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

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Table of Contents
 
Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Etiology And Pathophysiology
  6. Differential Diagnosis
  7. Prehospital Care
  8. Emergency Department Evaluation
    1. History
    2. Physical Examination
  9. Diagnostic Studies
    1. Laboratory Testing
    2. Imaging
  10. Treatment
    1. Mild-To-Moderately Severe Pelvic Inflammatory Disease
    2. Antibiotic Allergies
    3. Severe Pelvic Inflammatory Disease
    4. Treatment Of Special Populations
      1. Pregnant Women
      2. Adolescents
      3. Patients With HIV
      4. Patients With An Intrauterine Device
      5. Partner Treatment
  11. Quality Improvement And Additional Considerations
  12. Controversies And Cutting Edge
    1. Mycoplasma genitalium
    2. Use Of Azithromycin In Place Of Doxycycline
    3. When To Add Metronidazole
    4. Drug-Resistant Organisms
    5. Patients With Suspected Treatment Failure
    6. Point-Of-Care Testing In Low-Resource Settings
  13. Disposition And Transition Of Care
  14. Summary
  15. Must-Do Markers Of Quality Care
  16. Risk Management Pitfalls In Pelvic Inflammatory Disease
  17. Time- And Cost-Effective Strategies
  18. Case Conclusions
  19. Clinical Pathway For Antimicrobial Treatment For Pelvic Inflammatory Disease
  20. Clinical Pathway For Determining Need For Admission For Treatment Of Pelvic Inflammatory Disease
  21. Tables And Figures
    1. Table 1. Pathogens Associated With Pelvic Inflammatory Disease
    2. Table 2. Differential Diagnosis Of A Patient With Potential Pelvic Inflammatory Disease
    3. Table 3. Diagnostic Studies For Pelvic Inflammatory Disease
    4. Table 4. Ultrasound Findings In Pelvic Inflammatory Disease
    5. Table 5. Computed Tomography Findings Pelvic Inflammatory Disease
    6. Table 6. Recommended Intramuscular Oral Therapies For Mild-To-Moderately Severe Pelvic Inflammatory Disease
    7. Table 7. Recommended Alternative Therapies For Mild-To-Moderately Severe Pelvic Inflammatory Disease
    8. Table 8. Recommended Parenteral Therapy For Pelvic Inflammatory Disease
    9. Table 9. Alternative Parenteral Therapy For pelvic Inflammatory Disease
    10. Table 10. Criteria For Consideration For Hospital Admission
    11. Figure 1. Thickened Tubal Walls
    12. Figure 2. The Cogwheel Sign
  22. References

Abstract

Pelvic inflammatory disease is a common disease that is associated with significant complications including 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 it is properly identified, 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

You arrive for your shift in the ED. The final patient you are signed out is a 30-year-old woman with lower abdominal pain whose ultrasound results are pending to rule out torsion versus ovarian cyst. You nod dutifully and go about seeing new patients. An hour into the shift, the clerk hands you the ultrasound results with the radiologist’s impression: “No radiological etiology of patient’s abdominal pain is found.” You review the chart and confirm that there is no concern for any nongynecological etiologies for her pain. The previous physician documented mild left adnexal tenderness without cervical motion tenderness or adnexal masses. Labs are notable for a urinalysis that is small leukocyte esterase positive and nitrite negative, and a wet mount without clue cells, yeast, or Trichomonas vaginalis. You confirm the documented history with the patient, who additionally denies any urinary complaints or flank pain. On your physical examination, you note only mild left lower abdominal tenderness. 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. She does not have access to primary care and was instructed to return to the ED for repeat evaluation. She was supposed to return to the ED after 2 days, but could not because of work. 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 only mild left adnexal tenderness without a palpable mass. She states that she has been fully compliant with the doxycycline and has not had intercourse since her diagnosis. Her previous records show a negative pelvic ultrasound, urinalysis, urine culture, and 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…

Introduction

Pelvic inflammatory disease (PID) is an inflammatory disease of the upper female reproductive system that is caused by an ascending infection. It is characterized by inflammation and tenderness of the uterus, cervix, and adnexa. PID is common and costly, with a yearly incidence of 750,000 to 800,000 cases and $2 billion in annual direct costs in the United States.1,2 The majority of patients with PID present with mild-to-moderately severe disease and are managed as outpatients.Only a small percentage of patients progress to severe or complicated illness.Although the rate of direct morbidity and mortality is low, treatment prevents subsequent infertility, pelvic scarring, chronic pelvic pain, and ectopic pregnancy.5

PID can be a difficult and frustrating diagnosis; patients commonly present with nonspecific symptoms such as vaginal discharge, postcoital bleeding, dyspareunia, and dysuria.There is no single historical, laboratory, physical examination finding, or imaging modality that provides adequate sensitivity or specificity for the diagnosis.7-10

The United States Centers for Disease Control and Prevention (CDC) recommend that clinicians make the clinical diagnosis of PID and start empiric treatment in sexually active women with unexplained lower abdominal or pelvic pain with:

  • Cervical motion tenderness, or
  • Uterine tenderness, or
  • Adnexal tenderness.

There are no requirements for any specific laboratory findings, physiological parameters, or imaging.11 While this definition may seem overly broad, it has a sensitivity of > 95% and a specificity of 75% and reflects the need to minimize the rates of misdiagnosis and prevent the resulting impact on fertility.This issue of Emergency Medicine Practice presents a review of the current evidence and best-practice guidelines of the evaluation and treatment of PID.

