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Enfermedad inflamatoria pélvica: manifestaciones clínicas

y diagnóstico.
Autores Jonathan Ross, MD, Mariam R. Chacko, MD
Editor de sección: Jeanne Marrazzo, MD, MPH, FACP, FIDSA
Subdirector: Allyson Bloom, MD

Todos los temas se actualizan a medida que hay nuevas pruebas disponibles y nuestro proceso de revisión por pares
está completo.

Revisión de literatura actualizada hasta: agosto de 2019. | Última actualización de este tema: 07 de enero de
2018.

INTRODUCCIÓN

La enfermedad inflamatoria pélvica (EPI) se refiere a la infección aguda y subclínica del tracto
genital superior en las mujeres, que afecta a todo el útero, las trompas de Falopio y los ovarios;
Esto suele ir acompañado de la afectación de los órganos pélvicos vecinos. Resulta en
endometritis, salpingitis, ooforitis, peritonitis, perihepatitis y / o absceso tubo-ovárico.

La mayoría de los casos de PID (85 por ciento) son causados por patógenos de transmisión
sexual o patógenos bacterianos asociados a la vaginosis. Menos del 15 por ciento de los casos
agudos de EPI no se transmiten sexualmente y, en cambio, están asociados con entéricos (p. Ej.,
Escherichia coli, Bacteroides fragilis , estreptococos del grupo B y Campylobacter spp) o agentes
patógenos respiratorios (p. Ej., Haemophilus influenzae , Streptococcus pneumoniae ,
estreptococos del grupo A y Staphylococcus aureus ) que han colonizado el tracto genital inferior [
1] La celulitis pélvica postoperatoria y el absceso, la infección pélvica relacionada con el
embarazo, la lesión o infección por traumatismo relacionada con el trauma y la infección pélvica
secundaria a la propagación de otra infección (p. Ej., Apendicitis, diverticulitis, tumor) también
pueden producir un cuadro clínico muy similar. Sin embargo, las diferencias etiológicas entre
estos procesos, principalmente porque no son causadas por una infección de transmisión sexual
(ITS), tienen implicaciones significativas para el tratamiento y la prevención. Las complicaciones
infecciosas de la cirugía ginecológica y el embarazo se discuten en otra parte. (Ver "Absceso
pélvico posthisterectomía" y "Tromboflebitis pélvica séptica" y "Endometritis posparto" ).

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PID representa un espectro de infección y no hay un estándar de oro de diagnóstico único. El

diagnóstico clínico sigue siendo el enfoque práctico más importante. Varias pautas de expertos
discuten el enfoque clínico para el diagnóstico de EPI. Estas incluyen las pautas de los Centros
para el Control y la Prevención de Enfermedades de los Estados Unidos sobre el manejo de las
ITS, las pautas europeas de la Unión Internacional contra las ITS para el manejo de las PID y las
pautas de la Asociación Británica para la Salud Sexual y el VIH sobre el manejo de las PID [ 2-4 ]
La discusión en este tema generalmente es consistente con estas pautas.

Las características clínicas y el diagnóstico de PID de transmisión sexual se revisarán aquí. La

patogenia, la microbiología, los factores de riesgo para la adquisición, el tratamiento y las
secuelas asociadas con este trastorno se analizan por separado. (Ver "Enfermedad inflamatoria
pélvica: patogénesis, microbiología y factores de riesgo" y "Enfermedad inflamatoria pélvica:
tratamiento en adultos y adolescentes" .)

CARACTERÍSTICAS CLÍNICAS

Patients at risk — Any sexually active female is at risk for sexually transmitted infection (STI)
associated pelvic inflammatory disease (PID), but those with multiple sexual partners are at the
highest risk. Additionally, age younger than 25, a partner with a sexually transmitted infection, and
a history of prior PID or a sexually transmitted infection are important risk factors. The use of
barrier contraception is protective. These are discussed in detail elsewhere. (See "Pelvic
inflammatory disease: Pathogenesis, microbiology, and risk factors", section on 'Risk factors'.)

While it is rare to have PID during pregnancy because the mucus plug and decidua seal off the
uterus from ascending bacteria, PID can occur in the first 12 weeks of gestation before this
occurs.

Women who undergo instrumentation of the cervix (eg, termination of pregnancy) are at higher
risk of infection ascending to cause PID. Older women less commonly present with PID, but when
they do, the cause is more likely to be non-STI related. Salpingitis has been reported in
premenarcheal girls and adolescents who are not sexually active, but it is very rare. In such
situations, respiratory and enteric bacteria should be also considered.

