> [!summary] > - PID is infection/inflammation of upper genital tract > - clinical features: purulent discharge is sensitive marker for PID > - *chlamydia trachomatis* is the most common pathogen STI; others include *neisseria gonorrhoeae*, mixed anaerobes, and trichomonas > - **complications**: [[Ectopic pregnancy]], infertility, and [[Pelvic pain (female)| chronic pelvic pain]] > - **workup**: need to exclude ectopic pregnancy, ruptured oarian cyst, appendicitis, UTI; everyone should have a full sexual health workup (hep B, syphilis, HIV, partner contact tracing) # complications - salpingitis - oophoritis - peritonitis - peri-hepatitis (fitz-hugh-curtis syndrome) - tubo-ovarian abscess - [[Ectopic pregnancy]] - chronic pelvic pain - infertility ## Fitz-Hugh-Curtis syndrome - rare complication of PID involving liver capsule inflammation leading to adhesions - presents with right upper quadrant pain - may have referred pain to right shoulder - also right upper abdo tenderness, fevers, pelvic pain, dyspareunia, vaginal discharge, dysuria - may make you think its cholecystitis, appendicitis, hepatitis, pyelo, renal colic, others - LFTs normal or slightly elevated - gold standard is laparoscopy showing "violin string adhesions" along liver capsule with scaring and inflammation # risk factors - sexually active especially <25 years old - multiple partners - history of STI or recent procedure - **IUD increases risk of PID in first 3 weeks following insertion** - increase risk of PID during and shortly after menses > the presence of Gonorrhea, herpes, Candida, chlamydia, or trichomonas in prepubertal children is highly suggestive of sexual abuse # presentation - no specific symptom or sign is pathognomonic - pelvic pain in 60-90% - may radiate to posterior pelvis and low back - unilateral pain more suggestive of an ectopic pregnancy than salpingitis - vaginal discharge in 50-75% - irregular bleeding in >30% - systemic symptoms (fever, nausea, vomiting) - physical examination has poor sensitivity and specificity -- history more useful - lower abdo tenderness - uterine and *bilateral* adnexal tenderness - cervical motion tenderness > PID is *rare* in pregnancy, especially after 12 weeks b/c endometrial cavity btwn cervix and fallopian tubes is obliterated by fusion of the chorion w/ the decidua ![[Pasted image 20240725193246.png|Rosen's STIs]] "a - In a sexually active woman at risk for sexually transmitted infections (STIs) who presents with abdominal pain and no alternative diagnosis is identified, a presumptive diagnosis of [pelvic inflammatory disease](x-devonthink-item://0B8792DB-8E15-4804-8933-24358A65AAF4?page=9) (PID) may be based upon the criteria listed in this table. b - Additional criteria increase specificity but decrease sensitivity for the diagnosis of PID." # investigation - urinalysis for STI - higher sensitivity for chlamydia (95% vs 80%) than swabs - lower sensitivity (92% vs 97%) for gonorrhoea than swabs - vaginal and cervical swabs for m/c/s - self-collected swabs are 95% sensitive compared to health care worker swabs - HCG - USS if abscess suspected # Management outpatient if mild to moderate PID; inpatient if sever, cannot tolerate orals, failed oral therapy, pregnancy where surgical emergency cannot be excluded - IUD removal not required unless: - severe infection - no clinical improvement within 48-72 hours of appropriate treatment ## mild to moderate PID - *ceftriaxone* 500mg IM or IV as single dose - metronidazole 400mg PO Q12H for 14 days - Plus either: - doxycycline 100mg PO Q12 H for 14 days - OR azithromycin 1g PO as single dose + 1g 1 week later if cannot tolerate doxy or are pregnant ## severe PID - ceftriaxone 2g IV od or cefotaxime 2g IV Q8H - azithromycin 500mg IV (or PO) daily - metronidazole 500mg IV Q12H *penicillin allergy* - gentamicin & clindamycin ## non-sexually acquired PID - mild to moderate: augmentin 875/125BD 14 days + doxycycline 100mg PO Q12H for 14 days # Disposition review within 24-48 hours to assess response to therapy # mnemonic for gynancological causes: *THINRIM* Torsion Haemorrhage infection Necrosis Rupture Incarceration Malignancy # Related Questions ## pelvic inflammatory disease - [ ] 1Q: [Pelvic Inflammatory Disease](x-devonthink-item://84CE632D-3DD4-4F41-A900-23F41BE57287?page=16) -- [Answer](x-devonthink-item://D25C2F83-6C30-4F45-8B5B-6E7E57BD24A3?page=27) - [ ] 2Q: [Pelvic Inflammatory Disease](x-devonthink-item://2504F01B-CEAF-41E8-803B-B3AE1B07A49E?page=4) -- [Answer](x-devonthink-item://00427DF6-6D28-4FEB-A0CA-DF96DBBBCE97?page=23) - [ ] 3Q: [RLQ pain in 22y old Female](x-devonthink-item://B9F58929-18E6-4557-B393-263A6C98DFEF?page=10) -- [Answer](x-devonthink-item://DE4A2FC7-79D2-4B5D-805E-E481F1189654?page=9) ## pid - [x] DUPLICATE Q: [RLQ pain in 22y old Female](x-devonthink-item://B9F58929-18E6-4557-B393-263A6C98DFEF?page=10) -- [Answer](x-devonthink-item://DE4A2FC7-79D2-4B5D-805E-E481F1189654?page=9)