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…
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.3 Only a small percentage of patients progress to severe or complicated illness.4 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.6 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:
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.8 This issue of Emergency Medicine Practice presents a review of the current evidence and best-practice guidelines of the evaluation and treatment of PID.
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:
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.
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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Charles Walter Bugg, MD, PhD;Taku Taira, MD
December 1, 2016
January 1, 2020
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 2 Pharmacology CME credits
Date of Original Release: December 1, 2016. Date of most recent review: November 10, 2016. Termination date: December 1, 2019.
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AAFP Accreditation: This Medical Journal activity, Emergency Medicine Practice, has been reviewed and is acceptable for up to 48 Prescribed credits by the American Academy of Family Physicians per year. AAFP accreditation begins July 1, 2016. Term of approval is for one year from this date. Each issue is approved for 4 Prescribed credits. Credit may be claimed for one year from the date of each issue. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 2 Pharmacology CME credits, subject to your state and institutional approval.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
Discussion of Investigational Information: As part of the journal, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration–approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
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