C. Nathan Webb
History of present illness
A 23-year-old gravida 1, para 1 woman presents to clinic with a month-long history of vague lower abdominal pain that has acutely worsened over the past several days. She initially had cramping, which progressed to a diffuse ache along with marked dyspareunia. She has felt feverish since yesterday but denies any rigors. She denies any nausea or emesis and has no dysuria or vaginal bleeding. She has scant vaginal discharge.
She had a levonorgestrel-releasing intrauterine device (IUD) placed last year and is happy with this method of contraception. Her menses have since diminished to a few days of spotting most months. She is unsure of her last menstrual period. She is sexually active with one male partner, most recentlyfive days ago, and does not use condoms. She has no medical problems. She has never had surgery. She takes no medications. She had a single prior uncomplicated vaginal delivery.
Physical examination
General appearance:Well-nourished woman appearing moderately uncomfortable and tearful
Vital signs:
Temperature: 38.0°C Pulse: 84 beats/min
Blood pressure: 108/74 mmHg Respiratory rate: 16 breaths/min Oxygen saturation: 100% on room air
Cardiovascular:Regular rate and rhythm, no murmurs, rubs or gallops, no peripheral edema
Chest:Clear to auscultation throughout
Abdomen:Soft, obese, nondistended, bilateral lower quadrants are moderately tender to light palpation without rebound or guarding, active bowel sounds, noflank tenderness
External genitalia:Unremarkable Vagina:Scant white discharge, no lesions
Cervix:Mucopurulent discharge present at os (Fig. 22.1) Bimanual exam:Cervical motion tenderness, normal-sized anteverted uterus moderately tender to palpation,
right-sided adnexal fullness with moderate tenderness on palpation
Laboratory studies:
Saline microscopy of vaginalfluid:>25% clue cells, numerous leukocytes, no blood, yeast, or trichomonads
WBCs: 14 000/μL
NAATs:Neisseria gonorrhoeaeandChlamydia trachomatistests sent
Urine pregnancy test: Negative Urinalysis: Unremarkable
Imaging:A transvaginal ultrasound is obtained (Fig. 22.2)
How would you manage this patient?
This patient has pelvic inflammatory disease (PID). Immediate treatment is indicated. Since her symptoms are mild to moderate, outpatient therapy with an appropriate antibiotic regimen based on current Centers for Disease Control and Prevention (CDC) 2010 guidelines [1] is appropriate. Her IUD may be left in place. When treating PID with an IUD in
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
Fig. 22.1 Mucopurulent cervical discharge.
place, close follow-up within two to three days is essential.
Consideration should be given to removal of her IUD should she fail outpatient treatment. Her partner should be examined and offered appropriate treatment for N. gonorrhea and C. trachomatis.
Pelvic inflammatory disease
Pelvic inflammatory disease (PID) is an ascending bacterial infection of the upper female genital tract characterized by inflammation of contiguous structures ranging from cervicitis, endometritis, and salpingitis to pelvic abscess formation and peritonitis. These infections are often polymicrobial and causative organisms include sexually transmitted bacteria such as N. gonorrhea and C. trachomatis, as well as endogenous vaginal anaerobes, enteric gram-negative rods, and genital mycoplasmas [1].
PID can have diverse and often subtle presentations, as seen in this patient whose infection likely began nearly one month ago, as suggested by her initial vague abdominal dis- comfort. These subtle and nonspecific findings often confuse the diagnosis of PID and delay treatment. This delay can have
serious consequences for women, since PID puts them at risk for tubal infertility, ectopic pregnancy, and chronic pelvic pain.
Delay in treatment by as few as three days has been associated with a threefold increase in risk of these sequelae [2]. For this reason, the CDC has established a low threshold for diagnosing PID and recommends treatment of a presumptive diagnosis of PID even while the patient is being evaluated for other causes of her symptoms [1].
