Pelvic inflammatory disease

Pelvic inflammatory disease is inflammation of the upper female genital tract, including the endometrium, fallopian tubes, ovaries, and adjacent pelvic tissues. The infection commonly follows ascent of Chlamydia trachomatis or Neisseria gonorrhoeae from the cervix, but vaginal and enteric bacteria may also contribute, so PID is often polymicrobial.

Risk is increased by a recent sexually transmitted infection, multiple or new sex partners, previous PID, and inconsistent condom use. PID can occur without a detectable cervical infection, and a negative test for chlamydia or gonorrhea does not exclude it. The condition is distinct from isolated vaginitis or cervicitis because it involves structures above the cervix.

Lower abdominal or pelvic pain is the key presenting symptom, but the clinical picture ranges from subtle discomfort to severe systemic illness. Abnormal bleeding, pain during intercourse, abnormal vaginal discharge, fever, painful urination, nausea, or vomiting may occur; some people have few or no symptoms.

Clinicians generally treat empirically when pelvic or lower abdominal pain is present and examination shows cervical motion, uterine, or adnexal tenderness, provided another cause is not more likely. Pregnancy testing, molecular tests for chlamydia and gonorrhea, testing for HIV and syphilis, urinalysis, and assessment for ectopic pregnancy are commonly relevant. Ultrasound or other imaging helps identify a tubo-ovarian abscess or alternative diagnoses; no single test reliably rules PID in or out.

Early broad-spectrum antibiotics are used because delayed treatment increases the chance of reproductive-tract damage, and treatment should cover gonorrhea, chlamydia, and anaerobic bacteria. A commonly recommended outpatient regimen is ceftriaxone plus 14 days of doxycycline and metronidazole, with variations for allergy, pregnancy, severity, or local guidance.

Hospital care is considered for pregnancy, severe illness, vomiting or inability to take oral medicine, suspected surgical emergency, tubo-ovarian abscess, or lack of improvement. Sex partners from the preceding 60 days should be evaluated and treated when appropriate; sexual activity should wait until therapy is completed, symptoms have resolved, and partners have been treated. Condoms, regular testing, and prompt treatment of cervical infections reduce risk, but screening cannot prevent every case.

PID may leave permanent tubal damage even when the initial illness is mild or unrecognized. Scarring can impair fertility, increase the risk of ectopic pregnancy, and contribute to chronic pelvic pain; repeated episodes generally raise the risk of these outcomes.

A less familiar manifestation is Fitz-Hugh–Curtis syndrome, in which PID-associated inflammation affects the liver capsule and causes right-upper-quadrant pain, sometimes without prominent pelvic symptoms. A tubo-ovarian abscess is another serious complication and may require drainage or surgery in addition to antibiotics. An intrauterine device does not usually need to be removed when PID develops; removal may be considered if there is no clinical improvement after 48–72 hours.

Ascending infection

Spread of microorganisms upward from the vagina or cervix into the uterus, tubes, or other pelvic tissues.

Tubo-ovarian abscess

A collection of infected fluid involving a fallopian tube and ovary, often requiring hospitalization and sometimes drainage.

Cervical motion tenderness

Pain produced when the cervix is gently moved during pelvic examination; a clinical sign supporting possible PID.

Fitz-Hugh–Curtis syndrome

Perihepatitis associated with PID, characterized by inflammation around the liver capsule and sometimes right-upper-quadrant pain.