Current Infectious Disease Reports

, Volume 14, Issue 2, pp 194–203 | Cite as

Pelvic Inflammatory Disease: Current Concepts of Diagnosis and Management

Sexually Transmitted Diseases (L Bachmann, Section Editor)


Pelvic inflammatory disease (PID), one of the most common infections in non-pregnant women of reproductive age, remains an important public health problem. It is associated with major long-term sequelae, including tubal factor infertility, ectopic pregnancy, and chronic pelvic pain. In addition, treatment of acute PID and its complications incurs substantial health care costs. Prevention of these long-term sequelae is dependent upon clinicians having a high index of suspicion in order to make an early diagnosis and development of treatment strategies based on knowledge of the microbiologic etiology of acute PID. It is well accepted that acute PID is a polymicrobic infection. The sexually transmitted organisms, Neisseria gonorrhoeae and Chlamydia trachomatis, are present in many cases and microorganisms comprising the endogenous vaginal and cervical flora are frequently associated with PID. This includes anaerobic and facultative bacteria, similar to those associated with bacterial vaginosis. Genital tract mycoplasmas, most importantly Mycoplasma genitalium, have recently also been implicated as a cause of acute PID. As a consequence, treatment regimens for acute PID should provide broad spectrum coverage that is effective against these microorganisms.


Salpingitis Pelvic inflammatory disease Diagnosis Treatment 


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    •• Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2010. MMWR 2010;59(No. RR-12):63–67. Major resource for the treatment of acute PID Google Scholar
  2. 2.
    Ross J, Judlin P, Niles L. European guideline for the management of pelvic inflammatory disease. Int J STD AIDS. 2007;18:662–6.PubMedCrossRefGoogle Scholar
  3. 3.
    Sweet RL. Microbiology. In: Sweet RL, Wiesenfeld HC, editors. Pelvic inflammatory disease. London: Taylor & Francis; 2006. p. 19–48.Google Scholar
  4. 4.
    • Haggerty CL, Ness RB: Diagnosis and treatment of pelvic inflammatory disease. Women’s Health 2008;4:383–97. Excellent review of the diagnosis and treatment of PID PubMedGoogle Scholar
  5. 5.
    Smith KJ, Ness RB, Wiesenfeld HC, Roberts MS. Cost-effectiveness of alternative outpatient pelvic inflammatory disease treatment strategies. Sex Transm Dis. 2007;34:960–6.PubMedGoogle Scholar
  6. 6.
    Sutton MY, Sternberg M, Zaidi A, et al. Trends in pelvic inflammatory disease hospital discharges and ambulatory visits, United States; 1985–2001. Sex Transm Dis. 2005;32:778–84.PubMedCrossRefGoogle Scholar
  7. 7.
    Rein DB, Kassler WJ, Irwin KL, Rabiee L. Direct medical cost of pelvic inflammatory disease and its sequelae: decreasing but still substantial. Obstet Gynecol. 2000;95:397–402.PubMedCrossRefGoogle Scholar
  8. 8.
    Botte J, Peipert JF. Epidemiology. In: Sweet RL, Wiesenfeld HC, editors. Pelvic inflammatory disease. London: Taylor & Francis; 2006. p. 1–18.Google Scholar
  9. 9.
    Haggerty CL, Ress RB. Epidemiology, pathogenesis and treatment of pelvic inflammatory disease. Expert Rev Anti Infect Ther. 2006;4:235–47.PubMedCrossRefGoogle Scholar
  10. 10.
    •• Westrom L: Effect of acute pelvic inflammatory disease on fertility. Am J Obstet Gynecol 1975;121:707–13. Classic study on impact of PID on reproductive health of women PubMedGoogle Scholar
  11. 11.
    Westrom L, Josef R, Reynolds G, et al. Pelvic inflammatory disease and fertility. A cohort study of 1844 women with laparoscopically verified disease and 657 control women with normal laparoscopic results. Sex Transm Dis. 1992;19:185–92.PubMedCrossRefGoogle Scholar
  12. 12.
    Haggerty CL, Shultz R, Ness RB. Lower quality of life among women with chronic pelvic pain after pelvic inflammatory disease. Obstet Gynecol. 2003;102:934–9.PubMedCrossRefGoogle Scholar
  13. 13.
