Diagnosis

PID represents a spectrum of infection, ranging from patients who are minimally symptomatic to those who are toxic with fever, vomiting, and severe pain at the time of presentation.

As a result, the diagnosis of PID often presents a challenge for the emergency physician because of the nonspecific nature of the most common presenting signs and symptoms.

However, while there is no gold standard for the diagnosis of PID, information garnered from the history and physical exam will certainly aid in diagnosis.

More than 90% of patients diagnosed with PID present with bilateral lower abdominal pain.¹² The onset of this pain during or shortly after menses is particularly suggestive, as up to 75% of cases occur within the first 7 days of menses, when the quality of the cervical mucus favors the ascension of vaginal bacteria.¹³

New vaginal discharge is also present in up to 75% of cases but is neither sensitive nor specific for the diagnosis.¹⁴ Abnormal uterine bleeding occurs in one-third of patients.14

More than 90% of patients with PID will have a tender lower abdomen, but only half of all patients exhibit fever.¹⁵

The pelvic examination is unequivocally the most useful component of the physical exam to aid in the diagnosis of PID. Mucopurulent endocervical discharge, cervical motion tenderness, and bilateral adnexal tenderness are all highly suggestive of PID.¹⁵ Endocervical cultures for N. gonorrhoeae and C. trachomatis should be obtained in all cases of presumed PID.

There is no single test or combination of tests that is sensitive and specific for the diagnosis of PID. Additional criteria used to enhance specificity for the diagnosis include oral temperature higher than 101° F, abnormal cervical or vaginal mucopurulent discharge, presence of abundant numbers of white blood cells on saline microscopy of vaginal secretions, elevated ESR, elevated CRP, and laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis.¹⁵