EM · Pelvic inflammatory disease
Pelvic inflammatory disease
Also known as PID · Acute salpingitis · Upper genital tract infection
Pelvic inflammatory disease is the ascending infection of the upper female genital tract — endometritis progressing to salpingitis, oophoritis, parametritis and sometimes a tubo-ovarian abscess. It is a clinical syndrome with polymicrobial aetiology (Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, anaerobes and bacterial-vaginosis-associated organisms). The Fellowship candidate must hold the clinical diagnosis (the minimum CDC criteria of cervical motion, uterine or adnexal tenderness, sharpened by fever, discharge and raised inflammatory markers), the mandatory beta-hCG to exclude ectopic pregnancy, the outpatient and inpatient antibiotic regimens, the admission criteria, the tubo-ovarian abscess pathway, the partner treatment, and the 72-hour review — and must never forget the long-term sequelae of tubal infertility, ectopic pregnancy and chronic pelvic pain. ACEM-primary, globally tagged.
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Red flags
- Every woman of reproductive age with lower abdominal pain has ectopic pregnancy excluded first by a beta-hCG — a positive test reframes suspected PID completely
- Pregnant women with suspected PID are admitted for parenteral antibiotics — pregnancy, a tubo-ovarian abscess, peritonitis, sepsis or a surgical mimic that cannot be excluded are admission criteria
- Treatment failure is defined as no clinical improvement at 48 to 72 hours — it mandates admission, intravenous antibiotics, re-imaging for a tubo-ovarian abscess and reconsideration of the differential
- Metronidazole is not optional — anaerobic and bacterial-vaginosis cover is part of the standard regimen, and omitting it undertreats a polymicrobial infection
- The sequela of one untreated or recurrent episode is tubal factor infertility, ectopic pregnancy or chronic pelvic pain — partner treatment and the three-month re-screen prevent reinfection
- Right upper quadrant pleuritic pain in suspected PID is Fitz-Hugh-Curtis perihepatitis until proven otherwise
Meet the patient
A 22-year-old nulliparous woman has three days of bilateral lower abdominal pain, a yellow-green discharge, and dyspareunia. She is sexually active with two male partners in two months and uses no barrier contraception. On bimanual examination she has cervical motion tenderness, bilateral adnexal tenderness, and a mucopurulent discharge. The urine beta-hCG is negative. The next action is not to wait for the swab result — it is to start the antibiotics now, because every hour of delay is an hour of tubal scarring.[1]
The two questions that govern every suspected PID are the two that protect her fertility: is this PID, and is ectopic pregnancy excluded? (the beta-hCG and the bimanual examination) and outpatient or inpatient? (severity, pregnancy, a tubo-ovarian abscess, and whether she can return at 72 hours). The third question — silent but load-bearing — is whether her tubes will still work in ten years, and the answer is set by how completely you treat her now.[1]
References10ShowHide
- [1]Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021 MMWR Recomm Rep, 2021.PMID 34292926
- [2]Ross J, Guaschino S, Cusini M, et al. 2017 European guideline for the management of pelvic inflammatory disease Int J STD AIDS, 2018.PMID 29198181
- [3]Ness RB, Soper DE, Holley RL, et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial Am J Obstet Gynecol, 2002.PMID 12015517
- [4]Ness RB, Trautmann G, Richter HE, et al. Effectiveness of treatment strategies of some women with pelvic inflammatory disease: a randomized trial Obstet Gynecol, 2005.PMID 16135590
- [5]Trent M, Haggerty CL, Jennings JM, et al. Adverse adolescent reproductive health outcomes after pelvic inflammatory disease Arch Pediatr Adolesc Med, 2011.PMID 21199980
- [6]Jalloul RJ, Thomas M, Ward C, et al. Clinical Predictors of Failed Medical Treatment in Patients with Tubo-ovarian Abscess: External Validation of a Recently Published Risk Score J Minim Invasive Gynecol, 2022.PMID 35051659
- [7]Workowski KA, Bolan GA. Sexually transmitted diseases treatment guidelines, 2015 MMWR Recomm Rep, 2015.PMID 26042815
- [8]Couldwell DL, Lewis DA. Mycoplasma genitalium infection: current treatment options, therapeutic failure, and resistance-associated mutations Infect Drug Resist, 2015.PMID 26060411
- [9]Weström L, Joesoef R, Reynolds G, et al. Pelvic inflammatory disease and fertility. A cohort study of 1,844 women with laparoscopically verified disease and 657 control women with normal laparoscopic results. Sex Transm Dis, 1992.PMID 1411832
- [10]Marshall A, Wimsett J, Handforth C, et al. The Tubo-ovarian abscess study (TOAST): A single-center retrospective review of predictors of failed medical management. Int J Gynaecol Obstet, 2025.PMID 40162547