An Update on Pelvic Inflammatory Disease

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We last covered PID and TOA on the podcast in February 2019 — and since then, as with our gonorrhea and chlamydia update, have some new updates to reflect the 2021 CDC Treatment Guidelines.

What is PID/TOA? 

  • PID: pelvic inflammatory disease 

    • This is a wide variety of inflammatory disorders of the upper female genital tract, including: 

      • Endometritis

      • Salpingitis

      • TOA: tubo-ovarian abscess

      • Pelvic peritonitis 

    • Caused by many infectious diseases. 

      • Most common: N. gonorrhoeae and C. trachomatis (gonorrhea and chlamydia)

        • 50% of PID diagnoses test positive for GC/CT, though this proportion is decreasing.

    • Other organisms that can be implicated:

      • Anaerobes, 

      • G. vaginalis 

      • H. influenzae

      • Enteric GNRs

      • Strep agalactiae

      • Cytomegalovirus 

      • Trichomonas (Trichomonas vaginalis)

      • Mycoplasima hominis and M. genitalium

      • Ureaplasma urealyticum

Diagnosis of PID

  • Can be difficult because of many vague symptoms, and some are asymptomatic 

  • Differential diagnosis is broad for abdominopelvic pain: 

    • Appendicitis 

    • Ectopic pregnancy

    • Ovarian torsion or ovarian cysts

    • Diverticulitis

    • Functional GI pain, IBS, IBD

    • Etc. etc. etc. 

  • A presumptive dx should be made, and treatment started,

    • In sexually active women and those at risk for STIs experiencing pelvic/lower abdominal pain, if no other cause for illness can be identified,

    • and if they have 1 or more of these minimum clinical criteria: 

    • Cervical motion tenderness 

    • Uterine tenderness 

    • Adnexal tenderness  

  • One or more of the following can be used to enhance specificity of the minimal clinical criteria: 

    • Oral temp > 101 F (38.3) 

    • Abnormal cervical mucopurulent discharge or friability 

    • Presence of abundant WBC on saline microscopy of vaginal fluid 

    • Elevated erythrocyte sedimentation rate 

    • Elevated C-reactive protein 

    • Laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis 

  • Even more specific criteria can include:

  • Endometrial biopsy with histopathologic evidence of endometritis 

  • TVUS or MRI showing thickened, fluid-filled tubes with or without free fluid or tubo-ovarian complex

  • Laparoscopic findings of PID (Fitz-Hugh-Curtis syndrome) 

What should I do if I think someone has PID?

  • Testing:

  • HIV

    • Testing recommended by CDC “in all persons seeking STI testing who do not have a known diagnosis of HIV.” 

  • GC/CT

    • 50% will test positive, so they are high yield for PID testing.

    • NAAT testing is preferred method.

      • Patient self-collected swabs are just as accurate as clinician-collected.

      • First void urine is most sensitive; decreases with later voids during the day.

        • Urine testing may miss over 400k infections per year in USA - vaginal swab testing should be offered first, and patient-collected may help improve acceptability.

  • Imaging

    • Not recommended outright by CDC in PID evaluation.

    • Will frequently be part of your evaluation in a differential diagnosis

      • TVUS - may continue to have cervical motion tenderness, can demonstrate TOA. Can also demonstrate other GYN pathologies.

      • CT/MRI - unlikely to demonstrate specific findings for PID outside of large TOAs.

  • Treatment:

    • Primary Considerations: 

  • Choice of medication:

    • Treatment is empiric, requiring broad spectrum coverage of likely pathogens

    • All treatment types should be effective against gonorrhea and chlamydia 

  • Need for hospitalization:

    • Recommended if:

      • A surgical emergency (ie. appendicitis) cannot be excluded

      • Presence of tubo-ovarian abscess 

      • Pregnancy

      • Severe illness including nausea, vomiting, or high fever,

      • Inability to tolerate or follow outpatient regimen

      • Failed outpatient therapy based on follow up

    • Parenteral treatments

      • Ceftriaxone (1g IV q24 hrs) + doxycycline (100 mg oral or IV q12hrs) + metronidazole (500mg oral or IV q12h).

      • Cefoxitin (2g IV q6hrs) + doxycycline (100mg oral or IV q12hrs) 

      • Cefotetan (2g IV q12h) + doxycycline (100mg oral or IV q12hrs)

    • Because of pain associated with IV infusion, doxycycline should be given orally whenever possible.

    • Oral and IV doxycycline and metronidazole have similar bioavailability

  • Alternative regimens pending allergies and antibiotic availability:

    • Clindamycin (900 mg IV q8hrs) + gentamicin (2mg/kg loading dose IV or IM, then maintenance of 1.5mg/kg every 8 hrs, or single daily dosing of 3-5mg/kg) 

    • Ampicillin-sulbactam (Unasyn) 3g IV q6hrs + doxycycline 100mg q12hrs  

  • Goal of parenteral therapy will be to transition to oral antibiotics within 24-48 hours if clinical improvement.

    • Those with TOA should have at least 24 hours of inpatient observation

    • IM/Oral treatment - For continuation of inpatient treatment, or start here in those with mild-to-moderate symptoms of acute PID. 

  • Clinical outcomes are similar to those treated with IV therapy, but if women don’t respond in 72 hours, should be re-evaluated and treated with IV

    • Ceftriaxone 500mg IM x1 + doxycycline 100mg BID x14 days + metronidazole 500 mg BID x14 days 

    • Cefoxitin 2g IM + Probenecid 1g orally + doxycyline 100mg BID x14 days + metronidazole 500mg BID x14 days 

    • Some other 3rd generation cephalosporin + doxy + metronidazole 

  • If starting with outpatient treatment, improvement should be documented by follow up within 72 hours.

    • If no improvement has occurred, then hospitalization, assessment of the antimicrobial regimen, and considering potential additional diagnostics (imaging, laparoscopy) are indicated.

  • Retesting should occur at 3 months after treatment, regardless of treatment of sex partners, to assess for reinfection.

    • Patients should refrain from sex until treatment is completed, symptoms resolved, and sex partners have been treated.

    • Sex partners within previous 60 days of patients with PID should also be treated presumptively for gonorrhea and chlamydia

      • This is regardless of PID etiology or pathogens isolated 

      • Consider expedited partner therapy (EPT).

Managing TOAs 

  • Surgical drainage indicated if:

    • Failure to respond to treatment within 48-72 hours 

    • Clinical decline (ie. becoming septic) 

  • Likelihood of need for surgical intervention is related to the size of TOA: 

    • 60% of those with abscess >10cm 

    • 30% in 7-9cm 

    • 15% in those of 4-6 cm

Special considerations for treatment in certain populations:

  • Pregnancy

    • Pregnant patients with PID are at high risk of morbidity, pregnancy loss, preterm delivery.

    • Hospitalization and consultation with ID are recommended.

  • Persons with HIV

    • Patients with HIV may be more likely to have TOA, though symptoms are similar overall to those without HIV.

    • No data currently to suggest more aggressive therapy is needed in patients with HIV.

  • If patient has an IUD:

    • IUD is not required to be removed with a diagnosis of PID.

    • However, if there is no clinical improvement in 48-72 hours, then should consider removing the IUD.