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Infectious Diseases in Obstetrics and Gynecology logoLink to Infectious Diseases in Obstetrics and Gynecology
. 1994;2(1):38–48. doi: 10.1155/S1064744994000384

Diagnostic Evaluation of Pelvic Inflammatory Disease

Jeffrey F Peipert 1,, David E Soper 2
PMCID: PMC2364353  PMID: 18475365

Abstract

Pelvic inflammatory disease (PID) is a serious public health and reproductive health problem in the United States. An early and accurate diagnosis of PID is extremely important for the effective management of the acute illness and for the prevention of long-term sequelae. The diagnosis of PID is difficult, with considerable numbers of false-positive and false-negative diagnoses. An abnormal vaginal discharge or evidence of lower genital tract infection is an important and predictive finding that is often underemphasized and overlooked. This paper reviews the clinical diagnosis and supportive laboratory tests for the diagnosis of PID and outlines an appropriate diagnostic plan for the clinician and the researcher.

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Selected References

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  1. Adler M. W., Belsey E. H., O'Connor B. H. Morbidity associated with pelvic inflammatory disease. Br J Vener Dis. 1982 Jun;58(3):151–157. doi: 10.1136/sti.58.3.151. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Barron A. L., Pasley J. N., Rank R. G., White H. J., Mrak R. E. Chlamydial salpingitis in female guinea pigs receiving oral contraceptives. Sex Transm Dis. 1988 Jul-Sep;15(3):169–173. doi: 10.1097/00007435-198807000-00013. [DOI] [PubMed] [Google Scholar]
  3. Berland L. L., Lawson T. L., Foley W. D., Albarelli J. N. Ultrasound evaluation of pelvic infections. Radiol Clin North Am. 1982 Jun;20(2):367–382. [PubMed] [Google Scholar]
  4. Binstock M., Muzsnai D., Apodaca L., Goldman N., Keith L. Laparoscopy in the diagnosis and treatment of pelvic inflammatory disease: a review and discussion. Int J Fertil. 1986 Nov-Dec;31(5):341–351. [PubMed] [Google Scholar]
  5. Bowie W. R., Jones H. Acute pelvic inflammatory disease in outpatients: association with Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Intern Med. 1981 Dec;95(6):685–688. doi: 10.7326/0003-4819-95-6-685. [DOI] [PubMed] [Google Scholar]
  6. Brunham R. C., Paavonen J., Stevens C. E., Kiviat N., Kuo C. C., Critchlow C. W., Holmes K. K. Mucopurulent cervicitis--the ignored counterpart in women of urethritis in men. N Engl J Med. 1984 Jul 5;311(1):1–6. doi: 10.1056/NEJM198407053110101. [DOI] [PubMed] [Google Scholar]
  7. Cacciatore B., Leminen A., Ingman-Friberg S., Ylöstalo P., Paavonen J. Transvaginal sonographic findings in ambulatory patients with suspected pelvic inflammatory disease. Obstet Gynecol. 1992 Dec;80(6):912–916. [PubMed] [Google Scholar]
  8. Cacciatore B., Stenman U. H., Ylöstalo P. Comparison of abdominal and vaginal sonography in suspected ectopic pregnancy. Obstet Gynecol. 1989 May;73(5 Pt 1):770–774. [PubMed] [Google Scholar]
  9. Cates W., Jr, Joesoef M. R., Goldman M. B. Atypical pelvic inflammatory disease: can we identify clinical predictors? Am J Obstet Gynecol. 1993 Aug;169(2 Pt 1):341–346. doi: 10.1016/0002-9378(93)90085-w. [DOI] [PubMed] [Google Scholar]
  10. Cates W., Jr, Rolfs R. T., Jr, Aral S. O. Sexually transmitted diseases, pelvic inflammatory disease, and infertility: an epidemiologic update. Epidemiol Rev. 1990;12:199–220. doi: 10.1093/oxfordjournals.epirev.a036054. [DOI] [PubMed] [Google Scholar]
