Pelvic Inflammatory Disease: Diagnosis and Treatment in Urgent Care (Infectious Disease CME and Pharmacology CME)

Table of Contents

 

About This Issue

Most cases of mild to moderately severe PID can be managed in the urgent care setting, but prompt empiric treatment is essential to prevent life-threatening and fertility-related complications associated with PID. Recent research and evolving pathogens have led to updated guidelines for the management of pelvic inflammatory disease (PID). In this issue, you will learn:

The pathogens that are primarily responsible for PID

The CDC clinical criteria for diagnosing PID

The laboratory tests for PID that are available in urgent care

The up-to-date recommendations for drug therapy

Recommendations for partner treatment

The importance of timely follow-up care

The indications for ED referral

CHARTING & CODING: Learn how to select the appropriate level of service for the management of pelvic inflammatory disease.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Etiology and Pathophysiology
   1. Pelvic Inflammatory Disease Pathogens
6. Differential Diagnosis
7. Urgent Care Evaluation
   1. History
   2. Physical Examination
   3. Pelvic Examination
8. Diagnostic Studies
   1. Laboratory Testing
   2. Imaging
9. Treatment
   1. Mild to Moderately Severe Pelvic Inflammatory Disease
   2. Patients With Antibiotic Allergies
   3. Severe Pelvic Inflammatory Disease
   4. Observation and Admission for Inpatient Therapy
   5. Discharge Instructions and Follow-Up
10. Treatment of Special Populations
    1. Pregnant Patients
    2. Transgender Male Patients
    3. Patients With HIV
    4. Patients With an Intrauterine Device
    5. Partner Treatment
11. Quality Improvement
12. Controversies and Cutting Edge
    1. Mycoplasma genitalium
    2. Addition of Metronidazole to the Standard Treatment Regimen
    3. Drug-Resistant Organisms
    4. Patients With Suspected Treatment Failure
    5. Point-of-Care Testing in Low-Resource Settings
13. Disposition and Transition of Care
14. Summary
15. Time- and Cost-Effective Strategies
16. KidBits: Special Considerations in Pediatric Patients
    1. Pelvic Inflammatory Disease in Adolescents
17. 4 Things That Will Change Your Practice
18. Risk Management Pitfalls for Management of Pelvic Inflammatory Disease
19. Critical Appraisal of the Literature
20. Case Conclusions
21. Coding & Charting: What You Need to Know
    1. Number and Complexity of Problems Addressed
    2. Amount and/or Complexity of Data to be Reviewed and Analyzed
    3. Risk of Complications and/or Morbidity or Mortality of Patient Management
22. Clinical Pathway for Treatment of Pelvic Inflammatory Disease
23. References
24. Acknowledgments

Abstract

Pelvic inflammatory disease is associated with complications that include infertility, chronic pelvic pain, ruptured tubo-ovarian abscess, and ectopic pregnancy. When only nonspecific signs and symptoms are present at clinical evaluation, the diagnosis may be delayed. Even when properly diagnosed, pelvic inflammatory disease is often treated in a suboptimal manner. This review provides evidence-based recommendations for the diagnosis, treatment, disposition, and follow-up of patients with pelvic inflammatory disease. Emerging issues, including new pathogens and evolving resistance patterns among long-established pathogens, are also reviewed.

Case Presentations

A 30-year-old woman presents with lower abdominal pain...

• The patient denies any other gastrointestinal or urinary complaints and has no complaints of flank pain; she has normal vital signs. You note mild left adnexal tenderness without cervical motion tenderness or adnexal masses. There is no abnormal vaginal discharge.
• Her urine pregnancy test is negative, urinalysis is positive for small leukocyte esterase but is nitrite-negative, and a wet mount is without clue cells, yeast, or Trichomonas vaginalis.
• The patient asks, “Why do you think I am having this pain?” and 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 was sent for an outpatient pelvic ultrasound after the initial visit; it showed no evidence of PID complications. Aftercare instructions were to return to the ED or urgent care in 48 to 72 hours for a recheck because she does not have access to primary care. She did not return until a week after the initial visit 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…

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Clinical Pathway for Treatment of Pelvic Inflammatory Disease

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

11. * Workowski KA, Bachman LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-180. (CDC guidelines) DOI: 10.15585/mmwr.rr7004a1

25. * Wiesenfeld HC, Meyn LA, Darville T, et al. A randomized controlled trial of ceftriaxone and doxycycline, with or without metronidazole, for the treatment of acute pelvic inflammatory disease. Clin Infect Dis. 2021;72(7):1181-1189. (Randomized double-blind placebo-controlled trial; 233 patients) DOI: 10.1093/cid/ciaa101

66. * Simms I, Warburton F, Weström L. Diagnosis of pelvic inflammatory disease: time for a rethink. Sex Transm Infect. 2003;79(6):491-494. (Retrospective; 623 patients) DOI: 10.1136/sti.79.6.491

90. * Tomas ME, Getman D, Donskey CJ, et al. Overdiagnosis of urinary tract infection and underdiagnosis of sexually transmitted infection in adult women presenting to an emergency department. J Clin Microbiol. 2015;53(8):2686-2692. (Prospective; 264 patients) DOI: 10.1128/JCM.00670-15

92. * Lee MH, Moon MH, Sung CK, et al. CT findings of acute pelvic inflammatory disease. Abdom Imaging. 2014;39(6):1350-1355. (Prospective; 231 patients) DOI: 10.1007/s00261-014-0158-1

96. Ross J, Cole M, Evans C, et al. United Kingdom national guideline for the management of pelvic inflammatory disease (2019 interim update).2019. (Guideline)

117. *Goyal M, Hersh A, Luan X, et al. National trends in pelvic inflammatory disease among adolescents in the emergency department. J Adolesc Health. 2013;53(2):249-252. (Retrospective NAHMCS database study) DOI: 10.1016/j.jadohealth.2013.03.016

135. *Marrazzo J. Molecular characterization of microbes in the female upper genital tract: a valiant quest to “redefine” pelvic inflammatory disease. J Infect Dis. 2021;224(12 Suppl 2):S36-S38. (Review) DOI: 10.1093/infdis/jiab301

136. *Mitchell C. To effectively treat pelvic inflammatory disease, look beyond coverage for gonorrhea and chlamydia. Clin Infect Dis. 2021;72(7):1190-1191. (Review) DOI: 10.1093/cid/ciaa103

Acknowledgments

Portions of this content were adapted from:

Taira T, Broussard N, Bugg C. Pelvic inflammatory disease: diagnosis and treatment in the emergency department. Emerg Med Pract. 2022;24(12):1-24. Used with permission of EB Medicine.

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Keywords: pelvic, cervical, uterus, adnexa, STI, endometritis, salpingitis, tubo-ovarian abscess, Fitz-Hugh-Curtis, ectopic, infertility, gonorrhea, chlamydia