Spectrum of disease — The term PID encompasses a wide spectrum of clinical presentations.
The time course of presentation is typically acute over several days, but a more indolent
presentation over weeks to months can also occur. Some women do not present to care with
symptoms of PID but are later suspected to have had it because of tubal factor infertility. Even
acute symptomatic PID represents a spectrum of clinical disease, from mild, vague pelvic
symptoms to tubo-ovarian abscess and, rarely, fatal intra-abdominal sepsis. In some women, the
inflammatory process can extend to the liver capsule to cause perihepatitis (the Fitz-Hugh Curtis
syndrome).

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These varied clinical syndromes are discussed in more detail in the sections that follow.

Acute symptomatic PID — Acute symptomatic PID is characterized by the acute onset of lower
abdominal or pelvic pain, pelvic organ tenderness, and evidence of inflammation of the genital
tract. The findings can be subtle and nonspecific.

Symptoms — Lower abdominal pain is the cardinal presenting symptom in women with PID.
The abdominal pain is usually bilateral and rarely of more than two weeks' duration [2-4]. The
character of the pain is variable, and in some cases, may be quite subtle. The recent onset of pain
that worsens during coitus or with jarring movement may be the only presenting symptom of PID.
The onset of pain during or shortly after menses is particularly suggestive [5].

The majority of women with PID have mild to moderate disease and only a minority develop
peritonitis or pelvic abscess, which are usually manifest by more severe pain, greater tenderness
on examination, and systemic features such as fever.

Abnormal uterine bleeding (post-coital bleeding, inter-menstrual bleeding, menorrhagia) occurs in

one-third or more of patients with PID [6,7]. Other non-specific complaints include urinary
frequency and abnormal vaginal discharge.

Examination findings — On physical examination, most women with PID have abdominal
tenderness on palpation, greatest in the lower quadrants, which may or may not be symmetrical.
Rebound tenderness, fever, and decreased bowel sounds are usually limited to women with more
severe PID.

Acute cervical motion, uterine, and adnexal tenderness on bimanual pelvic examination are the
defining characteristic of acute symptomatic PID [7,8]. Purulent endocervical discharge and/or
vaginal discharge is also common. However, significant lateralization of adnexal tenderness is
uncommon in PID.

Laboratory findings — Most laboratory findings in PID are nonspecific. Although PID is
usually an acute process, only a minority of PID patients with more severe disease exhibit
peripheral blood leukocytosis [9]. Similarly, an elevated erythrocyte sedimentation rate (ESR) and
C-reactive protein (CRP) have poor sensitivity and specificity.

Perihepatitis — Perihepatitis (Fitz-Hugh Curtis Syndrome) occurs in the setting of PID when
there is inflammation of the liver capsule and peritoneal surfaces of the anterior right upper
quadrant. There is generally minimal stromal hepatic involvement. It occurs in approximately 10
percent of women with acute PID and is characterized by right upper quadrant abdominal pain
with a distinct pleuritic component, sometimes referred to the right shoulder. Marked tenderness in
the right upper quadrant can be seen on exam. The severity of the pain in this location may mask
the diagnosis of PID and lead to concerns regarding cholecystitis [10]. Aminotransferases are
usually normal or only slightly elevated [11,12].

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On laparoscopy or visual inspection, perihepatitis manifests as a patchy purulent and fibrinous

exudate ("violin string" adhesions), most prominently affecting the anterior surfaces of the liver (not
the liver parenchyma).

The syndrome was first associated with gonococcal salpingitis in 1920 [13] and subsequently with
Chlamydia trachomatis [14,15].

Tubo-ovarian abscess — A tubo-ovarian abscess is an inflammatory mass involving the

fallopian tube, ovary, and, occasionally, other adjacent pelvic organs. Women with a tubo-ovarian
abscess may have a palpable adnexal mass on examination. Other associated clinical findings are
discussed elsewhere. (See "Epidemiology, clinical manifestations, and diagnosis of tubo-ovarian
abscess", section on 'Clinical presentation'.)

Subclinical PID — Subclinical infection of the upper reproductive tract that does not prompt a
woman to present to medical care but is severe enough to produce significant sequelae appears
to be relatively common [7]. Women with tubal factor infertility that appears likely to have been a
result of past episodes of PID often give no history of PID [16-18]. As an example, in one study of
112 infertile women, 36 had adhesions or distal tube occlusion on laparoscopy suggestive of PID,
but only 11 had a documented history of a PID diagnosis [18].

