Pelvic inflammatory disease diagnostic criteria: Difference between revisions
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{{CMG}} | {{CMG}} | ||
==Diagnostic Criteria== | ==Diagnostic Criteria== | ||
===Diagnostic Challenges=== | |||
Acute PID is difficult to diagnose because of the wide variation in the symptoms and signs. Many women with PID have subtle or mild symptoms. Delay in diagnosis and treatment probably contributes to inflammatory sequelae in the upper reproductive tract. | |||
*[[Laparoscopy]] can be used to obtain a more accurate diagnosis of [[salpingitis]] and a more complete bacteriologic diagnosis. However, this diagnostic tool frequently is not readily available, and its use is not easy to justify when symptoms are mild or vague. Moreover, [[laparoscopy]] will not detect [[endometritis]] and might not detect subtle inflammation of the [[fallopian tube]]s. Consequently, a diagnosis of PID usually is based on clinical findings. | |||
*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% compared with [[laparoscopy]]. | |||
*The PPV of a clinical diagnosis of acute PID depends on the epidemiologic characteristics of the population, with higher PPVs among sexually active young women (particularly adolescents), patients attending STD clinics, and those who live in other settings where the rates of [[gonorrhea]] or [[chlamydia]] are high. *Regardlesss of PPV, however, in all settings, '''no single historical, physical, or laboratory finding is both sensitive and specific for the diagnosis of acute PID'''. | |||
*Combinations of diagnostic findings that improve either sensitivity (i.e., detect more women who have PID) or specificity (i.e., exclude more women who do not have PID) do so only at the expense of the other. For example, requiring two or more findings excludes more women who do not have PID but also reduces the number of women with PID who are identified. | |||
*Many episodes of PID go unrecognized. | |||
*Although some cases are asymptomatic, others are not diagnosed because the patient or the health-care provider fails to recognize the implications of mild or nonspecific symptoms or signs (e.g., abnormal bleeding, [[dyspareunia]], and [[vaginal discharge]]). | |||
Because of the difficulty of diagnosis and the potential for damage to the reproductive health of women (even by apparently mild or subclinical PID), health-care providers should maintain a low threshold for the diagnosis of PID. | |||
===Diagnostic Recommendations=== | |||
The following recommendations for diagnosing PID are intended to help health-care providers recognize when PID should be suspected and when they need to obtain additional information to increase diagnostic certainty. | The following recommendations for diagnosing PID are intended to help health-care providers recognize when PID should be suspected and when they need to obtain additional information to increase diagnostic certainty. | ||
Empiric treatment for PID should be initiated in sexually active young women and other women at risk for STDs if they are experiencing pelvic or lower abdominal pain, if no cause for the illness other than PID can be identified, and if one or more of the following minimum criteria are present on pelvic examination: | Empiric treatment for PID should be initiated in sexually active young women and other women at risk for STDs if they are experiencing pelvic or lower abdominal pain, if no cause for the illness other than PID can be identified, and if one or more of the following minimum criteria are present on pelvic examination: | ||
* [[ | * [[Cervix|Cervical]] motion tenderness | ||
or | or | ||
* [[Uterus|Uterine]] tenderness | * [[Uterus|Uterine]] tenderness | ||
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Most women with PID have either mucopurulent cervical discharge or evidence of WBCs on a microscopic evaluation of a saline preparation of vaginal fluid (i.e., wet prep). If the cervical discharge appears normal and no WBCs are observed on the wet prep of vaginal fluid, the diagnosis of PID is unlikely, and alternative causes of pain should be considered. A wet prep of vaginal fluid offers the ability to detect the presence of concomitant infections (e.g., [[Bacterial vaginosis]] and [[trichomoniasis]]). | Most women with PID have either mucopurulent cervical discharge or evidence of WBCs on a microscopic evaluation of a saline preparation of vaginal fluid (i.e., wet prep). If the cervical discharge appears normal and no WBCs are observed on the wet prep of vaginal fluid, the diagnosis of PID is unlikely, and alternative causes of pain should be considered. A wet prep of vaginal fluid offers the ability to detect the presence of concomitant infections (e.g., [[Bacterial vaginosis]] and [[trichomoniasis]]). | ||
===The Most Specific Criteria for Diagnosing PID Include=== | ====The Most Specific Criteria for Diagnosing PID Include==== | ||
* Endometrial biopsy with histopathologic evidence of endometritis; | * Endometrial biopsy with histopathologic evidence of endometritis; | ||
Revision as of 19:05, 28 December 2012
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Diagnostic Criteria
Diagnostic Challenges
Acute PID is difficult to diagnose because of the wide variation in the symptoms and signs. Many women with PID have subtle or mild symptoms. Delay in diagnosis and treatment probably contributes to inflammatory sequelae in the upper reproductive tract.
