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Pelvic Inflammatory Disease (PID) is a bacterial inflammation of the fallopian tubes, ovaries, uterus and cervix.

Initial infections are caused by single-agent STDs, such as gonorrhea or chlamydia. Subsequent infections are often caused by multiple non-STD organisms (E. Coli, Bacteroides, etc.). Responsible organisms include STDs, normal vaginal inhabitants, and enteric bacteria.

Most cases of PID have no long-term adverse effects, but some have such serious (or disastrous) consequences as infertility, tubo-ovarian abscess, and sepsis. Women with a history of PID are at increased risk for subsequent tubal ectopic pregnancy.

Symptoms of PID vary from nearly trivial pelvic discomfort and vaginal discharge to incapacitating abdominal pain with nausea and vomiting. Leukocytosis, like fever, is variable in cases of PID. The diagnosis can be based on such imprecise findings as uterine and adnexal tenderness without other explanation, or such precise findings as laparoscopic visualization of inflamed tubes with surrounding purulence. Cervical cultures may or may not be positive. Ultrasound findings may be normal or may include a generalized haziness due to edema. In more advanced cases, hydrosalpinx may be seen with ultrasound, CT or MRI.

From a clinical management point of view, there are two forms of PID:

• Mild, and
• Moderate to Severe

CDC Treatment Guidelines

Mild PID
Gradual onset of mild bilateral pelvic pain with purulent vaginal discharge is the typical complaint. Fever <100.4 and deep dyspareunia are common.

Moderate pain on motion of the cervix and uterus with purulent or mucopurulent cervical discharge is found on examination. Gram-negative diplococci or positive chlamydia culture may or may not be present. WBC may be minimally elevated or normal. These cases are treated aggressively, but usually with oral medications. Prompt response is expected. Sexual partners should also be treated.

Oral treatment may consist of

Ofloxacin 400 mg orally twice a day for 14 days
     OR
Levofloxacin 500 mg orally once daily for 14 days
     WITH or WITHOUT
Metronidazole 500 mg orally twice a day for 14 days.

Another primarily oral regimen is:

Ceftriaxone 250 mg IM in a single dose
     OR
Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally administered concurrently in a single dose
     OR
Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime)
     PLUS
Doxycycline 100 mg orally twice a day for 14 days
     WITH or WITHOUT
Metronidazole 500 mg orally twice a day for 14 days.

For further information, read the CDC Treatment Guidelines for PID

Moderate to Severe PID
With moderate to severe PID, there is a gradual onset of moderate to severe bilateral pelvic pain with purulent vaginal discharge, fever >100.4 (38.0), lassitude, and headache. Symptoms more often occur shortly after the onset or completion of menses.

Excruciating pain on movement of the cervix and uterus is characteristic of this condition. Hypoactive bowel sounds, purulent cervical discharge, and abdominal dissension are often present. Pelvic and abdominal tenderness is always bilateral except in the presence of an IUD.

Gram-negative diplococci in cervical discharge or positive chlamydia culture may or may not be present. WBC and ESR are elevated.

These more serious infections require more aggressive management, often consisting of bedrest, IV fluids, IV antibiotics, and NG suction if ileus is present. A more gradual recovery is expected and it may be several weeks before the patient is feeling normal.

ANTIBIOTIC REGIMEN: (Center for Disease Control, 2002)

Cefotetan 2 g IV every 12 hours
     OR
Cefoxitin 2 g IV every 6 hours
     PLUS
Doxycycline 100 mg orally or IV every 12 hours.

The doxycycline is continued for 14 days. The parenteral medication may be stopped 24 hours after clinical improvement.

OTHER ALTERNATIVE ANTIBIOTIC REGIMENS: (Center for Disease Control, 2002)

Clindamycin 900 mg IV every 8 hours
     PLUS
Gentamicin loading dose IV or IM (2 mg/kg of body weight) followed by a maintenance dose (1.5 mg/kg) every 8 hours. Single daily dosing may be substituted.

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Ofloxacin 400 mg IV every 12 hours
     OR
Levofloxacin 500 mg IV once daily
     WITH or WITHOUT
Metronidazole 500 mg IV every 8 hours

---

Ampicillin/Sulbactam 3 g IV every 6 hours
     PLUS
Doxycycline 100 mg orally or IV every 12 hours.

For further information, read the CDC Treatment Guidelines for PID

OB-GYN 101: Introductory Obstetrics & Gynecology
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