3-51
Subjective: Symptoms
Lower abdominal pain with or without signs of peritoneal irritation; severe and continuous pain in both lower
quadrants, increased by movement and intercourse (dyspareunia); abnormal vaginal bleeding in 15-35%; fever
in less than 50%; onset of symptoms likely within 7 days of onset of menses.
Objective: Signs
Using Basic Tools: Lower abdominal tenderness, bilateral adnexal tenderness, cervical motion tenderness;
also fever >101°F, mucopurulent cervicitis.
Using Advanced Tools: Lab: Cervical culture positive for gonorrhea (chocolate bar), WBC count > 10,500;
Gram stain of cervical discharge with gram-negative intracellular diplococci and >10 WBC/hpf.
Assessment:
Minimum criteria for clinical diagnosis of PID: Lower abdominal tenderness, bilateral adnexal tenderness,
cervical motion tenderness
Differential Diagnosis: Appendicitis, pregnancy, constipation, UTI, ovarian torsion, endometriosis, ruptured
ovarian cyst
Plan:
Treatment
Outpatient:
- Ceftriaxone 250 mg IM plus doxycycline 100 mg po q 12 hours X 14 days or cefoxitin 2 gm IM plus
probenecid 1 gm po plus doxycycline 100 mg po q 12 hours X 14 days. - Tetracycline 500 mg po qid X 10-14 days may be substituted for doxycycline.
- Pregnant patients or those with GI intolerance to doxy/tetracycline may use erythromycin 500 mg po qid
X 10 days. - Azithromycin 1 gm x 1 day may be substituted for doxy/tetracycline or erythromycin.
- Strict rest is mandatory during the first 72 hours of therapy. Family members should facilitate patient
compliance. - Treat partners after patient provides identity.
- Due to the significant consequences of PID, it is better to treat the patient at risk that has only uterine
tenderness or lower pelvic discomfort. This is particularly true in the field setting where all diagnostic
testing will not be available.
Inpatient (unstable, pregnant or unresponsive to outpatient therapy in 72 hours, unable to tolerate
oupatient medication, if 72 hour follow-up cannot be arranged or guaranteed):
- Refer immediately. While awaiting transfer:
- Start antibiotic treatments: Either cefoxitin 2 grams IV q 6 hours plus doxycycline 100 mg po/IV q 12
hours or cefotetan 2 grams IV q 12 hours plus doxycycline 100 mg po/IV q 12 hours. - Alternatively, the IM cephalosporin regimen (above) with azithromycin or doxycycline can be used.
Consider repeating the IM ceftriaxone in 24 hours if the patient cannot be transferred, is worsening and
IV therapy is not available. - Start IV hydration with one or two large bore IVs.
- Maintain the patient on bedrest and NPO in case surgery will be necessary.
- If you have any doubt regarding compliance, always treat the patient with ceftriaxone or cefoxitin IM and
the oral azithromycin 1 gm dose which the patient can take under observation. - Treat partners after patient provides identity.
Patient Education