium and/or fallopian tubes. Inflammation may extend to cause pelvic peritonitis, generalized peritonitis, perihepatitis, perisplenitis, or pelvic abscess. The spectrum of involvement forms a continuum of:
- Endometritis → Salpingitis → Peritonitis → Tubo-ovarian abscess (TOA)
Rarely, infection extends secondarily to the pelvic organs from adjacent foci (appendicitis, diverticulitis), hematogenous dissemination (tuberculosis), or as a complication of intrauterine surgical procedures.
— Harrison's Principles of Internal Medicine 22E, p. 1148 | Berek & Novak's Gynecology, p. 817
Etiology (Microbiology)
PID is polymicrobial. Key pathogens include:
| Category | Organisms |
|---|---|
| Primary STI pathogens | Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium |
| BV-associated anaerobes | Prevotella spp., Peptostreptococci, Gardnerella vaginalis |
| Facultative gram-negatives | E. coli, Haemophilus influenzae, group B streptococci |
| Respiratory pathogens (rare) | Group A streptococci, Streptococcus pneumoniae |
N. gonorrhoeae predominates in high-prevalence settings. M. genitalium causes mild PID similar to chlamydial PID. Bacterial vaginosis (BV) alters cervical mucus enzymatically, facilitating ascending spread.
One-fourth to one-third of cases in the US have anaerobic/facultative organisms isolated from peritoneal fluid or fallopian tubes.
— Harrison's 22E, p. 1148 | Berek & Novak's, p. 817–818
Epidemiology & Risk Factors
- US annual physician visits for PID fell from ~400,000 (1980s) → 51,000 (2014), but hospitalisations have remained at 70,000–100,000/year since 1995
- Risk factors:
- Endocervical gonorrhoea or chlamydial infection
- Bacterial vaginosis
- Prior episode of salpingitis
- Recent vaginal douching
- Recent IUD insertion
- Invasive intrauterine procedures (D&C, termination of pregnancy, hysterosalpingography)
- Onset often coincides with menstruation (facilitates ascending spread)
- Protective factors: Oral contraceptive use (decreased symptomatic PID); tubal sterilisation (prevents intraluminal spread)
— Harrison's 22E, p. 1148
Clinical Manifestations
Endometritis
- Uterine tenderness ± abnormal uterine bleeding
- May occur without salpingitis
Acute Salpingitis
- Lower abdominal/pelvic pain (bilateral), often dull and constant
- Cervical motion tenderness (CMT) — pain on moving the cervix stretches the adnexa against the peritoneum
- Adnexal tenderness (bilateral in most cases)
- Fever (>38°C), chills
- Vaginal discharge (mucopurulent)
- Nausea and vomiting (with peritonitis)
- Menorrhagia, metrorrhagia, urinary symptoms may occur
Many women have subtle or mild symptoms, causing diagnostic delay.
Tubo-ovarian Abscess (TOA)
- Develops in ~15% of women hospitalised with PID
- Presents with pelvic/abdominal mass, high fever, and severe tenderness
- Most TOAs involve multiple organisms including B. fragilis and other anaerobes
Perihepatitis (Fitz-Hugh–Curtis Syndrome)
- Right upper quadrant pain (pleuritic, worsened by breathing/movement)
- Results from spread of infection to the liver capsule
- "Violin-string" adhesions seen on laparoscopy
— Harrison's 22E, p. 1148–1150 | Berek & Novak's, p. 818
Diagnosis
Minimum Criteria (CDC) — treat empirically if present with no other cause identified:
- Cervical motion tenderness
- Uterine tenderness
- Adnexal tenderness
Additional Supportive Criteria:
- Oral temperature >38.3°C
- Mucopurulent cervical or vaginal discharge
- Abundant WBCs on wet mount of vaginal secretions
- Elevated ESR or CRP
- Laboratory documentation of N. gonorrhoeae or C. trachomatis
Definitive Criteria:
- Histopathological evidence of endometritis on endometrial biopsy
- Laparoscopy — the gold standard; visually confirms salpingitis and excludes other diagnoses
- Imaging (ultrasound/MRI) — characterises TOA; may show thickened fluid-filled tubes
The clinical diagnosis confirmed by laparoscopy in ~90% of women who also have positive N. gonorrhoeae or C. trachomatis cultures.
— Harrison's 22E, p. 1150–1151 | Berek & Novak's, p. 818
Treatment
Indications for Hospitalisation:
- Surgical emergency cannot be excluded (e.g., appendicitis)
- Tubo-ovarian abscess
- Pregnancy
- Severe illness (nausea, vomiting, high fever), unable to take oral medications
- No clinical response to oral therapy after 72 hours
- Non-compliance likely
Outpatient Regimen (CDC 2021):
| Drug | Dose |
|---|---|
| Ceftriaxone | 500 mg IM × 1 dose |
| + Doxycycline | 100 mg PO twice daily × 14 days |
| + Metronidazole | 500 mg PO twice daily × 14 days |
Metronidazole addition reduces endometrial anaerobes, M. genitalium, and pelvic tenderness.
Parenteral Regimens:
Regimen A (continue until 48h after clinical improvement, then switch to oral):
| Drug | Dose |
|---|---|
| Cefotetan | 2 g IV q12h or Cefoxitin 2 g IV q6h |
| + Doxycycline | 100 mg IV or PO q12h |
Regimen B:
| Drug | Dose |
|---|---|
| Clindamycin | 900 mg IV q8h |
| + Gentamicin | Loading 2 mg/kg IV/IM, then 1.5 mg/kg q8h |
The PEACH trial showed outpatient treatment is as effective as inpatient treatment for mild-to-moderate PID with regard to long-term outcomes.
— Harrison's 22E, p. 1151 | Berek & Novak's, p. 818–819
Complications & Sequelae
| Complication | Mechanism / Note |
|---|---|
| Ectopic pregnancy | Tubal scarring and adhesions impede ovum transport; risk increases with each PID episode |
| Infertility | ~12% after 1 episode, ~23% after 2, ~54% after 3 episodes (Swedish cohort data) |
| Chronic pelvic pain | Peritubal/periovarian adhesions |
| Tubo-ovarian abscess | Requires prolonged IV antibiotics; drainage if no response in 72h |
| Recurrent PID | Risk increases substantially with each episode due to tubal damage |
| Fitz-Hugh–Curtis | Perihepatitis with RUQ pain |
— Harrison's 22E, p. 1151–1152 | Berek & Novak's, p. 819
Key Points Summary
- PID is a clinical diagnosis; treat empirically when minimum CDC criteria are met — do not wait for confirmatory tests
- Always test for N. gonorrhoeae, C. trachomatis, and BV
- Broad-spectrum therapy covering STI pathogens and anaerobes is mandatory
- Partner notification and treatment is essential to prevent re-infection
- IUDs need not be routinely removed if the patient responds to antibiotics within 72 hours
- Repeated episodes cause exponentially greater risk of infertility and ectopic pregnancy
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