Critical Appraisal Of The Literature

A literature search was performed using PubMed, with the search terms pelvic inflammatory disease, endometritis, salpingitis, oophoritis, and tubo-ovarian abscess. The search included clinical trials, systematic reviews, review articles, and clinical guidelines. A review of the Cochrane Database of Systematic Reviews revealed no relevant reviews. The National Guideline Clearinghouse (www.guideline.gov) noted 3 guidelines:

  • CDC: Sexually Transmitted Diseases Treatment Guidelines 201511
  • British Association for Sexual Health and HIV: United Kingdom National Guideline for the Management of Pelvic Inflammatory Disease 201112
  • American College of Radiology (ACR): ACR Appropriateness Criteria® Acute Pelvic Pain in the Reproductive Age Group13

References from articles were examined to ensure accurate representation of the literature. The recommendations for the first-line treatment, management, and diagnostic evaluation are based on multiple well-performed studies with large sample sizes that looked at both short- and long-term outcomes; however, the bulk of the remaining literature suffers from sampling bias toward sicker patients, which affects generalizability of findings, and focuses on shorter-term outcomes instead of the longer-term outcomes that comprise the bulk of the morbidity associated with PID. These biases make it difficult to make high-level recommendations regarding alternative treatments and management.

Risk Management Pitfalls In Pelvic Inflammatory Disease

  1. “She had a negative CT and pelvic ultrasound, so I ruled out PID.”
    Emergency clinicians should not use negative imaging to exclude the diagnosis of PID. Even pelvic ultrasound lacks sufficient sensitivity to exclude the diagnosis. Patients at risk for PID who have lower abdominal pain that is not easily explained by another diagnosis should have empiric treatment for PID started.
     
  2. “Yes, she could have had PID, but she looked so well that I discharged her and deferred treatment to her primary care physician.”
    All patients who have the clinical diagnosis of PID should have empiric therapy started. Initial presentation does not predict progression of the disease and, therefore, should not be used to determine who should have treatment initiated.
     
  3.  “I gave a gram of azithromycin and a shot of ceftriaxone to treat her PID.”
    There is no single-dose treatment of PID, as standard treatment regimens last for 14 days. This particular regimen is used to treat cervicitis in the absence of signs and symptoms of PID. Failure to provide adequate duration of treatment places the patient at risk for undertreatment and the development of a resistant organism. If azithromycin is being used as the sole agent, use one of the accepted treatment regimens for PID
     
  4. “When she came back to the ED, I checked her records and saw that she had a negative N gonorrhoeae/C trachomatis test, so I stopped her medication and reassured her that she didn’t have PID.”
    A negative N gonorrhoeae/C trachomatis test cannot be used to rule out the possibility of PID. A cervical N gonorrhoeae/C trachomatis NAAT is a test of lower-tract disease and does not exclude the presence of an upper-tract infection. Additionally, the test does not test for anaerobes or M genitalium, both of which are implicated in PID. For these reasons, a negative N gonorrhoeae/C trachomatis NAAT cannot be used to rule out the possibility of PID.
     
  5.  “When I told her to see her doctor in 2 days, I assumed she would do it. If she didn’t have a doctor, she should have just come back to the ED.”
    Most patients with PID should have a clinical response within 48 to 72 hours. Many of the decision points are based on the response to treatment at this repeat visit, especially with regard to the need for imaging, changes in antibiotics, or need for parenteral therapy. Therefore, it is important that the patient has access to and understands the importance of the follow-up.
     
  6. “I told her that her PID was probably sexually transmitted and assumed she understood that she should avoid any further sexual interactions with her partner.”
    Patients with a diagnosis of PID should abstain from intercourse until the resolution of therapy and until after the partners have completed empiric treatment. This recommendation is true regardless of the cause of the PID. While it may seem intuitive, it is important to speak to the patient directly about the importance of partner treatment to prevent re-infection.
     
  7. “She had white blood cells on the urine microscopy, so I treated her for a urinary tract infection even though she had no dysuria.”
    Patients with PID commonly have white blood cells on urine microscopy. Additionally, uterine tenderness can be mistaken for suprapubic tenderness due to cystitis. Patient risk factors must always be considered, and the presence or absence of dysuria is not diagnostically specific to differentiate PID from a urinary tract infection.
     
  8. “She came back with continued pain, so I refilled her pain medications.”
    When a patient fails to show adequate response to treatment, you must first consider the need for parenteral treatment, development of a complication, and infection with a resistant organism. Consider additional testing with a cervical culture, which would allow for the identification of a resistant organism. Additionally, strongly consider increased coverage of anaerobic organisms.
     
  9. “Her CBC, chemistries, and all of her imaging were normal. If it was anything consequential, we would have picked it up on our workup, so PID can be ruled out.”
    There are no laboratory tests or imaging modalities that have adequate sensitivity to exclude the diagnosis of PID. Laboratory tests and imaging are typically only abnormal with sicker patients. Overreliance on laboratory testing and imaging will lead to missed diagnoses.
     
  10. “She had clue cells and white blood cells on her wet mount, so I treated her for bacterial vaginosis.”
    The presence of bacterial vaginosis does not exclude the diagnosis of PID. Bacterial vaginosis can be associated with PID. In some cases, it may be due to direct ascension of anaerobic bacteria, while in other cases it may be secondary to the loss of mucosal immunity secondary to the bacterial overgrowth.

Tables and Figures

Table 1. Pathogens Associated With Pelvic Inflammatory Disease

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available.

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Authors

Charles Walter Bugg, MD, PhD;Taku Taira, MD

Publication Date

December 1, 2016

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