    Thurman AR, Soper DE. Sequelae. In: Sweet RL, Wiesenfeld HC, editors. Pelvic inflammatory disease. London: Taylor & Francis; 2006. p. 69–84.Google Scholar
  14. 14.
    •• Wiesenfeld HC, Hillier SL, Krohn MA, et al.: Lower genital tract infection and endometritis: insight into subclinical pelvic inflammatory disease. Obstet Gynecol 2002;100:265–63. Study clearly demonstrates the association of subclinical PID with lower genital tract infection with N. gonorrhoeae, C. trachomatis and BV CrossRefGoogle Scholar
  15. 15.
    Wolner-Hanssen P, Kiviat NB, Holmes KK. Atypical pelvic inflammatory disease: subacute, chronic or subclinical upper genital tract infection in women. In: Holmes KK, Mardh P-A, Sparling PF, et al., editors. Sexually transmitted diseases. New York: McGraw-Hill; 1990. p. 615–20.Google Scholar
  16. 16.
    Westrom L, Eschenbach DA. Pelvic inflammatory disease. In: Holmes KK, Sparling PF, Mardh P-A, Lemon J, Stamm W, Piot P, Wasserheit JN, editors. Sexually transmitted diseases. New York: McGraw-Hill; 1999. p. 783–809.Google Scholar
  17. 17.
    Walker CK, Wiesenfeld HC. Antibiotic therapy for acute pelvic inflammatory disease: the 2006 centers for disease control and prevention sexually transmitted diseases treatment guidelines. Clin Infect Dis. 2007;44:S111–22.PubMedCrossRefGoogle Scholar
  18. 18.
    Haggerty CL, Ness RB. Newest approaches to treatment of pelvic inflammatory disease: a review of recent randomized trials. Clin Infect Dis. 2007;44:953–60.PubMedCrossRefGoogle Scholar
  19. 19.
    •• Sweet RL, Gibbs RS: Pelvic inflammatory disease. In Sweet RL, Gibbs RS Infectious Diseases of the Female Genital Tract. Lippincott, Williams & Wilkins, Philadelphia, 2009, pp 220–44. Very comprehensive review of the epidemiology, pathogenesis, etiology, diagnosis, and treatment of acute PID Google Scholar
  20. 20.
    Kiviat NB, Wolner-Hanssen P, Eschenbach DA, et al. Endometrial histopathology in patients with culture-proven upper genital tract infection and laparoscopically diagnosed acute salpingitis. Am J Surg Pathol. 1990;14:167–75.PubMedCrossRefGoogle Scholar
  21. 21.
    Wiesenfeld HC, Sweet RL, Ness RB, et al. Comparison of acute and subclinical pelvic inflammatory disease. Sex Transm Dis. 2005;32:400–5.PubMedCrossRefGoogle Scholar
  22. 22.
    •• Jacobsen L, Westrom L: Objectivized diagnosis of acute pelvic inflammatory disease. Am J Obstet Gynecol 1969;105:1088. Classic study on use of laparoscopy to confirm diagnosis of acute salpingitis Google Scholar
  23. 23.
    Hager WD, Eschenbach DA, Spence MR, Sweet RL. Criteria for diagnosis and grading of salpingitis. Obstet Gynecol. 1983;61:113–4.PubMedGoogle Scholar
  24. 24.
    Kahn JG, Walker CK, Washington AE, et al. Diagnosing pelvic inflammatory disease: a comprehensive analysis and considerations for developing a new model. JAMA. 1991;266:2594–604.PubMedCrossRefGoogle Scholar
  25. 25.
    Soper DE. Surgical considerations in the diagnosis and treatment of pelvic inflammatory disease. Surg Clin North Am. 1991;71:947–62.PubMedGoogle Scholar
  26. 26.
    Hemila M, Henriksson L, Ylkorkala O. Serum CRP in the diagnosis of pelvic inflammatory disease. Arch Gynecol Obstet. 1987;241:177–82.PubMedCrossRefGoogle Scholar
  27. 27.
