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Pelvic Inflammatory Disease

Last Updated: December 7, 2005

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Synonyms and related keywords: pelvic inflammatory disease, PID, uterus, fallopian tubes, intrauterine
device, IUD, tubal infertility, genital tract, vagina, cervix, sexually transmitted diseases, STD, ectopic
pregnancy, tubal pregnancy, pelvic pain, dysuria, vaginal discharge, vaginal bleeding, Chlamydia
trachomatis, C trachomatis, Gardnerella vaginalis, G vaginalis, Haemophilus influenzae, H influenzae,
Escherichia coli, E coli, Peptococcus species, Streptococcus agalactiae, S agalactiae, Bacteroides fragilis,
B fragilis, Neisseria gonorrhoeae, N gonorrhoeae, Mycoplasma genitalium, M genitalium, cytomegalovirus,
CMV, endogenous microflora

AUTHOR INFORMATION

Section 1 of 10

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Author: James B Hill, MD, Chief, Division of Obstetrics, Staff Physician, Department of
Obstetrics and Gynecology, Womack Army Medical Center
Coauthor(s): Ernest Lockrow, DO, Chief of Gynecology Service, Department of
Obstetrics and Gynecology, Walter Reed Army Medical Center; Assistant Professor,
Department of Obstetrics and Gynecology, Uniformed Services University of the Health
Sciences
James B Hill, MD, is a member of the following medical societies: Society for MaternalFetal Medicine
Editor(s): Ronald Levine, MD, Director, Section of Gynecologic Endoscopy, Professor,
Department of Obstetrics and Gynecology, University of Louisville School of Medicine;
Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Michel E
Rivlin, MD, Coordinator, Quality Assurance/Quality Improvement, Associate Professor,
Department of Obstetrics and Gynecology, University of Mississippi Medical Center;
Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Assumption
Community Hospital; and Lee P Shulman, MD, Professor of Obstetrics and Gynecology,
Feinberg School of Medicine, Northwestern University; Chief, Division of Reproductive
Genetics, Department of Obstetrics and Gynecology, Prentice Women's Hospital,
Northwestern Memorial Hospital

IN
T
R
O
D
U
C

Section 2 of 10

TI
O
N
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Background: Pelvic inflammatory disease (PID) is an inflammatory disorder of the

uterus, fallopian tubes, and adjacent pelvic structures. Risk factors for PID include
young age at first intercourse, multiple sexual partners, intrauterine device (IUD)
insertion, and tobacco smoking. A delay in diagnosis or treatment can result in longterm sequelae such as tubal infertility.
Pathophysiology: In PID, the upper female genital tract is infected by direct spread of
microorganisms ascending from the vagina and cervix. The cervix produces mucus that
usually protects against upward spread, but bacteria may penetrate the cervical mucus
and cause widespread extension of infection.
Frequency:

In the US: PID affects 11% of women of reproductive age. Approximately 1

million women experience an episode of PID per year, and 20% of these women
require hospitalization for treatment. The disease produces 2.5 million office
visits and 125,000-150,000 hospitalizations yearly.

Internationally: Public health efforts implemented in Scandinavia to decrease

the prevalence of sexually transmitted diseases (STDs) have been quite
effective.

Mortality/Morbidity: A delay in diagnosis or treatment can result in long-term

reproductive sequelae, such as tubal infertility. Each repeat episode of PID doubles the
risk for tubal factor infertility. Women with a history of PID have a 7- to 10-fold
increased risk for ectopic pregnancy (tubal pregnancy) compared with women with no
history of PID. Chronic pelvic pain can also follow PID and occurs in 25-75% of women.
Sex: PID is an infection of the female genital tract.
Age: PID may occur more frequently in adolescents (ie, 15-19 y), but it can occur in
any patients who are sexually active. Age distributions vary with geographic location
and etiology. Young age at first intercourse increases risk for PID.

CLINICAL

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History: Patients can present with a variety of symptoms, ranging from lower
abdominal pain to dysuria. A direct correlation exists between the incidence of STDs
and pelvic inflammatory disease (PID) in any given population.

Pain is present in more than 90% of documented cases and is by far the most
common presenting symptom.
o

Usually, pain is described as dull, aching, and constant; it begins a few

days after the onset of the last menstrual period and tends to be
accentuated by motion, exercise, or coitus.

