Sexually Transmitted Infections (STI) in Adolescents — Pelvic Inflammatory Disease — Clinical Pathway: Emergency and Primary Care

Sexually Transmitted Infections (STI) in Adolescents Clinical Pathway — Emergency Department and Primary Care

Pelvic Inflammatory Disease

General

  • Inflammatory disease of upper female genital tract, includes any combination of Endometritis, salpingitis, tubo-ovarian abscess, pelvic peritonitis
  • Challenging Diagnosis
    • Classic presentation bilateral, lower abdominal crampy pain, tenderness
    • Abnormal vaginal bleeding, discharge, dyspareunia
    • Many have subtle, non-specific symptoms or may be asymptomatic
    • Infection is polymicrobial, < 50% test positive for GC, chlamydia
  • Low Threshold for Empiric Treatment for suspected PID
    • Strongly consider treatment in sexually active young women with lower abdominal pain w/o another clear cause of symptoms
    • Delay in diagnosis and treatment contributes to sequelae of chronic pelvic pain and infertility

Criteria to Guide Clinical Diagnosis (65-90% PPV Compared to Laparoscopy)

Minimum Criteria:
> 1 of the Following Present		 One or more of the following criteria can increase the specificity of the minimum criteria
  • Cervical motion tenderness
  • Uterine tenderness
  • Adnexal tenderness
  • PO temperature > 38.3 °C
  • Abnormal cervical mucopurulent discharge to cervical friability
  • Presence of abundant WBCs on saline microscopy of vaginal fluid
  • Elevated ESR
  • Elevated CRP
  • Laboratory documentation of N. gonorrhoeae or C. trachomatis
  • Note: Lack of abnormal cervical discharge and WBCs on vaginal fluid on microscopy makes the diagnosis of PID unlikely.

Differential Diagnosis

  • Pyelonephritis, urolithiasis
  • Gastroenteritis, constipation, IBS, IBD, functional abdominal pain
  • Ovarian cyst, torsion, mass, mittelschmerz

Clinical Evaluation and Treatment

  • Complete physical exam, genital exam
  • STI Testing
  • Lower abdominal US to evaluate for endometritis, TOA, tube or ovarian torsion
  • Antibiotics, Disposition