#83: Ascend Your Understanding of Pelvic Inflammatory Disease (PID)

April 26, 2023 | By Sam Masur

Audio

Summary:

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) Pearls

1. PID is an ascension of bacteria (most often gonorrhea, chlamydia, and trichomonas but sometimes commensal bacteria in the genital tract, ureaplasma, or mycoplasma genitalium) beyond the cervix to the uterus, fallopian tubes, ovary, and/or peritoneum.
2. The diagnosis of PID is made by physical exam findings of cervical motion, uterine, or adnexal tenderness. 
3. Lab and imaging workup is used to exclude other diagnoses rather than confirm a diagnosis of PID
4. There is a low threshold to treat PID due to the complications of untreated sequelae including infertility, ectopic pregnancy, and chronic pelvic pain.

Pelvic Inflammatory Disease Notes 

Definition

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:

• Cervical Motion Tenderness
• Uterine Tenderness
• Adnexal Tenderness

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)

Workup

History

Asking relevant questions to help diagnose other etiologies of lower abdominal pain is crucial.

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.

Exam

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

Imaging is most helpful to rule out other etiologies of lower quadrant abdominal pain.

• Appendix US for right lower quadrant pain
• Pelvic US for ovarian torsion or tubo-ovarian abscess

Laboratory Testing

• CBC for leukocytosis
• Cervicitis testing – gonorrhea, chlamydia, and trichomonas. Please be mindful that urine testing is 7-8% less sensitive than the cervical swab (Annals Fam Med 2023). There is no sensitivity difference between patient and provider swab.
• FYI: elevated transaminases is NOT consistent with PID or Fitz-Hugh-Curtis, which is inflammation of the liver capsule, not the hepatocytes themselves.

Etiology

Microbiology

85% of cases come from sexual transmitted infections, including gonorrhea, chlamydia, and trichomonas. 

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).

Disparities

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)

Treatment

Outpatient Therapy

• Ceftriaxone 500mg IM x1 (increased from 250mg due to resistant gonococcal infections) if weight < 150kg 
• Followed by doxycycline 100mg PO and metronidazole 500mg PO twice daily for 14 days
• Follow up closely in 48-72 hours to ensure improvement with repeat pelvic exam. If no improvement or worsening, recommend sending to the hospital for further imaging and possible IV treatment.

Inpatient Therapy

• IV Cefoxitin (or Cefotetan) 2g and doxycycline 100mg every 12 hours
• When transitioning to oral, will need metronidazole 500mg twice daily
• All Tubo-Ovarian abscesses require inpatient treatment for minimum of 24 hours
• If no improvement on IV regimen, consider covering for M. Gen with moxifloxacin
  • The currently recommended regimen is doxycycline 100mg twice daily for 7 days followed by 400mg moxifloxacin daily for 7 days
  • Prior to treating, Dr. Wood recommends sending NAAT and resistance testing

Follow Up

• NAAT will stay positive for approximately 3-4 weeks
• Dr. Wood advises against sex until all antibiotics have been completed by both the patient and partner (if he/she/they are receiving expedited partner therapy).
• Guidelines recommend retesting in 3 months due to risk of re-infection rather than test of cure
• Unrelated to PID, CDC does recommend test of cure for pharyngeal gonorrhea in 2-4 weeks due to levels of gonococcal resistance
• Dr. Wood recommends HIV and Treponemal screening in all patients with PID, and discussion about HIV prevention, including PrEP.
• In general, Dr. Wood would wait 4 weeks after treatment to offer to place an IUD

Links

• CDC STI Treatment App
• I Know U Should 2 website has great youth centered information

Goal

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.  

Learning Objectives

After listening to this episode listeners will…  

1. Recall the basic pathophysiology of PID as an ascending infection. 
2. Be familiar with the diagnostic criteria of PID. 
3. Recognize disparities in PID diagnosis and STI testing. 
4. Learn about testing to help make a PID diagnosis as well as when to repeat STI testing
5. Understand the importance of treating PID to avoid future complications. 
6. Describe the appropriate treatment and  follow up for patients diagnosed with PID

Disclosures

Dr. Wood reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

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.