Pain from PID usually lasts less than 7 days; if pain lasts longer than 3
weeks, the likelihood that PID is the correct diagnosis declines
substantially.

Abnormal vaginal discharge is present in approximately 75% of cases.

Unanticipated vaginal bleeding coexists in about 40% of cases.

Temperature higher than 38C (30%), nausea, and vomiting manifest late in the
clinical course of the disease.

Physical: The sensitivity of the pelvic examination is only 60%. The Centers for
Disease Control and Prevention (CDC) recommends the following minimal clinical
criteria for the diagnosis of PID in sexually active young women: uterine/adnexal
tenderness or cervical motion tenderness.
Additional criteria may be used to enhance the specificity of the minimum criteria:

Temperature higher than 101F (38.3C)

Abnormal cervical or vaginal mucopurulent discharge

Presence of white blood cells (WBCs) on saline microscopy of vaginal secretions

Elevated erythrocyte sedimentation rate

Elevated C-reactive protein level

Laboratory documentation of cervical infection with Neisseria gonorrhoeae or

Chlamydia trachomatis

Causes: The classic high-risk patient is a menstruating woman younger than 25 years
who has multiple sex partners, does not use contraception, and lives in an area with a
high prevalence of STD. PID is also more prevalent among unmarried women and

individuals who are young at first intercourse. The IUD confers a relative risk of 2.0-3.0
for the first 4 months following insertion, but then it decreases to baseline thereafter.
Women who are not sexually active have a very low incidence of upper genital tract
infection, as do women who have undergone tubal sterilization.

C trachomatis: C trachomatis, an intracellular bacterial pathogen, is the

predominant STD organism causing PID. Clinically, infection with this obligate
intracellular parasite may manifest as mucopurulent cervicitis.

Cytomegalovirus (CMV): CMV has been found in the upper genital tracts of
women with PID, suggesting a potential role of CMV in PID.

Endogenous microflora: In iatrogenically induced infections, the endogenous

microflora of the vagina predominate.

Gardnerella vaginalis

Haemophilus influenzae

Enteric gram-negative organisms (Escherichia coli)

Peptococcus species

Streptococcus agalactiae

Bacteroides fragilis: This can cause tubal and epithelial destruction.

Pregnancy: PID is rare in pregnancy.

N gonorrhoeae: In the United States, the role of N gonorrhoeae as the primary

cause of PID has decreased.

Mycoplasma genitalium: M genitalium has been isolated in the endometrium and

fallopian tubes of women who have PID.

DIFFERENTIALS

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Adnexal Tumors
Appendicitis
Ectopic Pregnancy
Endometriosis

Other Problems to be Considered:

Rupture of an adnexal mass
Adnexal torsion
Perihepatic inflammation (Fitz-Hugh and Curtis syndrome)

WORKUP

Section 5 of 10

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Lab Studies:

Additional criteria may be used to increase the specificity of the diagnosis as

listed below.

Vaginal wet mount - Increased amount of white cells

Erythrocyte sedimentation rate (ESR) - Elevated, nonspecific

C-reactive protein (CRP) - Elevated, nonspecific

CBC count - Elevated white blood cell count

Gonorrhea cultures - Generally used to confirm diagnosis (frequently negative in

later stages)

Chlamydial cultures - Generally used to confirm diagnosis (large variability in

recovery from cervix [5-56%])

Imaging Studies:

Transvaginal sonography may not be useful in the diagnosis of PID. It has poor
sensitivity (81%) and specificity (78%) with mild or atypical PID. It can be used to
document an adnexal mass or demonstrate fluid-filled fallopian tubes.

Although the specificity (95%) and sensitivity (95%) of MRI is relatively high, it is
costly and rarely indicated in acute PID. If used in the management of PID, MRI
can demonstrate thickened fluid-filled tubes with or without free pelvic fluid or
tubo-ovarian complex.

Procedures:

Culdocentesis: With the advent of transvaginal sonography, culdocentesis is

rarely performed. In the absence of current technology, insertion of an 18-gauge
spinal needle attached to a syringe can be performed. The needle is inserted
transvaginally into the cul-de-sac, yielding either purulent fluid or bloody fluid
from the peritoneum.