  11. Cates W., Jr, Wasserheit J. N. Genital chlamydial infections: epidemiology and reproductive sequelae. Am J Obstet Gynecol. 1991 Jun;164(6 Pt 2):1771–1781. doi: 10.1016/0002-9378(91)90559-a. [DOI] [PubMed] [Google Scholar]
  12. Chaparro M. V., Ghosh S., Nashed A., Poliak A. Laparoscopy for the confirmation and prognostic evaluation of pelvic inflammatory disease. Int J Gynaecol Obstet. 1978;15(4):307–309. doi: 10.1002/j.1879-3479.1977.tb00699.x. [DOI] [PubMed] [Google Scholar]
  13. Eschenbach D. A., Buchanan T. M., Pollock H. M., Forsyth P. S., Alexander E. R., Lin J. S., Wang S. P., Wentworth B. B., MacCormack W. M., Holmes K. K. Polymicrobial etiology of acute pelvic inflammatory disease. N Engl J Med. 1975 Jul 24;293(4):166–171. doi: 10.1056/NEJM197507242930403. [DOI] [PubMed] [Google Scholar]
  14. Faro S., Martens M., Maccato M., Hammill H., Pearlman M. Vaginal flora and pelvic inflammatory disease. Am J Obstet Gynecol. 1993 Aug;169(2 Pt 2):470–474. doi: 10.1016/0002-9378(93)90344-i. [DOI] [PubMed] [Google Scholar]
  15. Golden N., Cohen H., Gennari G., Neuhoff S. The use of pelvic ultrasonography in the evaluation of adolescents with pelvic inflammatory disease. Am J Dis Child. 1987 Nov;141(11):1235–1238. doi: 10.1001/archpedi.1987.04460110105035. [DOI] [PubMed] [Google Scholar]
  16. Hadgu A., Westrom L., Brooks C. A., Reynolds G. H., Thompson S. E. Predicting acute pelvic inflammatory disease: a multivariate analysis. Am J Obstet Gynecol. 1986 Nov;155(5):954–960. doi: 10.1016/0002-9378(86)90324-8. [DOI] [PubMed] [Google Scholar]
  17. Hager W. D., Eschenbach D. A., Spence M. R., Sweet R. L. Criteria for diagnosis and grading of salpingitis. Obstet Gynecol. 1983 Jan;61(1):113–114. [PubMed] [Google Scholar]
  18. Hemilä M., Henriksson L., Ylikorkala O. Serum CRP in the diagnosis and treatment of pelvic inflammatory disease. Arch Gynecol Obstet. 1987;241(3):177–182. doi: 10.1007/BF00931315. [DOI] [PubMed] [Google Scholar]
  19. Hillis S. D., Joesoef R., Marchbanks P. A., Wasserheit J. N., Cates W., Jr, Westrom L. Delayed care of pelvic inflammatory disease as a risk factor for impaired fertility. Am J Obstet Gynecol. 1993 May;168(5):1503–1509. doi: 10.1016/s0002-9378(11)90790-x. [DOI] [PubMed] [Google Scholar]
  20. Jacobson L., Weström L. Objectivized diagnosis of acute pelvic inflammatory disease. Diagnostic and prognostic value of routine laparoscopy. Am J Obstet Gynecol. 1969 Dec 1;105(7):1088–1098. doi: 10.1016/0002-9378(69)90132-x. [DOI] [PubMed] [Google Scholar]
  21. Kahn J. G., Walker C. K., Washington A. E., Landers D. V., Sweet R. L. Diagnosing pelvic inflammatory disease. A comprehensive analysis and considerations for developing a new model. JAMA. 1991 Nov 13;266(18):2594–2604. doi: 10.1001/jama.266.18.2594. [DOI] [PubMed] [Google Scholar]
  22. Kessel E. Pelvic inflammatory disease with intrauterine device use: a reassessment. Fertil Steril. 1989 Jan;51(1):1–11. [PubMed] [Google Scholar]
  23. Kiviat N. B., Wølner-Hanssen P., Eschenbach D. A., Wasserheit J. N., Paavonen J. A., Bell T. A., Critchlow C. W., Stamm W. E., Moore D. E., Holmes K. K. Endometrial histopathology in patients with culture-proved upper genital tract infection and laparoscopically diagnosed acute salpingitis. Am J Surg Pathol. 1990 Feb;14(2):167–175. doi: 10.1097/00000478-199002000-00008. [DOI] [PubMed] [Google Scholar]