- Laparoscopy can be used to obtain a more accurate diagnosis of salpingitis and a more complete bacteriologic diagnosis. However, this diagnostic tool frequently is not readily available, and its use is not easy to justify when symptoms are mild or vague. Moreover, laparoscopy will not detect endometritis and might not detect subtle inflammation of the fallopian tubes. Consequently, a diagnosis of PID usually is based on clinical findings.
- 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% compared with laparoscopy.
- The PPV of a clinical diagnosis of acute PID depends on the epidemiologic characteristics of the population, with higher PPVs among sexually active young women (particularly adolescents), patients attending STD clinics, and those who live in other settings where the rates of gonorrhea or chlamydia are high. *Regardlesss of PPV, however, in all settings, no single historical, physical, or laboratory finding is both sensitive and specific for the diagnosis of acute PID.
- Combinations of diagnostic findings that improve either sensitivity (i.e., detect more women who have PID) or specificity (i.e., exclude more women who do not have PID) do so only at the expense of the other. For example, requiring two or more findings excludes more women who do not have PID but also reduces the number of women with PID who are identified.
- Many episodes of PID go unrecognized.
- Although some cases are asymptomatic, others are not diagnosed because the patient or the health-care provider fails to recognize the implications of mild or nonspecific symptoms or signs (e.g., abnormal bleeding, dyspareunia, and vaginal discharge).
Because of the difficulty of diagnosis and the potential for damage to the reproductive health of women (even by apparently mild or subclinical PID), health-care providers should maintain a low threshold for the diagnosis of PID.
Diagnostic Recommendations
The following recommendations for diagnosing PID are intended to help health-care providers recognize when PID should be suspected and when they need to obtain additional information to increase diagnostic certainty.
Empiric treatment for PID should be initiated in sexually active young women and other women at risk for STDs if they are experiencing pelvic or lower abdominal pain, if no cause for the illness other than PID can be identified, and if one or more of the following minimum criteria are present on pelvic examination:
- Cervical motion tenderness
or
- Uterine tenderness
or
- Adnexal tenderness.
The requirement that all three minimum criteria be present before the initiation of empiric treatment could result in insufficient sensitivity for the diagnosis of PID. The presence of signs of lower-genital–tract inflammation (predominance of leukocytes in vaginal secretions, cervical exudates, or cervical friability), in addition to one of the three minimum criteria, increases the specificity of the diagnosis. Upon deciding whether to initiate empiric treatment, clinicians should also consider the risk profile of the patient for STDs.
More elaborate diagnostic evaluation frequently is needed because incorrect diagnosis and management of PID might cause unnecessary morbidity. One or more of the following additional criteria can be used to enhance the specificity of the minimum criteria and support a diagnosis of PID:
- Oral temperature >101° F (>38.3° C);
- Abnormal cervical or vaginal mucopurulent discharge;
- Presence of abundant numbers of WBC on saline microscopy of vaginal fluid;
- Elevated erythrocyte sedimentation rate;
- Elevated C-reactive protein; and
- Laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis.
Most women with PID have either mucopurulent cervical discharge or evidence of WBCs on a microscopic evaluation of a saline preparation of vaginal fluid (i.e., wet prep). If the cervical discharge appears normal and no WBCs are observed on the wet prep of vaginal fluid, the diagnosis of PID is unlikely, and alternative causes of pain should be considered. A wet prep of vaginal fluid offers the ability to detect the presence of concomitant infections (e.g., Bacterial vaginosis and trichomoniasis).
The Most Specific Criteria for Diagnosing PID Include
- Endometrial biopsy with histopathologic evidence of endometritis;
- Transvaginal sonography or magnetic resonance imaging techniques showing thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex, or Doppler studies suggesting pelvic infection (e.g., tubal hyperemia); or
- Laparoscopic abnormalities consistent with PID.
A diagnostic evaluation that includes some of these more extensive procedures might be warranted in some cases. Endometrial biopsy is warranted in women undergoing laparoscopy who do not have visual evidence of salpingitis, because endometritis is the only sign of PID for some women.