Previously undiagnosed PID has also been identified in women with a history of previous mild
symptoms, but with an endometrial biopsy that demonstrates excess neutrophils and plasma cells,
consistent with inflammation and PID. Lower genital tract infection with gonorrhea, chlamydia, or
bacterial vaginosis is a risk factor for this finding [19]. As an example, in a study that included 562
women at risk for but without clinical findings suggestive of PID, 13 percent of them had
endometritis on endometrial biopsy, and rates of cervical C. trachomatis isolation were similar to
women with clinically evident PID [7]. Subclinical episodes of PID may occur more frequently in
oral contraceptive users [20,21].

Chronic PID — An indolent presentation of PID with low-grade fever, weight loss, and abdominal
pain has been reported with actinomycosis and tuberculosis. An association between an
indwelling IUD and risk of actinomycosis has been suggested, although this relationship remains
unclear. The diagnosis of this pathogen is discussed elsewhere. (See "Abdominal actinomycosis"
and "Clinical manifestations, diagnosis, and treatment of miliary tuberculosis", section on 'Clinical
manifestations'.)

EVALUATION

The evaluation of the woman with acute pelvic pain is discussed in detail elsewhere (see
"Evaluation of acute pelvic pain in nonpregnant adult women"). Elements of the evaluation that are
specific to female patients with suspected PID are outlined below.

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Initial evaluation — PID should be suspected in any young or sexually active female patient who
presents with lower abdominal pain and pelvic discomfort. The index of suspicion for PID should
be high, especially in adolescents. The goal of the initial evaluation of women with suspected PID
is to establish a presumptive clinical diagnosis of PID, assess for additional findings that increase
the likelihood of that diagnosis, and evaluate for other potential causes of pelvic pain.

A presumptive clinical diagnosis of PID can be made on the basis of history and physical exam
findings alone. Although laboratory testing is also done at the initial evaluation of all patients with
suspected PID, empiric treatment should not be delayed while awaiting results of these supportive
tests. (See 'Diagnosis' below and "Pelvic inflammatory disease: Treatment in adults and
adolescents", section on 'Threshold for treatment'.)

For women who are acutely ill and may have complications of PID, who do not improve with
empiric therapy for PID, or in whom the diagnosis remains uncertain, additional diagnostic tests,
such as pelvic imaging, can be useful. (See 'Additional evaluation for diagnostic uncertainty'
below.)

History — The history should focus on potential risk factors for PID. In particular, a sexual
history should be taken, assessing for new sexual partners and consistent use of condoms.

Additionally, the history should clarify the onset (usually recent) and character of pelvic pain
(usually constant and aching), with the understanding that even subtle and mild symptoms can be
consistent with PID (see 'Symptoms' above). Other symptoms such as prominent urinary or
gastrointestinal symptoms that might indicate alternative diagnoses should also be sought. (See
'Differential diagnosis' below.)

Physical and pelvic exam — All women suspected of having PID should undergo bimanual
exam to evaluate for cervical motion, uterine, or adnexal tenderness. Additionally, speculum exam
should be performed to evaluate for cervical mucopurulent discharge. (See 'Examination findings'
above.)

Pelvic organ tenderness is the defining characteristic of acute symptomatic PID. One study found
that adnexal tenderness was the sign that correlated best with the finding of endometritis on
endometrial biopsy [8]. Other diagnoses should also be considered if uterine and adnexal
tenderness are not prominent.

The presence of a palpable adnexal mass may suggest a tubo-ovarian abscess complicating PID,
but it could also reflect other disease processes in the differential diagnosis of PID. (See
"Approach to the patient with an adnexal mass" and "Differential diagnosis of the adnexal mass"
and "Epidemiology, clinical manifestations, and diagnosis of tubo-ovarian abscess".)