TREATMENT

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Medical Care:

Most patients are now managed as outpatients, but physicians should consider
hospitalization for patients with the following conditions, although no clear data
suggest that these patients benefit from hospitalization:
o
o
o
o
o
o
o
o

Inpatient treatment includes the following:

o

Uncertain diagnosis
Pelvic abscess on ultrasound
Pregnancy
Failure to respond to outpatient management
Inability to tolerate outpatient PO regimen
Severe illness or nausea and vomiting precluding outpatient treatment
Immunodeficiency (eg, HIV with low CD4 count, using
immunosuppressive medications)
Failure to improve clinically after 72 hours with outpatient therapy

Regimen A: Administer cefoxitin 2 g IV or cefotetan 2 g IV plus

doxycycline 100 mg PO/IV q12h. Continue this regimen for 48 hours after
the patient remains clinically improved, and then start doxycycline 100 mg
PO bid for a total of 14 days. Administer doxycycline PO when possible
because of pain associated with infusion. Bioavailability is similar with PO
and IV administrations. IV antibiotics may be discontinued 24 hours after
the patient improves clinically, and PO therapy with doxycycline is
continued for a total of 14 days. If tubo-ovarian abscess is present, use
clindamycin or metronidazole with doxycycline for more effective
anaerobic coverage.
Regimen B: Administer clindamycin 900 mg IV q8h plus a 2 mg/kg loading
dose of gentamicin IV or IM followed by a maintenance dose of 1.5 mg/kg
q8h. IV therapy may be discontinued 24 hours after the patient improves
clinically, and PO therapy of 100 mg bid of doxycycline should be
continued for a total of 14 days of therapy.

Outpatient treatment

Regimen A: Administer ofloxacin 400 mg PO bid for 14 days or

levofloxacin 500 mg PO qd for 14 days with or without metronidazole 500
mg PO bid for 14 days.
Regimen B: Administer ceftriaxone 250 mg IM in a single dose or cefoxitin
2 g IM in a single dose and probenecid 1 g PO concurrently in a single
dose or other parenteral third-generation cephalosporin plus doxycycline
100 mg PO bid for 14 days with or without metronidazole 500 mg PO bid
for 14 days.

Surgical Care: The advantage of laparoscopy is that it allows direct visualization of the
pelvis and provides a more accurate and bacteriologic diagnosis if cultures are
obtained. However, laparoscopy is not always available in acute PID. In addition, this
procedure is costly and requires general anesthesia. It should be used if the diagnosis
is in doubt. However, if operative laparoscopy is used early in the course of the
disease, copious irrigation and separation of thin adhesions by blunt dissection may
prevent later sequelae.
Consultations:

Obstetrician

Gynecologist

Diet: Patients should take nothing by mouth (NPO) if the diagnosis is uncertain or if the
patient is scheduled for surgery

MEDICATION

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See Medical Care for treatment regimens.

Drug Category: Antibiotics -- Therapy must be comprehensive and cover all

likely pathogens in the context of this clinical setting.

Drug Name

Cefoxitin (Mefoxin) -- Second-generation

cephalosporin indicated for infections
with gram-positive cocci and gramnegative rods. Infections caused by
cephalosporin- or penicillin-resistant
gram-negative bacteria may respond to
cefoxitin.

Adult Dose

2 g IV q6h

Pediatric Dose

80-160 mg/kg/d IV divided q4-6h; higher

doses for severe or serious infections;

not to exceed 12 g/d
Contraindications Documented hypersensitivity
Interactions

Probenecid may increase effects;

coadministration with aminoglycosides or
furosemide may increase nephrotoxicity
(closely monitor renal function)

Pregnancy

B - Usually safe but benefits must

outweigh the risks.

Precautions

Bacterial or fungal overgrowth of

nonsusceptible organisms may occur
with prolonged use or repeated
treatment; caution in patients with
previously diagnosed colitis

Drug Name

Cefotetan (Cefotan) -- Secondgeneration cephalosporin indicated for

infections caused by susceptible grampositive cocci and gram-negative rods.
Dose and route of administration depend
on condition of patient, severity of
infection, and susceptibility of causative
organism.

