Pelvic Inflammatory Disease Guidelines

Updated: May 03, 2019
  • Author: Kristi A Tough DeSapri, MD; Chief Editor: Nicole W Karjane, MD  more...
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SPILF/CNGOF Pelvic Inflammatory Disease Guidelines

Diagnosis of Pelvic Inflammatory Disease

Positive diagnosis of pelvic inflammatory disease (PID) is based on adnexal pain or tenderness upon cervical motion, reinforced by associated signs, including fever, leukorrhea, and metrorrhagia. [97]

Pelvic clinical examination is recommended in women with PID-compatible symptoms.

Laboratory Studies

Hyperleukocytosis accompanied by a high C-reactive protein (CRP) level suggests complicated PID or an alternative diagnosis (eg, acute appendicitis). Suspected PID should prompt serum analysis, including complete blood count (CBC) and CRP testing.

Imaging Studies

Pelvic ultrasonography is too insensitive and unspecific for diagnosis of uncomplicated PID, although ultrasonography is recommended to evaluate for signs of complicated PID (eg, polymorphic collection) or an alternate diagnosis. Initiation of antibiotic therapy should not be delayed awaiting ultrasonography.

Abdominal-pelvic CT scanning with contrast is useful to exclude urinary, digestive, or gynecological differential diagnoses.

Laparoscopy is not recommended for PID diagnosis.

Microbiologic Diagnosis

Chlamydia trachomatis is the most common bacterial cause of PID, particularly in women younger than 30 years. [98]

In uncomplicated cases of PID, endocervical sampling during gynecological examination under speculum is recommended to obtain a microbiological diagnosis, as follows:

  • First swab: Direct examination via smear (Gram stain, May-Grünwald Giemsa [MGG] stain)
  • Second swab: Sent via adapted transport for culture ( Neisseria gonorrhoeae and facultative vaginal flora bacteria), with antibiotic susceptibility testing
  • Third swab: Sent by appropriate transport for analysis via nucleic acid amplification techniques (NAATs) (for N gonorrhoeae, C trachomatis, Mycoplasma genitalium).

PID diagnosis is supported by NAAT positive for N gonorrhoeae, C trachomatis, and/or M genitalium from a genital sample. Conversely, negative NAAT results do not exclude a sexually transmitted infection (STI) agent for PID diagnosis.

If speculum use is not possible, vaginal sampling is performed. C trachomatis serology is not useful as a first-line diagnostic test for PID or as a tool for monitoring PID.

Follow-up for Pelvic Inflammatory Disease

The PID recurrence rate is 15%-21%, of which 20%-34% cases are due to recurrent STI. [99]

Follow-up is recommended. Personalized text message reminders improve the likelihood of follow-up compliance.

NAAT of vaginal samples to evaluate for N gonorrhoeae, C trachomatis, and M genitalium should be performed 3-6 months after treatment of STI-associated PID to rule out reinfection. Condom use after STI-associated PID reduces the recurrence risk. Systematic oral contraceptives are not recommended after PID.

Prior to insertion of an intrauterine device, vaginal sampling for microbiological diagnosis is recommended.

Women with PID are at high risk of ectopic pregnancy.