Point-of-care and laboratory tests — The following tests should be performed for all women
suspected of having PID:

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● Pregnancy test
● Microscopy of vaginal discharge (where available)
● Nucleic acid amplification tests (NAATs) for C. trachomatis and Neisseria gonorrhoeae
● NAATs for Mycoplasma genitalium (where available)
● HIV screening
● Serologic testing for syphilis

Testing for patients suspected of PID should always begin with a pregnancy test to rule out ectopic
pregnancy and complications of an intrauterine pregnancy, the main obstetric differential
diagnoses of PID. Saline microscopy of vaginal discharge is to assess for increased white blood
cells (WBC) in vaginal fluid which is sensitive for PID. The absence of WBC could thus suggest an
alternate diagnosis. However, the finding is not very specific for PID. Microscopy can also identify
coexisting bacterial vaginosis and trichomoniasis. Positive NAATs for C. trachomatis, N.
gonorrhoeae, or M. genitalium support the diagnosis of PID, but negative NAATs do not rule out
PID. HIV and syphilis testing are to evaluate for other sexually transmitted infections that share
similar risk factors with PID.

Additional tests can be potentially useful in certain situations. A Gram stain from cervical
discharge can also be a useful diagnostic tool, but is often not available in community settings. If a
cervical Gram stain is positive for gram-negative intracellular diplococci (suggestive of N.
gonorrhoeae) when interpreted by an experienced microscopist, the probability of PID greatly
increases [2-4]. However, if the Gram stain is negative, it is of limited value because most cases of
PID are not caused by gonorrhoea, and the sensitivity of microscopy is only around 60 percent.

A complete blood count, erythrocyte sedimentation rate, and C-reactive protein are often obtained
in patients seen in hospital-based settings who have more severe clinical presentations, including
fever, and may warrant inpatient therapy [4]. These tests have low sensitivity and specificity for the
diagnosis of PID in general, but can be useful in assessing severity (including cases of suspected
tubo-ovarian abscess) and monitoring the response to treatment. Urinalysis is also checked in
women with urinary symptoms. Hepatitis B virus testing may be appropriate depending on the
patient's risk history and vaccination history.

Testing for M. genitalium is useful to help guide the choice of specific antimicrobial therapy [22].
(See "Mycoplasma genitalium infection in men and women".)

Additional evaluation for diagnostic uncertainty — Additional testing may be warranted for
women who are acutely ill (eg, with fever, peritonitis, or a pelvic mass), whose symptoms are
atypical (eg, with an abnormal site or duration of symptoms) or do not improve significantly within
72 hours after starting empiric antibiotic therapy, or who have persisting pain after completing
therapy. These findings suggest the possibility of complications of PID (such as a tubo-ovarian
abscess) or alternate diagnosis. Pelvic imaging can be helpful to evaluate for these. Ultrasound is
generally the preferred imaging modality if an abscess or adnexal pathology is suspected clinically,

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as it produces high-quality images of the upper genital tract and does not expose the patient to
radiation. Otherwise, computed tomography (CT) or magnetic resonance imaging (MRI) may be
more helpful in identifying gastrointestinal pathology or alternate diagnoses. (See 'Imaging
techniques' below.)

Laparoscopy and transcervical endometrial biopsy are uncommonly performed. (See 'Other
studies' below.)

Imaging techniques — Pelvic imaging can help evaluate for alternative causes of pelvic pain
or complications of PID (such as a tubo-ovarian abscess). However, the absence of radiographic
findings consistent with PID does not rule out the possibility of PID and should not be a reason to
forgo or delay therapy for presumptive PID. Ultrasound is the imaging technique that has been
most studied for the evaluation of PID. There is limited evidence for the use of CT or MRI in
women with suspected PID [23-25]; however, they are useful to exclude alternative diagnoses in
women with an atypical and severe presentation.

The interpretation of sonographic findings are operator-dependent, and there are often minimal
changes seen in women with uncomplicated PID. Thickened, fluid-filled fallopian tubes [26] and
the cogwheel sign (cogwheel appearance on a cross-section of the tube) may be present. Among
women who have endometritis, ultrasound may show fluid or gas within the endometrial canal,
heterogeneous thickening, or indistinctness of the endometrial stripe, but these findings are
inconsistent. When a tubo-ovarian abscess is present, a complex thick-walled, multilocular cystic
collection can be seen in the adnexa, typically with internal echoes or multiple fluid levels. (See
"Epidemiology, clinical manifestations, and diagnosis of tubo-ovarian abscess", section on
'Imaging studies'.)

Doppler ultrasound scanning may be useful to identify areas of increased blood flow associated
with inflammation but is not used routinely because of the limited evidence to support its utility
[26].

Other studies — Findings on laparoscopy or transcervical endometrial biopsy can confirm the
clinical diagnosis of PID, but these tests are uncommonly performed.

