PID and Tubo-ovarian abscess

Question 1

What is PID?

Answer 1

PID is an acute clinical syndrome that frequently originates as a cervical infection with Neisseria gonorrhea and/or Chlamydia trachomatis, and becomes polymicrobial as it ascends into the uterus, fallopian tubes and ovaries.

Question 2

Common presentation of PID

Answer 2

Women typically present with bilateral lower abdominal pain, purulent vaginal discharge, or less frequently with abnormal vaginal bleeding. Symptoms begin shortly after the start of the menstrual cycle, when there are fewer defenses by the cervical mucosal barrier to ascending infections. Patients may also present with fever, nausea, vomiting and general malaise

Question 3

Risk factors for PID

Answer 3

Prior history of sexually transmitted diseases (STDs), multiple sexual partners, intrauterine device (IUD) contraception use, adolescence (75% of PID cases occur between the ages of 15-25), sexual intercourse at an early age, and recent instrumentation of the uterine cavity are all risk factors that warrant a heightened suspicion for PID.

Question 4

Physical exam findings

Answer 4

The most common physical exam findings are bilateral adnexal tenderness and purulent cervical discharge. Cervical motion, uterine, and lower abdominal tenderness may also be present. Unilateral adnexal tenderness or fullness may suggest the presence of a tuboovarian abscess, while right upper quadrant tenderness may suggest Fitz-Hugh-Curtis syndrome where the infection extends to cause a perihepatitis with inflammation of the liver capsule and ‘violin string’ scar tissue formation.

Question 5

PID diagnosis

Answer 5

In a patient with a negative pregnancy test and elevated WBC, in the setting of fever, bilateral adnexal tenderness, and a mucopurulent cervical discharge, the diagnosis of PID is certain

Question 6

Minimum criteria

Answer 6

This minimum criterion includes history of lower abdominal or pelvic pain coupled with adnexal, uterine or cervical motion tenderness on exam, in a patient at risk for STDs with no other discernible cause for the illness identified.
- Give prophylactic antibiotics in this scenario.

Question 7

Inpatient treatment of PID

Answer 7

Cefoxitin 2 grams IV q 6 hours with Doxycycline 100 mg PO or IV q 12 hours OR
Cefotetan 2 grams IV q 12 hours with Doxycycline 100 mg PO or IV q 12 hours.
If the patient is allergic to cephalosporins, they may be treated with Clindamycin 900 mg IV q 8 hours with Gentamycin.
Alternatively they may be treated with Unasyn 3 grams IV q 6 hours with Doxycycline 100 mg PO or IV q 12 hours. Doxycycline should always be given orally when possible, because it is caustic to vessels.

Question 8

Outpatient treatment of PID

Answer 8

Ceftriaxone 250 mg IM OR Cefoxitin 2 grams IM and Probenecid 1 gram PO. Doxycycline 100 mg BID for 14 days must also be prescribed. The addition of Metronidazole 500 mg BID for 14 days should be considered in women with more severe infection or history of uterine instrumentation within the preceding 3 weeks.