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:

• Lower abdominal tenderness
• Adnexal tenderness
• Cervical motion tenderness

Additional criteria, which increase the specificity of the diagnosis

• Oral temp >101
• Abnormal cervical or vaginal discharge
• Elevated ESR
• Cervical infection with N. gonorrhea or C. trachomatis  

What are the useful imaging modalities in evaluating PID?

• Trans vaginal ultrasound
• Abdominal ultrasound
• CT

What is the utility of each procedure?

• Ultrasound: 
  • An ultrasound is indicated, if an adnexal mass is suspected, the diagnosis is in question, or if the patient does not respond to initial therapy. 
  • Ultrasound is sensitive and specific for the presence of tuboovarian abscess. 
  • If an ectopic pregnancy is suspected, an US is diagnostic.   
• CT: 
  • A CT is indicated, if the diagnosis is uncertain.
  • PID can often be confused with appendicitis, especially if there is not a positive cervical culture. 
  • Also, a CT of the abdomen can show any other masses in the abdomen and pelvis. 

What are the radiological findings of PID?

• Ultrasound:
  • The uterus appears enlarged
  • More hypo echoic (darker) than normal
  • Small amounts of fluid may be present due to PID adhesions
  • Tubo-ovarian abscess - Pyosalpinx or hydrosalpix – cystic adnexal mass that looks echogenic because of debris
• CT:
  • Adnexal mass – soft-tissue mass, with area of low attenuation. Fluid filled.
  • May be difficult to differentiate an ovarian abscess from tumor

What is the procedure of choice?

• PID is a clinical diagnosis, but the procedure of choice is trans vaginal ultrasound.     
• Diagnostic algorithm:
  • If the patient has the clinical signs of PID – give antibiotic treatment.  
  • If patient fails to respond to antibiotics, or there is a suspicion of pelvic abscess, then suggest pelvic ultrasound. 
  • If the diagnosis is in question, give antibiotics, and procedure with other imaging – i.e., CT scan of abdomen and pelvis. 

What is the sensitivity and specificity of each procedure?

• If you see thickened fluid-filled tubes or free pelvic fluid on the ultrasound, it is 85% sensitive and 98% specific. 
• In another study, that looked at a patient who was diagnosed clinically for PID or by laparascopy (gold standard) the sensitivity was poor and the specificity was 98% if an abnormal oviduct was seen. 

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. 

Images: 

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

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