Pelvic organ tenderness, either uterine tenderness alone or uterine tenderness with adnexal tenderness, is present in patients with PID. Cervical motion tenderness suggests the presence of peritoneal inﬂammation, which causes pain when the peritoneum is stretched by moving the cervix and causing traction of the adnexa on the pelvic peritoneum. Direct or rebound abdominal tenderness may be present.
Evaluation of both vaginal and endocervical secretions is a crucial part of the workup of a patient with PID (38). In women with PID, an increased number of polymorphonuclear leukocytes may be detected in a wet mount of the vaginal secretions or in the mucopurulent discharge.
More elaborate tests may be used in women with severe symptoms because an incorrect diagnosis may cause unnecessary morbidity (39) (Table 18.4). These tests include endometrial biopsy to confirm the presence of endometritis, ultrasound or radiologic tests to characterize a tubo-ovarian abscess, and laparoscopy to confirm salpingitis visually.
Treatment Therapy regimens for PID must provide empirical, broad-spectrum coverage of likely pathogens, including N. gonorrhoeae, C. trachomatis, M. genitalium, gram-negative
Table 18.4 Clinical Criteria for the Diagnosis of Pelvic Inﬂammatory Disease
Additional criteria to increase the specificity of the diagnosis
Endometrial biopsy showing endometritis Elevated C-reactive protein or erythrocyte sedimentation rate Temperature higher than 38◦C (100.4◦F) Leukocytosis Positive test for gonorrhea or chlamydia
Table 18.5 Guidelines for Treatment of Pelvic Inﬂammatory Disease
Cefoxitin, 2 g intramuscularly, plus probenecid, 1 g orally concurrently, or
Ceftriaxone, 250 mg intramuscularly, or
Plus:
Doxycycline, 100 mg orally 2 times daily for 14 days, or
Azithromycin, 500 mg initially and then 250 mg daily for a total of 7 days
Cefoxitin, 2 g intravenously every 6 hours, or
Cefotetan, 2 g intravenously every 12 hours
Plus:
Doxycycline, 100 mg orally or intravenously every 12 hours
Clindamycin, 900 mg intravenously every 8 hours
Plus:
Ceftriaxone, 1–2 g intravenously every 12 hours, or Gentamicin, loading dose intravenously or intramuscularly (2 mg/kg of body weight) followed by a maintenance dose (1.5 mg/kg) every 8 hours aOutpatient treatment only, i.e., women treated for PID as an outpatient should also receive metronidazole gel for BV if they have BV. Adapted from Soper DE. Pelvic inﬂammatory disease. Obstet Gynecol 2010;116:419–428.