If greater accuracy for the diagnosis of PID is desirable, a number of procedures can be performed. These procedures are not necessary, nor are they indicated, in every case of presumptive PID. In fact, transvaginal pelvic ultrasound is the only procedure that may be considered part of routine evaluation whenever PID is considered within the differential diagnosis.

Transvaginal pelvic ultrasound may demonstrate thickened, fluid-filled fallopian tubes or free pelvic fluid in acute, severe PID. 15 These findings alone are not specific enough to make a definitive diagnosis. However, pelvic abscesses may be seen as complex adnexal masses with multiple internal echoes. Pelvic ultrasound will also be useful in evaluating the possibility of ectopic pregnancy in those patients where the differential includes both entities.

Endometrial biopsy can also be used for the definitive histopathologic diagnosis of endometritis. Endometritis is uniformly associated with salpingitis. Specimens for culture may also be obtained but will frequently be contaminated with vaginal flora. The procedure is performed with an endometrial suction pipelle curette and is well tolerated. Endometrial biopsy is approximately 90 percent specific with similar sensitivity. Although this procedure is not difficult, few emergency practitioners are currently trained to do it. Thus, it is best deferred to a gynecologist. Further, its diagnostic utility in the ED setting is limited as results are not immediately available.

Culdocentesis can also be performed rapidly in the ED. However, its utility is also limited. The potential positive findings of leukocytes and bacteria are non-specific and may be a product of other inflammatory processes, such as appendicitis or diverticulitis, or due to contamination with vaginal contents.

Laparoscopy is the current gold standard for the diagnosis of PID16. It is significantly more sensitive and specific than clinical criteria alone. The minimum criteria to diagnose PID laparoscopically include visible hyperemia of the tubal surface, tubal wall edema, and the presence of exudate on the tubal surface and fimbriae. Pelvic masses consistent with tubo-ovarian abscess or ectopic pregnancy can also be directly visualized. Hepatic capsule exudate and/or adhesions may be demonstrated. Material may be obtained for definitive culture without the risk of vaginal contamination. However, the procedure is invasive and expensive, requiring an operating room and anesthesia. Findings on laparoscopy do not necessarily correlate with the severity of illness, because the laparoscopist can see only the surface of structures. Laparoscopy may fail to define up to 20 percent of cases.

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