The diagnosis of PID is made with presence of pelvic or abdominal pain and either cervical motion tenderness, uterine tenderness, or adnexal tenderness on examination in any sexually active woman younger than 26 years or any woman with risk factors for sexually transmitted infections (STIs). Risk factors for STIs include prior history of STI and multiple sex partners. The lower threshold in younger women reflects both the increased incidence and greater need to protect fertility in these women.
The specificity of the diagnosis is increased if thesefindings occur in the setting of additional signs of genital infection and inflam- mation (Table 22.1), several of which were demonstrated by this patient: cervical mucopurulence (Fig. 22.1), leukorrhea on saline microscopy of vaginalfluid; and evidence of a dilated,fluid-filled tube on ultrasound (Fig. 22.2).
Fig. 22.2 Transvaginal ultrasound of a 23-year-old woman with pelvic pain and fever showing right-sided hydrosalpinx.
Imaging is not always necessary. For this patient, imaging was obtained to further evaluate the adnexal fullness noted on examination. Imaging would also be reasonable in any patient with PID that does not improve with initial antibiotic treat- ment, who requires hospitalization, or whose physical exam- ination is limited by habitus. Transvaginal sonography (TVUS) is readily available and rapidly obtained at the bed- side in most practice settings. Because of its ready availability and ability to visualize tubal changes consisted with PID, TVUS is a good first choice for imaging. CT (Fig. 22.3a,b) is also useful, particularly when evaluating other diagnoses such as appendicitis or to guide percutaneous drainage of abscesses. MRI offers the greatest sensitivity and specificity of any imaging modality in diagnosing PID but is less prac- tical given its high cost and limited availability in some settings.
Treatment of PID should be initiated at the time of diagnosis and be sufficiently broad to cover the most likely pathogens. At a minimum, all antibiotic treatment regimens should be effective against N. gonorrhea and C. trachomatis, regardless of cervical screening results since these tests are not predictive of upper genital tract infection. The CDC guidelines also recommend provision of anaerobic coverage because anaerobes have frequently been recovered from the upper genital tract of women with PID and several of these organ- isms can cause tubal damage with long-term effects on fertility [1]. The recommendations also allow supplemental coverage with metronidazole. Given valid concerns over the side effects of metronidazole and the consequent negative impact on
patient compliance, this additional coverage can be reserved for patients with bacterial vaginosis or pelvic abscesses [1,3].
For mild to moderate symptoms, outpatient management with oral antibiotics is appropriate and provides similar out- comes to parenteral therapy in rates of cure, risk of ectopic pregnancy, and future infertility (Table 22.2). It is important to reassess the patient within two to three days for compliance
Table 22.1 The CDC diagnostic criteria for PID*
Pelvic or lower abdominal pain in young (≤25 years) sexually active women or women with STI risk factors (prior STI, multiple sex partners) and one or more of the following Cervical motion tenderness
Uterine tenderness Adnexal tenderness
Additional criteria to enhance specificity of diagnosis Oral temperature>38.3°C
Cervical or vaginal mucopurulent discharge
Saline wet mount of vaginal discharge demonstrating leukorrhea
Elevated erythrocyte sedimentation rate Elevated C-reactive protein
Verification of cervical infection withNeisseria gonorrhoeaeor Chlamydia trachomatis
Most specific criteria for diagnosis of PID Endometrial biopsy demonstrating endometritis
Transvaginal sonography or MRI showing thickened,fluid- filled tubes with or without free pelvicfluid or tubo-ovarian complex, or Doppler studies suggesting inflammation Laparoscopic confirmation of PID
* Adapted from CDC Guidelines 2010 [1].
CDC, Centers for Disease Control and Prevention; PID, pelvic inflammatory disease; STI, sexually transmitted infections.
(a)
(b)
Fig. 22.3 Abdominal CT of a patient diagnosed with pelvic inflammatory disease and tubo-ovarian abscess. (a) Transverse and (b) coronal views.