● Laparoscopy — Despite its value in confirming a diagnosis of PID, laparoscopy is not

sensitive enough to be considered the diagnostic gold standard. The specificity of
laparoscopy is high, but its sensitivity is as low as 50 percent when compared with fimbrial
histopathology because it does not detect isolated endometritis or mild intra-tubal
inflammation [27]. Additionally, it is an invasive procedure, particularly for a condition that
does not typically warrant surgical intervention, and it is not universally available in the acute
setting.

Laparoscopy can be a useful part of the diagnostic workup for PID when imaging studies
have not been definitively informative in the following situations:
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• In a patient who has failed outpatient treatment for PID, to look for alternative causes of
the patient’s symptoms
• In a patient whose symptoms are not clearly improving or worsening after approximately
72 hours of inpatient treatment for PID, which suggests that PID may not be the correct
diagnosis

In addition, some surgeons may proceed directly to laparoscopy in an acutely ill patient with a
high suspicion of a competing diagnosis that would be diagnosed and intervened on through
laparoscopy (eg, appendicitis).

Consent for laparotomy at the same procedure should be obtained in advance for these
patients.

● Transcervical endometrial biopsy — This can be used to detect endometritis, which is

associated with salpingitis. However, it is not used routinely because the correlation is not 100
percent, there is a delay associated with processing the biopsy (which means that the result
seldom influences the decision to treat), and there is difficulty in interpreting the histology due
to the patchy nature of the inflammation, thus limiting consistency.

DIAGNOSIS

The presumptive clinical diagnosis of PID is made in sexually active young women, especially
women at high risk for sexually transmitted infections (STIs), who present with pelvic or lower
abdominal pain and have evidence of cervical motion, uterine, or adnexal tenderness on exam.

The sensitivity of this clinical diagnosis is only 65 to 90 percent [6,28,29], but because of the
potential for serious reproductive sequelae if PID treatment is delayed or not given, this
presumptive diagnosis is sufficient to warrant empiric antimicrobial therapy for PID. Even patients
with minimal or subtle findings should be treated since the potential consequences of withholding
therapy are great. (See "Pelvic inflammatory disease: Treatment in adults and adolescents",
section on 'Threshold for treatment'.)

In general, adding more diagnostic criteria increases the specificity, but decreases the sensitivity
of the diagnosis. The following additional findings can be used to support the clinical diagnosis of
PID [4]:

● Oral temperature >101°F (>38.3°C)

● Abnormal cervical or vaginal mucopurulent discharge or cervical friability
● Presence of abundant numbers of white blood cells (WBCs) on saline microscopy of vaginal
secretions (eg, >15 to 20 WBCs per high power field or more WBCs than epithelial cells)
● Documentation of cervical infection with N. gonorrhoeae or C. trachomatis

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The CDC also lists an elevated C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR)
as findings that may increase the specificity of the diagnosis of PID. However, these tests are not
particularly specific. In one study, a CRP ≥60 mg/L (or 6 mg/dL) or ESR ≥40 mm/h had a
specificity of only 61 percent for severe PID [30].

Certain findings can suggest against PID, such as the combination of normal cervical discharge
and absence of WBCs on microscopy of vaginal secretions. Also, prominent gastrointestinal and
urinary symptoms can suggest other etiologies of pelvic pain. (See 'Differential diagnosis' below.)

For women who have undergone additional testing, certain findings can help to confirm the
diagnosis of PID, although their absence does not rule out the possibility of PID:

● Pelvic imaging (transvaginal ultrasound, CT, or MRI) findings consistent with PID. These
include thickened, fluid-filled tubes/oviducts with or without free pelvic fluid, or tubo-ovarian
complex. Doppler studies may demonstrate tubal hyperemia suggestive of pelvic infection.

● Laparoscopic abnormalities consistent with PID. These include tubal erythema, edema, and
adhesions; purulent exudate or cul-de-sac fluid; and abnormal fimbriae.

● Histologic evidence of endometritis in a biopsy.

Standards for the diagnosis of subclinical PID remain to be established. It is typically diagnosed
retroactively in women who are ultimately found to have tubal factor infertility. Subclinical PID can
also be identified incidentally in women undergoing laparoscopy for other reasons.

