Pelvic inflammatory disease (PID) refers to the clinical syndrome (unrelated to pregnancy or surgery) that results when cervical microorganisms ascend to the endometrium, fallopian tubes and contiguous pelvic structures. 

This produces the inflammatory conditions of 

• endometritis
• salpingitils
• pelvic peritonitis or tubo-ovarian abscess

2.  How do microorganisms reach the upper genital tract?

PID results from direct canalicular spread of organisms from the endocervix to the endometrial and fallopian tube mucosa.

3. What conditions can present with the patient's complaints of fever and lower abdominal pain?

 Other causes of fever and lower abdominal pain include 

• acute appendicitis
• diverticulitis
• ectopic pregnancy
•  intraabdominal abscess secondary to perforation of colon
• colitis (ischemic or infectious)
•  mesenteric lymphadenitis, etc.
  
  

4. What are the minimum clinical criteria needed for the diagnosis of pelvic inflammatory disease?

•  The clinical diagnosis of acute PID is imprecise. 
  • Data indicate that a clinical diagnosis of symptomatic PID has a positive predictive value (PPV) for salpingitis of 65%-90% when compared with laparoscopy as the standard.
  • The PPV of a clinical diagnosis of acute PID varies depending on epidemiological characteristics and the clinical setting, with higher PPV among sexually active young women and among patients attending STD clinics or from settings with high rates of gonorrhea or Chlamydia. 
  • In all settings, however, no single historical, physical, or laboratory finding is both sensitive and specific for the diagnosis of acute PID.

5. What is the Empiric treatment of PID 

Empiric treatment of PID should be instituted on the basis of the presence of all of the following three minimum clinical criteria for pelvic inflammation and in the absence of an established cause other than PID:

1. lower abdominal tenderness,
2. adnexal tenderness, and
3. cervical motion tenderness.

For women with fever clinical signs, more elaborate diagnostic evaluation is warranted because incorrect diagnosis and management may cause unnecessary morbidity. These additional criteria may be used to increase the specificity of the diagnosis.

6. Listed are the routine criteria for diagnosing PID:

1. oral temperature >38.3
2. abnormal cervical or vaginal discharge
3. elevated erythrocyte sedimentation rate
4. elevated C-reactive protein
5. laboratory documentation of cervical infection with N. gonorrhea or C. trachomatis.

7. What is the relationship between PID and intrauterine devise?

The incidence of PID is 5 to 10 times higher in women with intrauterine devices than in those not using this form of contraception.

8. Name the common pathogens implicated in PID.

Sexually transmitted organisms, especially 

• Neisseria gonorrhea and 
• Chylamdia trachomatis, are implicated in the majority of cases; however, microorganisms that can be part of the vaginal flora, such as anaerobes, 
• Gardinerella vaginalis, 
• enteric Gram-negative rods, and 
• Streptococcus agalactiae also can cause PID.

 Some experts also believe that Mycoplasma hominis and Ureaplasma urealyticum are etiologic agents of PID.

9. How would you treat this patient?

Antimicrobial agents with activity against gonococci, chlamydia. trachomatis, and anaerobes are used in the treatment of PID. 

Regimens include 

• cefoxitin plus doxycycline
• clindamycin plus gentamicin
• ceftriaxone plus doxycycline
• ciprofloxacin plus clindamycin.