Case 22: A 23-year-old woman with pelvic pain and fever
and adequacy of clinical response to treatment. Recommended outpatient regimens consist of cefoxitin or a third-generation cephalosporin, typically ceftriaxone 250 mg IM OD along with doxycycline 100 mg PO BID for 14 days. The CDC guidelines also cite two studies using azithromycin 1 g orally once a week for 2 weeks as a substitute for doxycycline. The CDC guidelines recommend the addition of metronidazole 500 mg PO BID for 14 days if this regimen is employed [1]. The use of quinolones is no longer recommended for the treatment of PID due to the rising prevalence of quinolone-resistant N. gonorrhea[1].
The CDC has criteria for hospitalizing women with PID that should be applied combined with the provider’s judgment of clinical severity (Table 22.3). These criteria include preg- nancy, inadequate response to outpatient therapy, high fever, nausea, vomiting or poor tolerance of oral intake, inability to rule out surgical emergencies (e.g. appendicitis), and presence of an abscess. In the current case, the patient’s symptoms are mild to moderate and she has no gastrointestinal complaints, making outpatient treatment a reasonable choice.
Recommended parenteral regimens include either cefoxitin or cefotetan, both cephalosporins with excellent anaerobic coverage, along with doxycycline (Table 22.4). Conversion to oral antibiotics may be considered after 24–48 hours of sustained clinical improvement and should be continued for 14 days.
If a pelvic abscess is identified, hospitalization for paren- teral antibiotics and direct inpatient observation for at least 24 hours is recommended by the CDC. Any of the CDC- recommended parenteral regimens are appropriate; however, the effects of aminoglycosides are attenuated in low oxygen, acidic environments and may be less effective than cephalo- sporins in this setting [3]. The size of the abscess impacts success of antibiotic therapy and need for surgical drainage.
Up to 60% or women with abscesses 10 cm or larger in diameter will fail to respond to antibiotics alone, so imaging is helpful when abscesses are suspected [4]. Drainage may be undertaken via laparotomy, laparoscopy, or percutaneously.
Rupture of a tubo-ovarian abscess is a surgical emergency and must be suspected in women with PID progressing to sepsis. Surgical exploration, with drainage and excision of nonviable tissue may be necessary, which may require hyster- ectomy or salpingo-oophorectomy.
The presence of an IUD did not alter the management of PID in this patient. There is a small increase in risk of PID for the first three weeks after initiating IUD use, related to placement rather than presence of the device, but available data suggest retention of an IUD does not impact response to treatment for PID [5]. The decision to remove the device should be based upon clinical response to therapy or severity of initial presentation. If the device is left in place, close follow- up is vital. Presence of the endogenous anaerobe actinomyces is noted on cervical cytology in about 7% of IUD users. This likely represents colonization rather than infection and is not an indication for removal in asymptomatic patients. However,
Table 22.2 The CDC recommended outpatient antibiotic regimen for PID*
Ceftriaxone 250 mg IM in a single dose
Orcefoxitin 2 g IM and probenecid 1 g PO both given in a single dose
Orother parenteral third-generation cephalosporin (e.g. ceftizoxime or cefotaxime)
Plus:
Doxycycline 100 mg PO BID for 14 days With or without:
Metronidazole 500 mg PO BID for 14 days
* Adapted from CDC Guidelines 2010 [1].
BID, twice a day; CDC, Centers for Disease Control and Prevention; IM, intramuscular; PO,per os(orally).
Table 22.3 Suggested admission criteria for women with PID Severe illness, nausea and vomiting, or high fever Unable to follow or tolerate outpatient oral regimen Inadequate clinical response to oral antibiotic therapy Pregnancy
Presence of a tubo-ovarian abscess
Surgical emergencies (e.g. appendicitis) cannot be excluded
* Adapted from CDC Guidelines 2010 [1].
CDC, Centers for Disease Control and Prevention; PID, pelvic inflammatory disease.
Table 22.4 Parenteral antibiotic regimens for PID Regimen A
Cefotetan 2 g IV every12 hours Or
Cefoxitin 2 g IV every 6 hours Plus
Doxycycline 100 mg PO or IV every 12 hours Regimen B
Clindamycin 900 mg IV every 8 hours Plus
Gentamicin loading dose IV or IM (2 mg/kg body weight), followed by a maintenance dose (1.5 mg/kg) every 8 hours.
