Listen in for a great review with Dr. Sarah Wood (CHOP) about how to diagnose pelvic inflammatory disease, including tips on how to perform a pelvic exam, and what to do when your treatment for PID isn’t working.
Pelvic Inflammatory Disease (PID) is an ascending infection above the lower GU tract (vagina, cervix, and urethra) into the uterus (endometritis), fallopian tubes (salpingitis), and potentially the ovary and peritoneum (peritonitis). Fitz-Hugh-Curtis is when this infection extends through the peritoneum to the liver capsule.
The diagnosis is made with 1 of 3 findings on exam without another clinical explanation:
PID is ultimately a clinical diagnosis with a low threshold to treat. Dr. Wood explains that we’d rather overtreat than run into untreated sequelae such as infertility, ectopic pregnancy, or chronic pelvic pain. These sequelae can be quite common, with 18% women with PID experiencing infertility, 1% with ectopic pregnancy, and up to 30% with chronic pelvic pain (PEACH Trial, 2011)
For PID itself, important review of systems questions include: presence of vaginal discharge, vaginal bleeding or spotting, and fever. In addition, obtaining an appropriate sexual history is paramount with the caveat that teens may not feel comfortable disclosing details regarding sex.
Perhaps a half myth, Dr. Wood says intrauterine devices (IUDs) do not act as a reservoir for bacteria or the risk of PID at most times. However, if the patient has active cervicitis at the time of insertion, it can facilitate bacterial translocation and increase the risk of PID. Therefore, all patients are tested for sexually transmitted infections (STIs) at the time of placement.
Dr. Wood prefaces all pelvic exams with the “why”. She explains to the patient why an internal exam to check for organ tenderness will change her antibiotic strategy instead of just using a swab. Second, she tells the patient they are in the driver seat – we, as providers, can do whatever they need to make this exam more comfortable, including listening to music, hold hands, etc.
Dr. Wood recommends positioning the patient with their rear end 2 inches off the edge of the bed to help relax the pelvic floor. Have the patient move their knees outwards toward the wall. Insert 1 gloved finger into the vagina, followed by another, and feel for the cervix (expert opinion: it feels like the tip of a nose). Lift the cervix toward the abdomen with the pads of 2 fingers. At the same time, sweep down on the abdomen with the other hand toward the pubis. If pain with pressing upward, that is cervical motion tenderness. If pain with sweeping downward in the abdomen, that is uterine tenderness. Next, move the hand from the cervix into the right fornix (just to the right of the cervix) and sweep down from the iliac crest with the other hand. Repeat on the left side. If pain with sweeping, that is adnexal tenderness.
Dr. Wood says 90% of the time the pain is obviously out of proportion to the general discomfort of the internal pelvic exam. But there are times when the entire exam is uncomfortable for the patient, and the exam would be considered equivocal. As Dr. Wood discussed earlier, the bar to treat is low, and she would generally treat for these equivocal exams.
Lastly, a speculum exam is not required to make a diagnosis of PID. The speculum exam can help identify cervicitis, which will support an underlying GU infection. However, it is not necessary to make the clinical diagnosis of pelvic inflammatory disease.
Imaging is most helpful to rule out other etiologies of lower quadrant abdominal pain.
Some of the remaining cases are from commensal bacteria in the genital tract, including ureaplasma. Others are from emerging pathogens such as mycoplasma genitalium (M. Gen).
Doctors jump quicker to diagnosis of PID in black and latinX than white adolescents and may be anchored on the diagnosis, which is not always correct. Clinicians are more likely to test minority patients for sexually transmitted infections (Wiehe 2010)
Listeners will understand the key points in the history and physical exam of a patient with PID as well as indicated lab workup and treatment.
After listening to this episode listeners will…
Dr. Wood reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures.
Kelly JM, Wood SM, Masur S, Chiu C, Berk J. “#83: Ascend Your Understanding of Pelvic Inflammatory Disease (PID)”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ April 26, 2023.
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