Pelvic Inflammatory Disease: Diagnosis and Treatment in the Emergency Department (Infectious Disease CME credits Pharmacology CME)

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Delivery Method:	Online
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Publication Date: December 2022 (Volume 24, Number 12)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-A or 2-B CME credits. CME expires 12/01/2025.

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Infectious Disease CME credits and 2 Pharmacology CME credits, subject to your state and institutional approval.

Authors

Peer Reviewers

Abstract

Pelvic inflammatory disease is associated with complications that include infertility, chronic pelvic pain, ruptured tubo-ovarian abscess, and ectopic pregnancy. The diagnosis may be delayed when the presentation has nonspecific signs and symptoms. Even when properly diagnosed, pelvic inflammatory disease is often treated suboptimally. This review provides evidence-based recommendations for the diagnosis, treatment, disposition, and follow-up of patients with pelvic inflammatory disease. Arranging follow-up of patients within 48 to 72 hours and providing clear patient education are fundamental to ensuring good patient outcomes. Emerging issues, including new pathogens and evolving resistance patterns among pelvic inflammatory disease pathogens, are reviewed.

Case Presentations

A 30-year-old woman presents with abdominal pain…

• You note mild left adnexal tenderness without cervical motion tenderness or adnexal masses. Her laboratory test results are notable for a urinalysis that is positive for small leukocyte esterase and nitrite-negative, and a wet mount is without clue cells, yeast, or Trichomonas vaginalis. The patient denies any urinary complaints or flank pain.
• The patient’s ultrasound results contain the radiologist’s impression: “No radiological etiology of patient’s abdominal pain is found.” You review the chart and confirm there is no concern for any nongynecological etiologies for her pain.
• As the patient asks, “Why am I having this pain? Can I just go home?” you wonder if there is something else you should do…

A 22-year-old woman returns for re-evaluation 1 week after starting treatment for pelvic inflammatory disease…

• The patient was given 500 mg ceftriaxone IM in the ED followed by doxycycline 100 mg orally twice daily and metronidazole 500 mg twice daily. She does not have access to primary care and was instructed to return to the ED for repeat evaluation after 2 days, but she did not return because of a work conflict.
• She continues to complain of nonspecific left lower abdominal pain. She states that the pain may be a bit more intense, but it has not changed in quality, position, or associated features.
• On your physical examination, the patient has left lower quadrant abdominal tenderness without guarding or rebound. Bimanual examination reveals mild left adnexal tenderness without a palpable mass. She states that she has been fully compliant with the doxycycline and metronidazole. She has not had intercourse since her diagnosis. Her previous records show a reassuring pelvic ultrasound, urinalysis, urine culture, and a negative HIV test.
• You are surprised to find that her gonorrhea/chlamydia nucleic acid amplification test from a cervical specimen showed no evidence of infection. After being told about her negative gonorrhea and chlamydia tests, she asks if she can stop taking the antibiotics…

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.