Single daily dosing (3–5 mg/kg) can be substituted Alternative regimen
Ampicillin/sulbactam 3 g IV every 6 hours Plus
Doxycycline 100 mg PO or IV every 12 hours
* Adapted from CDC Guidelines 2010 [1].
CDC, Centers for Disease Control and Prevention; IM, intramuscularly; IV, intravenous; PID, pelvic inflammatory disease; PO,per os(orally).
women with PID symptoms and a history of colonization should receive appropriate evaluation and treatment for acti- nomycosis and the IUD should be removed [6,7].
The examination and treatment of sex partners is recom- mended if sexual contact was within the preceding 60 days.
Treatment should be given to the most recent sexual contact if this occurred more than 60 days prior to diagnosis. In both cases, treatment should cover both N. gonorrhea and C. trachomatis regardless of the cervical screening results in the affected women.
Long-term sequelae of PID include infertility, chronic pelvic pain, and ectopic pregnancy, all presumably from asso- ciated scarring of pelvic organs. The risks increase with number of recurrences, with infertility rates as high as 75%
and ectopic pregnancy risk up to 14% after three or more episodes [8]. Chronic pain affects up to 30% of women after a single occurrence [3].
For this patient, strong clinical suspicion of PID in a young sexually active woman with pelvic pain and evidence of upper genital inflammation as well as a low threshold for treatment are key to proper management. A CDC-recommended antibi- otic regimen was administered and further evaluation with imaging was performed based on examinationfindings. Clin- ical judgment was used to determine if her IUD could be left in place. Follow-up should include examination and treatment of
the patient’s sex partner with antibiotics adequate to treatN.
gonorrheaandC. trachomatis.
Key teaching points
Pelvic inflammatory disease (PID) should be considered in any sexually active, reproductive-aged woman with pelvic pain.
Early treatment of PID at the time of diagnosis improves long-term outcomes and should be started while alternate diagnoses are further evaluated.
Mild to moderate PID can be treated as an outpatient.
Clinical response to oral treatment should be assessed within 72 hours and the patient should be admitted for parenteral treatment if not improving appropriately.
PID in intrauterine device (IUD) users may be treated without removing the device. Close follow-up is essential.
Removal of the IUD is necessary in instances of treatment failure.
Treatment regimens should follow the Centers for Disease Control and Prevention (CDC) sexually transmitted diseases treatment guidelines.
Sex partners should be treated if contact was within the preceding 60 days.
References
1. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010.
MMWR2010;59(RR-12):63–7.
2. Hillis S, Joesoef R, Marchbanks P, et al.
Delayed care of pelvic inflammatory disease as a risk factor for impaired fertility.Am J Obstet Gynecol 1993;168:1503–9.
3. Soper DE. Pelvic inflammatory disease.
Obstet Gynecol2010;116:419–28.
4. Reed S, Landers D, Sweet R. Antibiotic treatment of tuboovarian abscess:
Comparison of broad-spectrum beta- lactam agents versus clindamycin- containing regimens.Am J Obstet Gynecol1991;164:1556–62.
5. Grimes DA. Intrauterine device and upper-genital-tract infection.Lancet 2000;356:1013–19.
6. Tepper NK, Steenland MW, Gaffield ME, Marchbanks PA, Curtis KM.
Retention of intrauterine devices in women who acquire pelvic inflammatory disease: A systematic review.Contraception2013;87:
655–60.
7. American College of Obstetricians and Gynecologists. Long-acting reversible contraception: Implants and intrauterine devices. Practice Bulletin No. 121.Obstet Gynecol2011;118:
184–96.
8. Westrửm L, Joesoef R, Reynolds G, Hagdu A, Thompson SE. Pelvic inflammatory disease and fertility.
A cohort study of 1,844 women with laparoscopically verified disease and 657 control women with normal laparoscopic results.Sex Transm Dis 1992;19:185–92.
Case 22: A 23-year-old woman with pelvic pain and fever