    Duk JM, Kauer FM, Fleuren GJ, deBruign HW. Serum CA 125 levels in patients with provisional diagnosis of pelvic inflammatory disease. Clinical and theoretical implications. Acta Obstet Gynecol Scand. 1989;68:637–41.PubMedCrossRefGoogle Scholar
  28. 28.
    Mozas J, Castilla JA, Jimena P, et al. Serum CA 125 in the diagnosis of acute pelvic inflammatory disease. Int J Gynaecol Obstet. 1994;44:53–7.PubMedCrossRefGoogle Scholar
  29. 29.
    Paavonen J, Mettinen A, Heinonen PK, et al. Serum CA-125 in acute pelvic inflammatory disease. Br J Obstet Gynaecol. 1989;96:574–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Moore E, Soper DE. Clinical utility of CA 125 levels in predicting laparoscopically confirmed salpingitis in patients with clinically diagnosed pelvic inflammatory disease. Infect Dis Obstet Gynecol. 1988;6:182–5.CrossRefGoogle Scholar
  31. 31.
    Paavonen J, Critchlow CW, DeRoven T, et al. Biology of cervical inflammation. Am J Obstet Gynecol. 1986;154:556–64.PubMedGoogle Scholar
  32. 32.
    Peipert JF, Boardman L, Hogan JW, et al. Laboratory evaluation of acute upper genital tract infection. Obstet Gynecol. 1996;87:730–6.PubMedCrossRefGoogle Scholar
  33. 33.
    Jaiyeoba O, Soper DE: A practical approach to the diagnosis of pelvic inflammatory disease. Infect Dis Ob Gyn (In Press).Google Scholar
  34. 34.
    Timor-Tritsch E, Rotten S. Transvaginal ultrasonographic study of the fallopian tube. Obstet Gynecol. 1987;70:424–8.PubMedGoogle Scholar
  35. 35.
    Tukeva TA, Aronen HJ, Karjalainen PT, et al. MR imaging in pelvic inflammatory disease: comparison with laparoscopy and US. Radiology. 1999;210:209–16.PubMedGoogle Scholar
  36. 36.
    Eschenbach DA, Buchanan T, Pollock HM, et al. Polymicrobial etiology of acute pelvic inflammatory disease. N Engl J Med. 1975;293:166–71.PubMedCrossRefGoogle Scholar
  37. 37.
    Sweet RL, Draper DL, Schachter J, et al. Microbiology and pathogenesis of acute salpingitis as determined by laparoscopy: what is the appropriate site to sample? Am J Obstet Gynecol. 1980;138:985–9.PubMedGoogle Scholar
  38. 38.
    Sweet RL. Sexually transmitted diseases. Pelvic inflammatory disease and infertility in women. Infect Dis Clin North Am. 1987;1:199–215.PubMedGoogle Scholar
  39. 39.
    Sweet RL, Schachter J, Robbie MO. Failure of beta-lactam antibiotics to eradicate Chlamydia trachomatis in the endometrium despite apparent clinical cure of acute salpingitis. JAMA. 1983;250:2641–5.PubMedCrossRefGoogle Scholar
  40. 40.
    Wasserheit JN, Bell TA, Kiviat NB, et al. Microbial causes of proven pelvic inflammatory disease and efficacy of clindamycin and tobramycin. Ann Int Med. 1986;104:187–93.PubMedGoogle Scholar
  41. 41.
    Heinonen PK, Teisala K, Punnonen R, et al. Anatomic sites of upper genital tract infection. Obstet Gynecol. 1985;66:384–90.PubMedGoogle Scholar
  42. 42.
    Paavonen J, Teisala K, Heinonen PK, et al. Microbiological and histopathological findings in acute pelvic inflammatory disease. Brit J Obstet Gynaecol. 1987;94:454–60.CrossRefGoogle Scholar
  43. 43.
    Brunham RC, Binns B, Guijon F, et al. Etiology and outcome of acute pelvic inflammatory disease. J Infect Dis. 1988;158:510–7.PubMedCrossRefGoogle Scholar
  44. 44.
    Soper DE, Brockwell NJ, Dalton HP, Johnson D. Observations concerning the microbial etiology of acute salpingitis. Am J Obstet Gynecol. 1994;170:1008–17.PubMedGoogle Scholar
  45. 45.
