Pelvic Inflammatory Disease

What is the clinical setting when you will consider PID?

A younger woman, who has multiple sexual partners (or a new partner in the last six months), who presents with lower abdominal and pelvic pain.  The pain is usually bilateral and dull in nature.  Often it will begin within a week after the onset of menses. 

Minimum criteria needed:

Additional criteria, which increase the specificity of the diagnosis

What are the useful imaging modalities in evaluating PID?
What is the utility of each procedure?
What are the radiological findings of PID?
What is the procedure of choice?
What is the sensitivity and specificity of each procedure?
Case 1

A 26-year-old female presents to you in the STD clinic with a complaint of fever of three days duration, nausea, and lower abdominal pain. She denies a history of dysuria, hematuria, or genital ulcerations. She denies that she may be pregnant. She has an intrauterine device for 2 years. She takes no prescribed medications and she has no allergies.
On examination, she has a temperature of 390 C, pulse rate of 110 per minute, respiration rate of 28 per minute, and B/P of 100/60. She is ill appearing and diaphoretic. There is no lymphadenapathy. She has right lower quadrant tenderness to deep palpation. Bowel sounds are present but hypoactive. Her pelvic examination reveals right adnexal tenderness and cervical motion tenderness. The uterus is tender and slightly enlarged. Thick yellow vaginal discharge is sent for microbiological studies.

Q: Does she need imaging studies? Can she be treated empirically?

Answer: Yes.Empiric treatment of PID should be instituted on the basis of the presence of all of the following three minimum clinical criteria for pelvic inflammation and in the absence of an established cause other than PID:

1. lower abdominal tenderness
2. adnexal tenderness
3. cervical motion tenderness

For women with fewer clinical signs, more elaborate diagnostic evaluation is warranted because incorrect diagnosis and management may cause unnecessary morbidity.

Case 2:

19 year old sexually active girl presents with right lower quadrant pain and fever. Her LMP was one week ago. She does not practice protective sex. She has right lower qudrant abdominal tenderness with rebound. On pellvic exam, there is some mucoid discharge from cervix. Uncertain about tenderness on cervical motion. Surgeon is debating between PID and appendicitis.

Q: Does she need any imaging procedure. If so which imaging procedure?

A: When you are uncertain of the diagnosis, imaging procedure should be utilized. CT would be the choice in this case as it will provide information about pelvis and abdomen.

Case 3:

Patient is a 17-year-old sexually active G0P0 who comes to her primary care physician complaining of severe abdominal pain for 2 days.  Her LMP was 2 weeks ago.  She states that she uses condoms for contraception.  Pt has a fever to 101.  She has a tender lower abdomen, but no rebound or guarding. On pelvic exam, the patient has a purulent cervical discharge. Patient has a positive chandelier sign (cervical motion tenderness) as well as bilateral adenxal tenderness. B-HCG is negative. 


This patient has Fitz-Hugh Curtis syndrome, which is perihepatits, a complication of untreated PID. 

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