Pelvic inflammatory disease (PID) remains a diagnostic and treatment challenge. It is typically defined as an infection of the female genital tract above the cervix and may include salpingitis, endometritis, tubuloovarian abscess (TOA), and/or frank peritonitis (64). Long-term sequelae of PID are severe and include ectopic pregnancy, infertility, and chronic pelvic pain (64). In the United States, the population most commonly affected by PID appears to be the young, nonwhite, unmarried urban dweller as well as those with a history of PID, multiple sexual partners, previous or current STDs, and cigarette smoking (64). Controversy surrounds the role of IUDs and douching as risk factors for PID (64).
The diagnosis of PID is imprecise and should be considered in any woman with pelvic pain. Definitive diagnosis can be made by culture of involved areas, but this frequently involves invasive procedures such as culdocentesis, endometrial biopsy, and/or laparoscopy. The differential diagnosis is extensive, and should include ectopic pregnancy, ovarian torsion, flare of endometriosis, ruptured ovarian cyst, appendicitis, cholecystitis, colitis, gastroenteritis, pyelonephritis, nephrolithiasis, and bowel perforation. The CDC recommends initiating antibiotic therapy for PID in patients with adnexal, lower abdominal or cervical motion tenderness (2). The presence of fever, an elevated erythrocyte sedimentation rate (ESR), and/or C-reactive protein (CRP), and cervical or vaginal discharge with proven chlamydial or gonorrheal infection support the diagnosis of PID (2). The findings of hydrosalpinx, pyosalpinx with thickened tubular walls with or without free fluid in the pelvis, or tuboovarian complex are considered to definitively establish a diagnosis of PID (2).
C. trachomatis and N. gonorrhea are well-documented causes of PID. One recent randomized, controlled trial found that identifying and treating women with chlamy-dial cervical infections reduced the incidence of PID (65). PID is frequently a polymicrobial infection with bacteria such as M. hominis, H. influenzae, G. vaginalis, staphylococci, Group B streptococci, E. coli, and anaerobes (66). Thus, the consensus is that PID necessitates broad-spectrum antibiotic therapy. Anaerobes are particularly frequent in women with TOA and with PID in the presence of HIV infection or bacterial vaginosis (64,66). There is an association between bacterial vaginosis and PID, but its significance is controversial.
Given the serious consequences of PID, prevention and early treatment should be a priority. The CDC recommends hospitalization for patients who are pregnant, immuno-compromised, noncompliant, failing outpatient regimens, not tolerating oral antibiotics, or who have a TOA or in whom a surgical cause cannot be excluded (2). Table 7 lists the CDC's treatment recommendations for PID. All patients, whether treated on an inpatient or outpatient basis, should have follow-up within 3 d of initiation of therapy. If no improvement is noted on appropriate treatment, then additional testing, other diagnoses, or surgical referral should be considered (2). Evaluation of male sexual partners of patients with PID is an essential component to treatment.
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