    Hillier SL, Kiviat NB, Hawes SE, et al. Role of bacterial vaginosis-associated microorganisms in endometritis. Am J Obstet Gynecol. 1996;175:435–41.PubMedCrossRefGoogle Scholar
  46. 46.
    Haggerty CL, Hillier SL, Bass DC, et al. Bacterial vaginosis and anaerobic bacteria are associated with endometritis. CID. 2004;39:990–5.CrossRefGoogle Scholar
  47. 47.
    Cohen CR, Manhart LE, Bukusi EA, et al. Association between Mycoplasma genitalium and acute endometritis. Lancet. 2002;359:765–6.PubMedCrossRefGoogle Scholar
  48. 48.
    Simms I, Eastick K, Mallinson H, et al. Association between Mycoplasma genitalium, Chlamydia trachomatis and pelvic inflammatory disease. J Clin Pathol. 2003;56:616–8.PubMedCrossRefGoogle Scholar
  49. 49.
    Cohen CR, Mugo NR, Astete SG, et al. Detection of Mycoplasma genitalium in women with laparoscopically diagnosed acute salpingitis. Sex Transm Infect. 2005;81:463–6.PubMedCrossRefGoogle Scholar
  50. 50.
    Haggerty CL, Totten PA, Astete SG, et al. Failure of cefoxitin and doxycycline to eradicate endometrial Mycoplasma genitalium and the consequence for clinical cure of pelvic inflammatory disease. Sex Transm Infect. 2008;84:338–42.PubMedCrossRefGoogle Scholar
  51. 51.
    • Short VL, Totten PA, Ness RB, et al.: Clinical presentation of Mycoplasma genitalium infection versus Neisseria gonorrhoeae infection among women with pelvic inflammatory disease. Clin Infect Dis 2009;48:41–7. Study identifies that M. genitalium may play an important putative role in the etiology of acute PID PubMedCrossRefGoogle Scholar
  52. 52.
    Ness RB, Soper DE, Holley RL, et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) randomized trial. Am J Obstet Gynecol. 2002;186:929–37.PubMedCrossRefGoogle Scholar
  53. 53.
    Ness RB, Hillier SL, Kip KE, et al. Bacterial vaginosis and risk of pelvic inflammatory disease. Obstet Gynecol. 2004;104:761–9.PubMedCrossRefGoogle Scholar
  54. 54.
    Korn AP, Bolan G, Padian N, et al. Plasma cell endometritis in women with symptomatic bacterial vaginosis. Obstet Gynecol. 1995;85:387–90.PubMedCrossRefGoogle Scholar
  55. 55.
    Peipert JF, Montagno AB, Cooper AS, Sung CJ. Bacterial vaginosis as a risk factor for upper genital tract infection. Am J Obstet Gynecol. 1997;177:1184–7.PubMedCrossRefGoogle Scholar
  56. 56.
    Sweet RL. Role of bacterial vaginosis in pelvic inflammatory disease. Clin Infect Dis. 1995;20 Suppl 2:271–5.CrossRefGoogle Scholar
  57. 57.
    Ness RB, Kip KE, Hillier SL, et al. A cluster analysis of bacterial vaginosis-associated microflora and pelvic inflammatory disease. Am J Epidemiol. 2005;162:585–90.PubMedCrossRefGoogle Scholar
  58. 58.
    Hebb JK, Cohen CR, Astete SG, et al. Detection of novel organisms associated with salpingitis, by use of 16S rDNA polymerase chain reaction. J Infect Dis. 2004;190:2109–20.PubMedCrossRefGoogle Scholar
  59. 59.
    Hillis SD, Joesoef R, Marchbanks PA, et al. Delayed care of pelvic inflammatory disease as a risk factor for impaired fertility. Am J Obstet Gynecol. 1993;168:1503–9.PubMedGoogle Scholar
  60. 60.
    Smith J, Ness RB, Wiesenfeld HC, et al. Cost-effectiveness of alternate outpatient pelvic inflammatory disease treatment strategies. Sex Transm Dis. 2007;34:960–6.PubMedGoogle Scholar
  61. 61.