  24. Kiviat N. B., Wølner-Hanssen P., Peterson M., Wasserheit J., Stamm W. E., Eschenbach D. A., Paavonen J., Lingenfelter J., Bell T., Zabriskie V. Localization of Chlamydia trachomatis infection by direct immunofluorescence and culture in pelvic inflammatory disease. Am J Obstet Gynecol. 1986 Apr;154(4):865–873. doi: 10.1016/0002-9378(86)90473-4. [DOI] [PubMed] [Google Scholar]
  25. Lee N. C., Rubin G. L., Borucki R. The intrauterine device and pelvic inflammatory disease revisited: new results from the Women's Health Study. Obstet Gynecol. 1988 Jul;72(1):1–6. [PubMed] [Google Scholar]
  26. Lee N. C., Rubin G. L., Ory H. W., Burkman R. T. Type of intrauterine device and the risk of pelvic inflammatory disease. Obstet Gynecol. 1983 Jul;62(1):1–6. [PubMed] [Google Scholar]
  27. Lehtinen M., Laine S., Heinonen P. K., Teisala K., Miettinen A., Aine R., Punnonen R., Grönroos P., Paavonen J. Serum C-reactive protein determination in acute pelvic inflammatory disease. Am J Obstet Gynecol. 1986 Jan;154(1):158–159. doi: 10.1016/0002-9378(86)90419-9. [DOI] [PubMed] [Google Scholar]
  28. Loeffelholz M. J., Lewinski C. A., Silver S. R., Purohit A. P., Herman S. A., Buonagurio D. A., Dragon E. A. Detection of Chlamydia trachomatis in endocervical specimens by polymerase chain reaction. J Clin Microbiol. 1992 Nov;30(11):2847–2851. doi: 10.1128/jcm.30.11.2847-2851.1992. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Maslow A. S., Davis C. H., Choong J., Wyrick P. B. Estrogen enhances attachment of Chlamydia trachomatis to human endometrial epithelial cells in vitro. Am J Obstet Gynecol. 1988 Oct;159(4):1006–1014. doi: 10.1016/s0002-9378(88)80189-3. [DOI] [PubMed] [Google Scholar]
  30. McCormack W. M. Pelvic inflammatory disease. N Engl J Med. 1994 Jan 13;330(2):115–119. doi: 10.1056/NEJM199401133300207. [DOI] [PubMed] [Google Scholar]
  31. Mårdh P. A. An overview of infectious agents of salpingitis, their biology, and recent advances in methods of detection. Am J Obstet Gynecol. 1980 Dec 1;138(7 Pt 2):933–951. doi: 10.1016/0002-9378(80)91084-4. [DOI] [PubMed] [Google Scholar]
  32. Nasri M. N., Setchell M. E., Chard T. Vaginal scans in acute gynaecology. Lancet. 1990 Feb 10;335(8685):360–361. doi: 10.1016/0140-6736(90)90653-m. [DOI] [PubMed] [Google Scholar]
  33. Paavonen J., Aine R., Teisala K., Heinonen P. K., Punnonen R. Comparison of endometrial biopsy and peritoneal fluid cytologic testing with laparoscopy in the diagnosis of acute pelvic inflammatory disease. Am J Obstet Gynecol. 1985 Mar 1;151(5):645–650. doi: 10.1016/0002-9378(85)90156-5. [DOI] [PubMed] [Google Scholar]
  34. Paavonen J., Aine R., Teisala K., Heinonen P. K., Punnonen R., Lehtinen M., Miettinen A., Grönroos P. Chlamydial endometritis. J Clin Pathol. 1985 Jul;38(7):726–732. doi: 10.1136/jcp.38.7.726. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Paavonen J., Critchlow C. W., DeRouen T., Stevens C. E., Kiviat N., Brunham R. C., Stamm W. E., Kuo C. C., Hyde K. E., Corey L. Etiology of cervical inflammation. Am J Obstet Gynecol. 1986 Mar;154(3):556–564. doi: 10.1016/0002-9378(86)90601-0. [DOI] [PubMed] [Google Scholar]
  36. Paavonen J., Kiviat N., Brunham R. C., Stevens C. E., Kuo C. C., Stamm W. E., Miettinen A., Soules M., Eschenbach D. A., Holmes K. K. Prevalence and manifestations of endometritis among women with cervicitis. Am J Obstet Gynecol. 1985 Jun 1;152(3):280–286. doi: 10.1016/s0002-9378(85)80210-6. [DOI] [PubMed] [Google Scholar]
