Clinical Findings

Lower abdominal pain is the most frequent presenting complaint in PID. Other symptoms may include abnormal vaginal discharge, vaginal bleeding, post-coital bleeding, dyspareunia, irritative voiding symptoms, fever, malaise, nausea, and vomiting. PID may be minimally symptomatic or asymptomatic.9

The physical examination is usually notable for lower abdominal tenderness, mucopurulent cervicitis, cervical motion tenderness, and bilateral adnexal tenderness. However, women with PID often present with mild pelvic pain, which can be overlooked by the clinician. Disproportionate unilateral adnexal tenderness and/or adnexal mass or fullness may indicate an ovarian abscess. Abdominal guarding and rebound tenderness will develop with peritonitis. Right upper quadrant tenderness, particularly with jaundice, may indicate Fitzhugh-Curtis syndrome. Signs of other STDs should be noted and evaluated.

Laboratory evaluation in the ED should always include a pregnancy test. The possibility of ectopic pregnancy or septic abortion must be considered, and concurrent pregnancy will affect the treatment for PID. Saline-treated and potassium hydroxide-treated wet preparations of vaginal secretions should be examined for leukorrhea (more than 1 pmn/epithelial cell), trichomoniasis, and clue cells. The absence of leukorrhea has been suggested to be a good negative predictor for PID. 13 Endocervical swabs should be sent for culture and can be gram stained for gonococci. DNA probes for gonorrhea and chlamydia are useful, if available. Elevated white blood cell counts, sedimentation rates, and/or C-reactive protein support the diagnosis of PID. The syphilis test for rapid plasma reagin should be performed. Patients should be counseled on testing for hepatitis and HIV. HIV-infected women with PID may present with more severe symptoms and more frequent coinfection with Candida and human papillomavirus.14

Due to the need for early treatment to minimize serious sequelae in vulnerable populations, the diagnosis of PID is usually based on clinical criteria with or without laboratory evidence. The wide range of clinical findings may lead to under or over diagnosis. Table 10.5:1 details the current Centers for Disease Control and

Prevention (CDC) diagnostic criteria for PID.14

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