Adult Dose

2 g IV q12h

Pediatric Dose

20-40 mg/kg/dose IV/IM q12h for 5-10 d

Contraindications Documented hypersensitivity

Interactions

Consumption of alcohol within 72 h may

produce disulfiramlike reactions; may
increase hypoprothrombinemic effects of
anticoagulants; coadministration with
potent diuretics (eg, loop diuretics) or
aminoglycosides may increase
nephrotoxicity

Pregnancy

B - Usually safe but benefits must

outweigh the risks.

Precautions

Drug Name

Reduce dosage by one half if CrCl is 1030 mL/min and by one fourth if CrCl <10
mL/min; bacterial or fungal overgrowth of
nonsusceptible organisms may occur
with prolonged or repeated therapy
Doxycycline (Vibramycin) -- Inhibits
protein synthesis and, thus, bacterial
growth by binding to 30S and possibly

50S ribosomal subunits of susceptible

bacteria.
Adult Dose

100 mg PO/IV q12h

Pediatric Dose

<8 years: Not recommended

>8 years: 2-5 mg/kg/d PO/IV qd or
divided bid; not to exceed 200 mg/d

Contraindications

Documented hypersensitivity; severe

hepatic dysfunction

Interactions

Bioavailability decreases with antacids

containing aluminum, calcium,
magnesium, iron, or bismuth
subsalicylate; tetracyclines can increase
hypoprothrombinemic effects of
anticoagulants; tetracyclines can
decrease effects of PO contraceptives,
causing breakthrough bleeding and
increased risk of pregnancy

Pregnancy

D - Unsafe in pregnancy

Precautions

Photosensitivity may occur with

prolonged exposure to sunlight or
tanning facilities; reduce dose in renal
impairment; consider drug serum level
determinations in prolonged therapy;
tetracycline use during tooth
development (<8 y) can cause
permanent discoloration of teeth;
Fanconilike syndrome may occur with
outdated tetracyclines

Drug Name

Clindamycin (Cleocin) -- Lincosamide for

treatment of serious skin and soft tissue
staphylococcal infections. Also effective
against aerobic and anaerobic
streptococci (except enterococci). Inhibits
bacterial growth, possibly by blocking
dissociation of peptidyl tRNA from
ribosomes, causing RNA-dependent
protein synthesis to arrest.

Adult Dose

900 mg IV q8h; if administered with

ofloxacin, 450 mg PO qid for 14 d

Pediatric Dose

8-20 mg/kg/d PO as hydrochloride and 825 mg/kg/d as palmitate tid/qid

20-40 mg/kg/d IV/IM tid/qid

Documented hypersensitivity; regional

Contraindications enteritis; ulcerative colitis; hepatic
impairment; antibiotic-associated colitis

Interactions

Increases duration of neuromuscular

blockade induced by tubocurarine and
pancuronium; erythromycin may
antagonize effects; antidiarrheals may
delay absorption

Pregnancy

B - Usually safe but benefits must

outweigh the risks.

Precautions

Adjust dose in severe hepatic

dysfunction; no adjustment necessary in
renal insufficiency; associated with
severe and possibly fatal colitis by
allowing overgrowth of Clostridium
difficile

Drug Name

Metronidazole (Flagyl) -- Imidazole ring

based antibiotic active against various
anaerobic bacteria and protozoa. Used in
combination with other antimicrobial
agents (except for C difficile
enterocolitis).

Adult Dose

Loading: 15 mg/kg, or 1 g for 70-kg adult,

IV over 1 h
Maintenance: 6 h following loading dose,
infuse 7.5 mg/kg IV, or 500 mg for 70-kg
adult, IV over 1 h, q6-8h; not to exceed 4
g/d
If administered with ofloxacin PO: 500
mg PO bid for 14 d

Pediatric Dose

Administer as in adults

Contraindications Documented hypersensitivity

Interactions

May increase toxicity of anticoagulants,

lithium, and phenytoin; cimetidine may
increase toxicity; disulfiramlike reaction
may occur with PO ethanol

Pregnancy

B - Usually safe but benefits must

outweigh the risks.