  37. Paavonen J., Teisala K., Heinonen P. K., Aine R., Laine S., Lehtinen M., Miettinen A., Punnonen R., Grönroos P. Microbiological and histopathological findings in acute pelvic inflammatory disease. Br J Obstet Gynaecol. 1987 May;94(5):454–460. doi: 10.1111/j.1471-0528.1987.tb03125.x. [DOI] [PubMed] [Google Scholar]
  38. Pasley J. N., Rank R. G., Hough A. J., Jr, Cohen C., Barron A. L. Absence of progesterone effects on chlamydial genital infection in female guinea pigs. Sex Transm Dis. 1985 Jul-Sep;12(3):155–158. doi: 10.1097/00007435-198507000-00012. [DOI] [PubMed] [Google Scholar]
  39. Patton D. L., Moore D. E., Spadoni L. R., Soules M. R., Halbert S. A., Wang S. P. A comparison of the fallopian tube's response to overt and silent salpingitis. Obstet Gynecol. 1989 Apr;73(4):622–630. [PubMed] [Google Scholar]
  40. Peipert J. F., Sweeney P. J. Diagnostic testing in obstetrics and gynecology: a clinician's guide. Obstet Gynecol. 1993 Oct;82(4 Pt 1):619–623. [PubMed] [Google Scholar]
  41. Peterson H. B., Galaid E. I., Cates W., Jr Pelvic inflammatory disease. Med Clin North Am. 1990 Nov;74(6):1603–1615. doi: 10.1016/s0025-7125(16)30497-7. [DOI] [PubMed] [Google Scholar]
  42. Rank R. G., Barron A. L. Specific effect of estradiol on the genital mucosal antibody response in chlamydial ocular and genital infections. Infect Immun. 1987 Sep;55(9):2317–2319. doi: 10.1128/iai.55.9.2317-2319.1987. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Rank R. G., White H. J., Hough A. J., Jr, Pasley J. N., Barron A. L. Effect of estradiol on chlamydial genital infection of female guinea pigs. Infect Immun. 1982 Nov;38(2):699–705. doi: 10.1128/iai.38.2.699-705.1982. [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Sellors J. W., Mahony J. B., Chernesky M. A., Rath D. J. Tubal factor infertility: an association with prior chlamydial infection and asymptomatic salpingitis. Fertil Steril. 1988 Mar;49(3):451–457. doi: 10.1016/s0015-0282(16)59772-6. [DOI] [PubMed] [Google Scholar]
  45. Sellors J., Mahony J., Goldsmith C., Rath D., Mander R., Hunter B., Taylor C., Groves D., Richardson H., Chernesky M. The accuracy of clinical findings and laparoscopy in pelvic inflammatory disease. Am J Obstet Gynecol. 1991 Jan;164(1 Pt 1):113–120. doi: 10.1016/0002-9378(91)90639-9. [DOI] [PubMed] [Google Scholar]
  46. Senanayake P., Kramer D. G. Contraception and the etiology of pelvic inflammatory disease: new perspectives. Am J Obstet Gynecol. 1980 Dec 1;138(7 Pt 2):852–860. doi: 10.1016/0002-9378(80)91070-4. [DOI] [PubMed] [Google Scholar]
  47. Soper D. E., Brockwell N. J., Dalton H. P., Johnson D. Observations concerning the microbial etiology of acute salpingitis. Am J Obstet Gynecol. 1994 Apr;170(4):1008–1017. doi: 10.1016/s0002-9378(94)70094-x. [DOI] [PubMed] [Google Scholar]
  48. Soper D. E. Diagnosis and laparoscopic grading of acute salpingitis. Am J Obstet Gynecol. 1991 May;164(5 Pt 2):1370–1376. doi: 10.1016/0002-9378(91)91474-b. [DOI] [PubMed] [Google Scholar]
  49. Stone K. M., Grimes D. A., Magder L. S. Personal protection against sexually transmitted diseases. Am J Obstet Gynecol. 1986 Jul;155(1):180–188. doi: 10.1016/0002-9378(86)90108-0. [DOI] [PubMed] [Google Scholar]
  50. Svensson L., Mårdh P. A., Weström L. Infertility after acute salpingitis with special reference to Chlamydia trachomatis. Fertil Steril. 1983 Sep;40(3):322–329. doi: 10.1016/s0015-0282(16)47294-8. [DOI] [PubMed] [Google Scholar]