    Amsden GW. Anti-inflammatory effects of macrolides-an underappreciated benefit in the treatment of community-acquired respiratory tract infections and chronic pulmonary conditions. J Antimicro Chemother. 2005;55:10–21.CrossRefGoogle Scholar
  62. 62.
    Patton DL, Sweeney YT, Stamm WE. Significant reduction in inflammatory response in the macaque model of chlamydial pelvic inflammatory disease with azithromycin treatment. JID. 2005;192:129–35.PubMedCrossRefGoogle Scholar
  63. 63.
    Bevan CD, Ridgway GL, Rothermel CD. Efficacy and safety of azithromycin as monotherapy or combined with metronidazole compared with two standard multidrug regimens for the treatment of acute pelvic inflammatory disease. J Int Med Res. 2003;31:45–54.PubMedGoogle Scholar
  64. 64.
    Ness RB, Trautmann G, Richter HE, et al. Effectiveness of treatment strategies of some women with pelvic inflammatory disease: a randomized trial. Obstet Gynecol. 2005;106:573–80.PubMedCrossRefGoogle Scholar
  65. 65.
    McGregor JA, Crombleholme WR, Newton E, et al. Randomized comparison of ampicillin-sulbactam to cefoxitin and doxycycline or clindamycin and gentamicin in the treatment of pelvic inflammatory disease or endometritis. Ostet Gynecol. 1994;83:998–1004.CrossRefGoogle Scholar
  66. 66.
    Savaris RF, Teixeira LM, Torres G, et al. Comparing ceftriaxone plus azithromycin or doxycyline for pelvic inflammatory disease, a randomized controlled trial. Obstet Gynecol. 2007;110:53–60.PubMedCrossRefGoogle Scholar
  67. 67.
    Yip L, Sweeny PJ, Bock BF. Acute suppurative salpingitis with concomitant intrauterine pregnancy. Am J Emerg Med. 1993;11:476–9.PubMedCrossRefGoogle Scholar
  68. 68.
    Blanchard AC, Pastorek 2nd JG, Weeks T. Pelvic inflammatory disease during pregnancy. South Med J. 1987;80:1363–5.PubMedCrossRefGoogle Scholar
  69. 69.
    Hemsell DL, Ledger WJ, Martens M, et al. Concerns regarding the centers for disease control’s published guidelines for pelvic inflammatory disease. Clin Infect Dis. 2001;32:103–7.CrossRefGoogle Scholar
  70. 70.
    Korn AP, Landers DV, Green JR, Sweet RL. Pelvic inflammatory disease in human immunodeficiency virus-infected women. Obstet Gynecol. 1993;82:765–8.PubMedGoogle Scholar
  71. 71.
    Irwin KL, Moorman AC, O’Sullivan MJ, et al. Influence of human immunodeficiency virus infection on pelvic inflammatory disease. Obstet Gynecol. 2000;95:525–34.PubMedCrossRefGoogle Scholar
  72. 72.
    Cohen CR, Sinei R, Reilly M, et al. Effect of human immunodeficiency virus type 1 infection upon acute salpingitis: a laparoscopic study. J Infect Dis. 1998;178:1352–8.PubMedCrossRefGoogle Scholar
  73. 73.
    Bakusi EA, Cohen CR, Stevens CE, et al. Effects of human immunodeficiency virus 1 infection on microbial origins of pelvic inflammatory disease and on the efficacy of ambulatory oral therapy. Am J Obstet Gynecol. 1999;181:1374–81.CrossRefGoogle Scholar
  74. 74.
    Mugo NR, Kiehlbauch JA, Nguti R, et al. Effect of human immunodeficiency virus-1 infection on treatment outcomes of acute salpingitis. Obstet Gynecol. 2006;107:807–12.PubMedCrossRefGoogle Scholar
  75. 75.
    Soderberg G, Lindgren S. Influence of an intrauterine device on the course of acute salpingitis. Contraception. 1981;24:137–43.PubMedCrossRefGoogle Scholar
  76. 76.
    Altunyurt S, Demir N, Posaci C. A randomized trial of coil removal prior to treatment of pelvic inflammatory disease. Eur J Obstet Gynecol Reprod Biol. 2003;107:81–4.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  1. 1.Department of Obstetrics and GynecologyUniversity of California, DavisSacramentoUSA

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