Precautions

Adjust dose in hepatic disease; monitor

for seizures and development of
peripheral neuropathy

Drug Name

Meropenem (Merrem) -- Bactericidal

broad-spectrum carbapenem antibiotic

that inhibits cell wall synthesis. Effective
against most gram-positive and gramnegative bacteria.
Adult Dose
Pediatric Dose

1 g IV q8h
40 mg/kg IV q8h

Contraindications Documented hypersensitivity

Interactions

Probenecid may inhibit renal excretion of

meropenem, increasing meropenem
levels

Pregnancy

B - Usually safe but benefits must

outweigh the risks.

Precautions

Pseudomembranous colitis and

thrombocytopenia may occur, requiring
immediate discontinuation of medication

Drug Name

Ceftriaxone (Rocephin) -- Thirdgeneration cephalosporin with broadspectrum gram-negative activity. Lower

efficacy against gram-positive organisms
and higher efficacy against resistant
organisms. Arrests bacterial growth by
binding to 1 or more penicillin-binding
proteins.

Adult Dose

250 mg IM once

Pediatric Dose

50-75 mg/kg/d IV/IM q12h; not to exceed

2 g/d

Contraindications Documented hypersensitivity

Interactions

Probenecid may increase levels;

coadministration with ethacrynic acid,
furosemide, or aminoglycosides may
increase nephrotoxicity

Pregnancy

B - Usually safe but benefits must

outweigh the risks.

Precautions

Adjust dose in renal impairment; caution

in breastfeeding women and in people
with allergy to penicillin

Drug Name

Ofloxacin (Floxin) -- Penetrates prostate

well and is effective against N
gonorrhoeae and C trachomatis.
A pyridine carboxylic acid derivative with
broad-spectrum bactericidal effect.

Adult Dose
Pediatric Dose

400 mg PO q12h for 14 d

<18 years: Not recommended
>18 years: Administer as in adults

Contraindications Documented hypersensitivity

Interactions

Antacids, iron salts, and zinc salts may

reduce serum levels; administer antacids
2-4 h before or after taking
fluoroquinolones; cimetidine may
interfere with metabolism of
fluoroquinolones; ciprofloxacin reduces
therapeutic effects of phenytoin;
probenecid may increase ciprofloxacin
serum concentrations; may increase
toxicity of theophylline, caffeine,
cyclosporine, and digoxin (monitor
digoxin levels); may increase effects of
anticoagulants (monitor PT)

Pregnancy

C - Safety for use during pregnancy has

not been established.

Precautions

In prolonged therapy, perform periodic

evaluations of organ system functions
(eg, renal, hepatic, hematopoietic); adjust
dose in renal impairment; superinfections
may occur with prolonged or repeated
antibiotic therapy

Drug Name

Gentamicin (Gentacidin, Garamycin) -Aminoglycoside antibiotic for gramnegative coverage. Used in combination
with an agent against gram-positive
organisms and one that covers
anaerobes. Dosing regimens are
numerous. Adjust dose based on CrCl
and changes in volume of distribution.
Follow each regimen by at least a trough
level drawn on the third or fourth dose
(0.5 h before dosing); may draw a peak
level 0.5 h after 30-min infusion.

Adult Dose

Loading: 2 mg/kg IV/IM

Maintenance: 1.5 mg/kg IV/IM q8h

Pediatric Dose

<5 years: 2.5 mg/kg per dose IV/IM q8h

>5 years: 1.5-2.5 mg/kg per dose IV/IM
q8h or 6-7.5 mg/kg/d divided q8h; not to
exceed 300 mg/d

Contraindications

Documented hypersensitivity; non

dialysis-dependent renal insufficiency

Interactions

Coadministration with other

aminoglycosides, cephalosporins,
penicillins, and amphotericin B may
increase nephrotoxicity; aminoglycosides
enhance effects of neuromuscular
blocking agents; thus, prolonged
respiratory depression may occur;
coadministration with loop diuretics may
increase auditory toxicity; irreversible
hearing loss of varying degrees may
occur (monitor regularly)

Pregnancy

C - Safety for use during pregnancy has

not been established.

Precautions

Narrow therapeutic index (not intended

for long-term therapy); caution in renal
failure (not on dialysis), myasthenia
gravis, hypocalcemia, and conditions that
depress neuromuscular transmission;
adjust dose in renal impairment

Drug Category: Uricosuric agents -- Reduce clearance of some types of

antibiotics, increasing their plasma levels.

