Pelvic Inflammatory Disease



  • Pelvic inflammatory disease (PID) refers to a spectrum of upper female genital tract inflammatory disorders, including endometritis, salpingitis, tubo-ovarian abscess (TOA), and peritonitis.
  • Definitive diagnosis of PID can be made by laparoscopy; however, diagnosis is usually made based on clinical findings.
  • Centers for Disease Control and Prevention (CDC) guidelines state that empiric PID therapy should be initiated in sexually active young women with pelvic or lower abdominal pain if no other cause for the symptoms can be identified and the patient has the following:
    • Uterine tenderness, OR
    • Adnexal tenderness, OR
    • Cervical motion tenderness
  • Additional criteria enhance diagnostic specificity but not required:
    • Oral temperature >38.3°C (101°F)
    • Abnormal cervical or vaginal discharge
    • Abundant WBCs on vaginal secretion wet mount
    • Elevated ESR or C-reactive protein (CRP)
    • Laboratory-documented evidence of infection with Neisseria gonorrhoeae or Chlamydia trachomatis
  • Definitive diagnostic criteria:
    • Histopathologic evidence of endometritis on endometrial biopsy
    • Transvaginal sonography or MRI showing thickened fluid-filled tubes with or without free pelvic fluid or TOA
    • Laparoscopic abnormalities consistent with PID


  • Estimated 750,000 cases annually in United States
  • In 2011, 90,000 initial visits to physician offices for PID:
    • Visits for PID declined between 2002 and 2011
    • Increased screening and treatment of chlamydia likely led to this decline.
  • Cases disproportionately higher among adolescent girls and racial minorities

Risk Factors

  • Factors that increase PID risk include the following:
    • Multiple sexual partners
    • Intercourse with a partner who has multiple sexual partners
    • Prior history of sexually transmitted infection (STI) or PID
    • Intercourse without condoms
    • Douching
    • Recent (within past 20 days) insertion of intrauterine device (IUD)
  • PID cases are highest among the following:
    • Sexually active adolescents and young women age <25 years
    • Women in communities with high prevalence of gonorrhea and chlamydia
    • Patients presenting to STD clinics

General Prevention

  • Consistent condom use
  • Regular STI screening
  • Partner screening for STIs
  • Limit number of sexual partners.
  • Avoid douching.


  • Ascending infection spreading from vagina/cervix to upper genital tract by the following:
    • Migration
    • Sperm transport
    • Refluxed menstrual blood flow
  • Up to 75% of cases occur within 7 days of menses.


  • Polymicrobial origin
  • Many cases associated with N. gonorrhoeae and C. trachomatis
  • Mycoplasma genitalium and Ureaplasma urealyticum have been associated with laparoscopic PID and infertility.
  • Other vaginal, enteric, and respiratory flora associated with PID include the following:
    • Gardnerella vaginalis, Escherichia coli, Bacteroides species, Haemophilus influenzae, group B to D streptococci, Streptococcus pneumoniae, and group A Streptococcus

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