Pelvic Inflammatory Disease Mgmt in Adults/Adolescents: 2015 CDC STD Guidelines | Epocrates Guideline Synopsis

Guideline
Pelvic Inflammatory Disease Mgmt in Adults/Adolescents: 2015 CDC STD Guidelines | Epocrates Guideline Synopsis
Key Points
Wide variation in s/sx makes PID difficult to diagnose; many episodes go unrecognized; can damage reproductive health. Maintain low threshold for dx; multiple etiologies possible, incl GC/CT; also test for HIV; abx tx is empiric, broad spectrum.
Choose Patient Type
  • Suspected PID
    Maintain low threshold for dx of PID;1 test all pts for STDs,2,3 incl GC and CT (via urine NAAT) and HIV
    Initiate presumptive PID tx in sexually active young women and other women at risk for STD who have pelvic or lower abd pain4 if no cause for sx other than PID can be identified, and if ≥1 of the following minimum criteria present on pelvic exam:5,6
    • cervical motion tenderness
    • uterine tenderness
    • adnexal tenderness
    Footnotes
    1 Wide variation in s/sx makes dx difficult; dx usually based on imprecise clinical findings. PID comprises spectrum of inflammatory disorders of upper genital tract, incl any combo of endometritis, salpingitis, tubo-ovarian abscess, pelvic peritonitis. Many women are asymptomatic or have nonspecific sx (eg, abnl bleeding, dyspareunia, vag discharge), and many episodes go unrecognized; delay in dx and tx probably contributes to upper reproductive tract sequelae, incl infertility—even in mild or asymptomatic PID; laparoscopy can more accurately diagnose salpingitis and provide a more complete bacteriologic dx, but is difficult to justify when sx are mild/vague; laparoscopy will not diagnose endometritis or subtle inflammation of fallopian tubes; specificity of clinical dx depends on epidemiology of population—increased w/ sexually active young women (esp adolescents), STD-clinic pts, those living in areas w/ high rates of GC, CT; no single finding on hx, PE, or lab is both sensitive/specific for dx.

    2 Sexually transmitted organisms are implicated in many cases, although <50% of women w/ PID test positive for GC, CT; vaginal flora assoc w/ PID (anaerobes, G vaginalis, H influenza, enteric gram-neg rods, S agalactiae), also possibly CMV, M hominisU urealyticum, and M genitalium; new data suggest that M genitalium may be assoc w/ milder sx, although its role in PID is unclear.

    3 Screening and treating sexually active women for CT reduces risk of PID; BV assoc w/ PID, but role of screening and tx to prevent PID unclear; value of testing women w/ PID for M genitalium unknown; no FDA-approved test is commercially available in U.S.

    4 Dx and tx of other causes of lower abd pain (eg, ectopic pregnancy, acute appendicitis, ovarian cyst, functional pain) unlikely to be impaired by initiating abx for PID.

    5 Requirement for all 3 could result in insufficient sensitivity for PID dx—more elaborate diagnostic eval often needed; in addition to minimal clinical criteria, ≥1 of the following can enhance specificity of PID dx:
    • oral temp >101° F (>38.3° C)
    • abnl cervical mucopurulent discharge or cervical friability
    • abundant WBC on saline microscopy of vaginal fluid
    • elevated ESR, CRP
    • lab documentation of cervical infxn w/ NG, CT
    Most women w/ PID have mucopurulent cervical discharge or WBC on saline wet prep of vaginal fluid—if cervical discharge appears normal and no WBC on vaginal-fluid wet prep, then PID dx unlikely. Vaginal-fluid wet prep can also detect other infxns (eg, BV, trichomonas).

    6 The most specific criteria for dx of PID include:
    • endometrial bx w/ histopathologic evidence of endometritis; or
    • transvaginal sonography or MRI showing thickened, fluid-filled tubes w/ or w/o free pelvic fluid or tubo-ovarian complex, or Doppler studies suggesting pelvic infxn (eg, tubal hyperemia); or
    • laparoscopic findings consistent w/ PID
    Diagnostic eval w/ some of these more extensive procedures might be warranted in some cases. Endometrial bx is warranted in women undergoing laparoscopy who do not have visual evidence of salpingitis, since endometritis is the only sign of PID in some women.

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