Drug Name

Probenecid -- Inhibits tubular secretion of

penicillin and usually increases penicillin
plasma levels by any route the antibiotic
is administered. Adjuvant to therapy with
penicillin, ampicillin, methicillin, oxacillin,
cloxacillin, or nafcillin. Two- to 4-fold
elevation of penicillin plasma levels
demonstrated.

Adult Dose

1 g PO once

Pediatric Dose

<2 years: Not recommended

>2 years: Not established

Documented hypersensitivity; blood

Contraindications dyscrasia; uric acid kidney stones;
coadministration of ketorolac
Interactions

Salicylates at high dosages and

nitrofurantoin may decrease effects;
increases levels/toxicity of methotrexate,
beta-lactam antibiotics, acyclovir,

thiopental, clofibrate, dyphylline,

pantothenic acid, ketorolac,
benzodiazepines, rifampin, sulfonamide,
dapsone, zidovudine, and sulfonylureas
Pregnancy
Precautions

B - Usually safe but benefits must

outweigh the risks.
Crosses placental barrier; caution in
history of peptic ulcer

FOLLOW-UP

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Further Inpatient Care:

Most patients clinically respond within 48-72 hours after medical therapy. If
the patient continues to have fever, chills, uterine tenderness, adnexal
tenderness, and cervical motion tenderness, consider other possible
causes.

Further Outpatient Care:

Perform a follow-up examination 48-72 hours after prescribing outpatient

therapy to ensure clinical improvement. If the patient continues to have
fevers, chills, uterine tenderness, adnexal tenderness, and cervical motion
tenderness, consider hospitalization.

Male sex partners of women with PID should be examined and treated if
they have had sexual contact with the patient during the 60 days
preceding the onset of symptoms in the patient.

In/Out Patient Meds:

See Medical Care.

Deterrence/Prevention:

Randomized controlled trials suggest that preventing chlamydial infection

reduces the incidence of PID. Other methods of preventing PID and STD
include reducing the number of sexual partners, avoiding unsafe sexual
practices, and using condoms with spermicide. Use of mechanical barriers
with spermicide also decreases the risk of acquiring STDs.

Notification of the female sex partners of men infected with C trachomatis

is recommended.

Complications:

Tubo-ovarian abscess is one of the major complications of acute PID, and

it occurs in up to 15-30% of women requiring hospitalization for treatment
of PID.

Prognosis:

Therapy using antibiotics alone is successful in 33-75% of cases. If

surgical therapy is warranted, the current trend in therapy is conservation
of reproductive potential with simple drainage, adhesiolysis, and copious
irrigation or unilateral adnexectomy, if possible. Further surgical therapy is
needed in 15-20% of cases so managed.

Chronic pelvic pain occurs in approximately 25% of patients with a history

of PID. This pain is thought to be related to cyclic menstrual changes, but
it also may be the result of adhesions or hydrosalpinx.

Impaired fertility is a major concern in women with a history of PID. The

rate of infertility increases with the number of episodes of infection.

The risk of ectopic pregnancy is increased in women with a history of PID.

Ectopic pregnancy is a direct result of damage to the fallopian tube.

Patient Education:

Asking women about high-risk sexual behavior is important.

Encourage screening tests for those at risk.

Ensure that male sex partners are evaluated and treated.

Counsel women about safe sex practices.

For excellent patient education resources, visit eMedicine's Women's

Health Center, Sexually Transmitted Diseases Center, and Pregnancy and
Reproduction Center. Also, see eMedicine's patient education articles
Pelvic Inflammatory Disease, Ectopic Pregnancy, Birth Control Overview,
Birth Control FAQs, and Female Sexual Problems.

MISCELLANEOUS

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Medical/Legal Pitfalls:

A frequent cause of litigation is failure to diagnose. The physician should

always clearly document the patient's symptoms, as well as the physical
examination and results of laboratory and radiological studies.
Documenting the diagnosis, treatment plan, and disposition of the case is
equally important. If the patient is referred to other services for
consultation, a copy of the consulting physician's note should be attached
to the medical record.

Special Concerns:

Women with HIV infection who have PID have similar symptoms when
compared to women who do not have HIV. However, women with HIV
infection are more likely to have tubo-ovarian abscess.

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