  51. Svensson L., Weström L., Mårdh P. A. Contraceptives and acute salpingitis. JAMA. 1984 May 18;251(19):2553–2555. [PubMed] [Google Scholar]
  52. Svensson L., Weström L., Ripa K. T., Mårdh P. A. Differences in some clinical and laboratory parameters in acute salpingitis related to culture and serologic findings. Am J Obstet Gynecol. 1980 Dec 1;138(7 Pt 2):1017–1021. doi: 10.1016/0002-9378(80)91099-6. [DOI] [PubMed] [Google Scholar]
  53. Swayne L. C., Love M. B., Karasick S. R. Pelvic inflammatory disease: sonographic-pathologic correlation. Radiology. 1984 Jun;151(3):751–755. doi: 10.1148/radiology.151.3.6718737. [DOI] [PubMed] [Google Scholar]
  54. Sweet R. L., Blankfort-Doyle M., Robbie M. O., Schacter J. The occurrence of chlamydial and gonococcal salpingitis during the menstrual cycle. JAMA. 1986 Apr 18;255(15):2062–2064. [PubMed] [Google Scholar]
  55. Sweet R. L., Mills J., Hadley K. W., Blumenstock E., Schachter J., Robbie M. O., Draper D. L. Use of laparoscopy to determine the microbiologic etiology of acute salpingitis. Am J Obstet Gynecol. 1979 May 1;134(1):68–74. doi: 10.1016/0002-9378(79)90798-1. [DOI] [PubMed] [Google Scholar]
  56. Tessler F. N., Perrella R. R., Fleischer A. C., Grant E. G. Endovaginal sonographic diagnosis of dilated fallopian tubes. AJR Am J Roentgenol. 1989 Sep;153(3):523–525. doi: 10.2214/ajr.153.3.523. [DOI] [PubMed] [Google Scholar]
  57. Vessey M. P., Yeates D., Flavel R., McPherson K. Pelvic inflammatory disease and the intrauterine device: findings in a large cohort study. Br Med J (Clin Res Ed) 1981 Mar 14;282(6267):855–857. doi: 10.1136/bmj.282.6267.855. [DOI] [PMC free article] [PubMed] [Google Scholar]
  58. Washington A. E., Aral S. O., Wølner-Hanssen P., Grimes D. A., Holmes K. K. Assessing risk for pelvic inflammatory disease and its sequelae. JAMA. 1991 Nov 13;266(18):2581–2586. [PubMed] [Google Scholar]
  59. Wasserheit J. N., Bell T. A., Kiviat N. B., Wølner-Hanssen P., Zabriskie V., Kirby B. D., Prince E. C., Holmes K. K., Stamm W. E., Eschenbach D. A. Microbial causes of proven pelvic inflammatory disease and efficacy of clindamycin and tobramycin. Ann Intern Med. 1986 Feb;104(2):187–193. doi: 10.7326/0003-4819-104-2-187. [DOI] [PubMed] [Google Scholar]
  60. Witkin S. S., Jeremias J., Toth M., Ledger W. J. Detection of Chlamydia trachomatis by the polymerase chain reaction in the cervices of women with acute salpingitis. Am J Obstet Gynecol. 1993 May;168(5):1438–1442. doi: 10.1016/s0002-9378(11)90778-9. [DOI] [PubMed] [Google Scholar]
  61. Wølner-Hanssen P., Eschenbach D. A., Paavonen J., Kiviat N., Stevens C. E., Critchlow C., DeRouen T., Holmes K. K. Decreased risk of symptomatic chlamydial pelvic inflammatory disease associated with oral contraceptive use. JAMA. 1990 Jan 5;263(1):54–59. doi: 10.1001/jama.1990.03440010052029. [DOI] [PubMed] [Google Scholar]
  62. Wølner-Hanssen P., Eschenbach D. A., Paavonen J., Stevens C. E., Kiviat N. B., Critchlow C., DeRouen T., Koutsky L., Holmes K. K. Association between vaginal douching and acute pelvic inflammatory disease. JAMA. 1990 Apr 11;263(14):1936–1941. doi: 10.1001/jama.1990.03440140062032. [DOI] [PubMed] [Google Scholar]
  63. Wølner-Hanssen P., Paavonen J., Kiviat N., Young M., Eschenbach D. A., Holmes K. K. Outpatient treatment of pelvic inflammatory disease with cefoxitin and doxycycline. Obstet Gynecol. 1988 Apr;71(4):595–600. [PubMed] [Google Scholar]

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