Pelvic inflammatory disease (Acute Salpingitis)

Pelvic inflammatory disease (PID) is usually the result of infection ascending from the endocervix causing endometritis, salpingitis, parametritis, oophoritis, tuboovarian abscess and/or pelvic peritonitis.

There is no single historical, physical or lab finding that is both sensitive and specific for the diagnosis of PID.

A combination of clinical and laboratory information is required. Symptoms alone are not a good predictor of PID, and clinical diagnosis alone is difficult.  A low threshold for diagnosis should be maintained to prevent sequelae.

On examination minimum criteria for diagnosis includes 

• cervical and uterine motion tenderness, and

• adnexal tenderness.

These findings may be sufficient for a diagnosis of PID and the commencement of empirical treatment in a woman with a mild presentation, at risk of STDs and in the absence of strong evidence for a competing diagnosis.

There should also be one of the following additional criteria suggesting genital tract infection or an inflammatory process. When symptoms are severe, other diagnoses should be considered, and more than one of the following criteria should be present to make a diagnosis of PID.

• Temperature >38° C

• Abnormal cervical discharge

• Pelvic abscess or inflammatory complex on bimanual examination

• Gram stain of the endocervix showing gram negative intracellular diplococci

• Positive chlamydia test

• Leucocytosis >10 x 10⁹ WBC/L

• Elevated ESR

• Elevated C-reactive protein

The definitive criteria for diagnosing PID include the following:

• histopathologic evidence of endometritis on endometrial biopsy

• transvaginal sonography or other imaging techniques showing thickened fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex

• laparoscopic abnormalities consistent with PID.

Objectives of antimicrobial therapy include:

• Short term - elimination of symptoms and signs of infection and eradication of pathogens

• Long term - reduction of tubal damage (impossible to evaluate using current data)

Treatment is usually initiated empirically before a microbial cause is established.

PID is polymicrobial. Neisseria gonorrhoeae and Chlamydia trachomatis are implicated most often but there are a variety of endogenous anaerobic and aerobic bacteria that may also cause PID. 

 Outpatient therapy

The following combination regimen should be used. If ongoing parenteral treatment is required, the woman should be hospitalised (see following section)

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Intravenous therapy is recommended for patients with more severe clinical disease such as those with fever, tuboovarian abscess or peritonitis.  Other indications for hospitalisation include the following:

• when surgical emergencies such as appendicitis and ectopic pregnancy cannot be excluded.

• the woman is pregnant

• failure to respond to outpatient oral therapy

• the woman is unable to follow or tolerate an outpatient oral regimen

• the woman is immunodeficient. 

Complications may occur in spite of adequate treatment. There are uncertainties regarding the effectiveness of antimicrobial therapy in totally eradicating tubal infection, even where cervical infection has been eliminated. Delay in diagnosis and treatment, or inadequate treatment may also increase the rate of complications.

Complications include:

• infertility

• chronic persistent pain

• increased incidence of ectopic pregnancy

• increased risk of further episodes of PID

• tubo-ovarian abscess.

The following points should be discussed:

• The nature of the infection

• It may not be sexually acquired

• Partners should be tested and treated for sexually transmitted infections

• Clinical review is required 

• Long term sequelae of PID

Contact tracing is required if a sexually transmitted infection is identified.