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B Minimum Diagnostic Criteria
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Women with uterine adnexal or cervical motion tenderness should be considered to have PID and be treated with antibiotics unless there is a competing diagnosis such as ectopic pregnancy or appendicitis
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The following criteria may be used to enhance the specificity of the diagnosis: (1) oral temperature greater than 383 C, (2) abnormal cervical or vaginal discharge with white cells on saline microscopy, (3) elevated erythrocyte sedimentation rate, (4) elevated C-reactive protein, and (5) laboratory documentation of cervical infection with N gonorrhoeae or C trachomatis Endocervical culture should be performed routinely, but treatment should not be delayed while awaiting results
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Refer to urogynecologist or gynecologist for stress urinary incontinence or stage III prolapse Refer if nonsurgical therapy is ineffective
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Mouritsen L Classification and evaluation of prolapse Best Pract Res Clin Obstet Gynaecol 2005 Dec;19(6):895 911 [PMID: 16185930] Novara G et al Surgery for pelvic organ prolapse: current status and future perspectives Curr Opin Urol 2005 Jul;15(4):256 62 [PMID: 15928515]
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In selected cases where the diagnosis based on clinical or laboratory evidence is uncertain, the following criteria may be used: (1) histopathologic evidence of endometritis on endometrial biopsy, (2) TVS or MRI showing thickened fluid-filled tubes with or without free pelvic fluid or tuboovarian complex, and (3) laparoscopic abnormalities consistent with PID
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PELVIC INFLAMMATORY DISEASE (SALPINGITIS, ENDOMETRITIS)
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ESSENTIALS OF DIAGNOSIS
Uterine, adnexal, or cervical motion tenderness Absence of a competing diagnosis
Differential Diagnosis
Appendicitis, ectopic pregnancy, septic abortion, hemorrhagic or ruptured ovarian cysts or tumors, twisted ovarian cyst, degeneration of a myoma, and acute enteritis must be considered PID is more likely to occur when there is a history of PID, recent sexual contact, recent onset of menses, or an IUD in place or if the partner has a sexually
General Considerations
PID is a polymicrobial infection of the upper genital tract associated with the sexually transmitted organisms N gon-
CMDT 2008
is suspected, institute high-dose antibiotic therapy in the hospital, and monitor therapy with ultrasound In 70% of cases, antibiotics are effective; in 30%, there is inadequate response in 48 72 hours, and intervention is required Unilateral adnexectomy is acceptable for unilateral abscess Hysterectomy and bilateral salpingo-oophorectomy may be necessary for overwhelming infection or in cases of chronic disease with intractable pelvic pain
transmitted disease Acute PID is highly unlikely when recent intercourse has not taken place or an IUD is not being used A sensitive serum pregnancy test should be obtained to rule out ectopic pregnancy Culdocentesis will differentiate hemoperitoneum (ruptured ectopic pregnancy or hemorrhagic cyst) from pelvic sepsis (salpingitis, ruptured pelvic abscess, or ruptured appendix) Pelvic and vaginal ultrasonography is helpful in the differential diagnosis of ectopic pregnancy of over 6 weeks Laparoscopy is often used to diagnose PID, and it is imperative if the diagnosis is not certain or if the patient has not responded to antibiotic therapy after 48 hours The appendix should be visualized at laparoscopy to rule out appendicitis Cultures obtained at the time of laparoscopy are often specific and helpful
Prognosis
In spite of treatment, long-term sequelae, including repeated episodes of infection, chronic pelvic pain, dyspareunia, ectopic pregnancy, or infertility, develop in onefourth of women with acute disease The risk of infertility increases with repeated episodes of salpingitis: it is estimated at 10% after the first episode, 25% after a second episode, and 50% after a third episode
Treatment
A Antibiotics
Early treatment with appropriate antibiotics effective against N gonorrhoeae, C trachomatis, and the endogenous organisms listed above is essential to prevent long-term sequelae The sexual partner should be examined and treated appropriately Two inpatient regimens have been shown to be effective in the treatment of acute PID: (1) Cefoxitin, 2 g intravenously every 6 hours, or cefotetan, 2 g every 12 hours, plus doxycycline, 100 mg intravenously or orally every 12 hours This regimen is continued for at least 24 hours after the patient shows significant clinical improvement Doxycycline, 100 mg twice daily, should be continued to complete a total of 14 days therapy If a tubo-ovarian abscess is present, it is advisable to add oral clindamycin or metronidazole to the doxycycline to provide more effective anaerobic coverage (2) Clindamycin, 900 mg intravenously every 8 hours, plus gentamicin intravenously in a loading dose of 2 mg/kg followed by 15 mg/kg every 8 hours This regimen is continued for at least 24 hours after the patient shows significant clinical improvement and is followed by either clindamycin, 450 mg four times daily, or doxycycline, 100 mg twice daily, to complete a total of 14 days of therapy Limited data exist on other parenteral regimens Two regimens providing broad-spectrum coverage have been investigated in at least one clinical trial: (1) ofloxacin, 400 mg intravenously every 12 hours, or levofloxacin, 500 mg intravenously once daily, plus metronidazole, 500 mg intravenously every 8 hours; and (2) ampicillin-sulbactam, 3 g intravenously every 6 hours, plus doxycycline, 100 mg intravenously or orally every 12 hours Two outpatient regimens are recommended: (1) ofloxacin, 400 mg orally twice daily for 14 days, or levofloxacin, 500 mg orally once daily for 14 days, plus metronidazole, 500 mg orally twice daily, for 14 days; and (2) either a single dose of cefoxitin, 2 g intramuscularly, with probenecid, 1 g orally, or ceftriaxone, 250 mg intramuscularly, plus doxycycline, 100 mg orally twice daily, for 14 days
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