DIFFERENTIAL DIAGNOSIS

The differential diagnosis of PID is broad and includes other pelvic pathology, urinary tract
processes, and gastrointestinal tract disorders. The main differential diagnoses for PID and their
suggestive features are summarized in the Table (table 1). Other diagnoses associated with acute
pelvic pain are discussed in further detail elsewhere. (See "Evaluation of acute pelvic pain in
nonpregnant adult women", section on 'Causes'.)

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Sexually transmitted
infections".)

INFORMATION FOR PATIENTS

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UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics."
The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading
level, and they answer the four or five key questions a patient might have about a given condition.
These articles are best for patients who want a general overview and who prefer short, easy-to-
read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and
more detailed. These articles are written at the 10th to 12th grade reading level and are best for
patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or
e-mail these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on "patient info" and the keyword(s) of interest.)

● Basics topics (see "Patient education: Pelvic inflammatory disease (The Basics)")

● Beyond the Basics topics (see "Patient education: Gonorrhea (Beyond the Basics)" and
"Patient education: Chlamydia (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

● Pelvic inflammatory disease (PID) refers to acute infection of the upper genital tract
structures, including the uterus, fallopian tubes, and/or ovaries. Neisseria gonorrhoeae and
Chlamydia trachomatis are often implicated, although vaginal flora may also play an important
role. Any sexually active female individual is at risk for PID, but those with multiple sexual
partners are at the highest risk. (See 'Introduction' above.)

● The term PID encompasses a wide spectrum of clinical presentations. Women with acute
symptomatic PID generally complain of recent onset of lower abdominal pain in association
with new vaginal discharge and/or intermenstrual bleeding. Constitutional symptoms may
occur and include fever and chills. Perihepatitis can also occur and present with marked
tenderness in the right upper quadrant. Pelvic organ tenderness on palpation is the defining
exam finding. (See 'Clinical features' above.)

● PID should be suspected in any young or sexually active female patient who presents with
pelvic discomfort. The index of suspicion for PID should be high, especially in adolescents.
The goal of the initial evaluation of women with suspected PID is to establish a presumptive
clinical diagnosis of PID, assess for additional findings that increase the likelihood of that
diagnosis, and evaluate for other potential causes of pelvic pain. Additionally, infections or co-
morbidities that can occur in women at risk for PID should be tested for. (See 'Initial
evaluation' above.)

In addition to a history, including sexual history, and physical and pelvic exams, the following
tests should be performed:

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• Pregnancy test
• Microscopy of vaginal discharge (where available)
• Nucleic acid amplification tests for C. trachomatis, N. gonorrhoeae, and M. genitalium
• HIV screening
• Serologic testing for syphilis

● For women who are acutely ill, who do not improve with empiric therapy for PID, or in whom
the diagnosis remains uncertain, imaging is warranted to evaluate for complications of PID
(eg, tubo-ovarian abscess) or alternative diagnoses. (See 'Additional evaluation for diagnostic
uncertainty' above and 'Differential diagnosis' above.)

● The presumptive clinical diagnosis of PID is made in sexually active young women or women
at risk for sexually transmitted infections (STIs) who present with pelvic or lower abdominal
pain and have evidence of cervical motion, uterine, or adnexal tenderness on exam. (See
'Diagnosis' above.)

● Because of the potential for serious reproductive sequelae if PID treatment is delayed or not
given, this presumptive diagnosis is sufficient to warrant empiric antimicrobial therapy for PID.
(See "Pelvic inflammatory disease: Treatment in adults and adolescents", section on
'Threshold for treatment'.)

● Other findings, such as fever, mucopurulent discharge or cervical friability, abundant white
blood cells on saline microscopy of vaginal secretions, and detection of genital infection with
N. gonorrhoeae, C. trachomatis, or M. genitalium, support the clinical diagnosis of PID.
Although not obtained in all patients, imaging studies with characteristic findings, laparoscopy
abnormalities consistent with PID, and histologic evidence of endometritis on biopsy can help
to confirm the diagnosis. (See 'Diagnosis' above.)

ACKNOWLEDGMENT — The editorial staff at UpToDate would like to acknowledge Charles

Livengood, MD, who contributed to an earlier version of this topic review.

Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES

1. Brunham RC, Gottlieb SL, Paavonen J. Pelvic inflammatory disease. N Engl J Med 2015;
372:2039.

2. Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections. 2012
European guideline for the management of pelvic inflammatory disease. Int J STD AIDS
2014; 25:1.

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3. Ross JDC, McCarthy J. UK National Guideline for the Management of PID. 2011. http://www.
bashh.org/guidelines (Accessed on June 18, 2015).

4. Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually transmitted
diseases treatment guidelines, 2015. MMWR Recomm Rep 2015; 64:1.

5. Korn AP, Hessol NA, Padian NS, et al. Risk factors for plasma cell endometritis among
women with cervical Neisseria gonorrhoeae, cervical Chlamydia trachomatis, or bacterial
vaginosis. Am J Obstet Gynecol 1998; 178:987.

6. Jacobson L, Weström L. Objectivized diagnosis of acute pelvic inflammatory disease.

Diagnostic and prognostic value of routine laparoscopy. Am J Obstet Gynecol 1969;
105:1088.

7. Wiesenfeld HC, Sweet RL, Ness RB, et al. Comparison of acute and subclinical pelvic
inflammatory disease. Sex Transm Dis 2005; 32:400.

8. Peipert JF, Ness RB, Blume J, et al. Clinical predictors of endometritis in women with
symptoms and signs of pelvic inflammatory disease. Am J Obstet Gynecol 2001; 184:856.

9. Eschenbach DA, Buchanan TM, Pollock HM, et al. Polymicrobial etiology of acute pelvic
inflammatory disease. N Engl J Med 1975; 293:166.

10. Piton S, Marie E, Parmentier JL. [Chlamydia trachomatis perihepatitis (Fitz Hugh-Curtis
syndrome). Apropos of 20 cases]. J Gynecol Obstet Biol Reprod (Paris) 1990; 19:447.

11. Litt IF, Cohen MI. Perihepatitis associated with salpingitis in adolescents. JAMA 1978;
240:1253.

12. Bolton JP, Darougar S. Perihepatitis. Br Med Bull 1983; 39:159.

13. Stajano C. La reaccio'n frenich en ginecologia. Semana Méd 1920; 27:243.

14. Wang SP, Eschenbach DA, Holmes KK, et al. Chlamydia trachomatis infection in Fitz-Hugh-
Curtis syndrome. Am J Obstet Gynecol 1980; 138:1034.

15. Paavonen J, Saikku P, von Knorring J, et al. Association of infection with Chlamydia
trachomatis with Fitz-Hugh-Curtis syndrome. J Infect Dis 1981; 144:176.

16. Moore DE, Spadoni LR, Foy HM, et al. Increased frequency of serum antibodies to
Chlamydia trachomatis in infertility due to distal tubal disease. Lancet 1982; 2:574.

17. Punnonen R, Terho P, Nikkanen V, Meurman O. Chlamydial serology in infertile women by

immunofluorescence. Fertil Steril 1979; 31:656.

https://www.uptodate.com/contents/pelvic-inflammatory-disease-clinical-manifestations-and-diagnosis/print?search=infecciones pelvicas&sourc… 12/16

20/9/2019 Pelvic inflammatory disease: Clinical manifestations and diagnosis - UpToDate

18. Wølner-Hanssen P. Silent pelvic inflammatory disease: is it overstated? Obstet Gynecol

1995; 86:321.

19. Wiesenfeld HC, Hillier SL, Krohn MA, et al. Lower genital tract infection and endometritis:
insight into subclinical pelvic inflammatory disease. Obstet Gynecol 2002; 100:456.

20. Washington AE, Gove S, Schachter J, Sweet RL. Oral contraceptives, Chlamydia
trachomatis infection, and pelvic inflammatory disease. A word of caution about protection.
JAMA 1985; 253:2246.

21. Ness RB, Keder LM, Soper DE, et al. Oral contraception and the recognition of endometritis.
Am J Obstet Gynecol 1997; 176:580.

22. Ross J, Guaschino S, Cusini M, Jensen J. 2017 European guideline for the management of
pelvic inflammatory disease. Int J STD AIDS 2018; 29:108.

23. Nishino M, Hayakawa K, Iwasaku K, Takasu K. Magnetic resonance imaging findings in

gynecologic emergencies. J Comput Assist Tomogr 2003; 27:564.

24. Bennett GL, Slywotzky CM, Giovanniello G. Gynecologic causes of acute pelvic pain:
spectrum of CT findings. Radiographics 2002; 22:785.

25. Tukeva TA, Aronen HJ, Karjalainen PT, et al. MR imaging in pelvic inflammatory disease:
comparison with laparoscopy and US. Radiology 1999; 210:209.

26. Romosan G, Valentin L. The sensitivity and specificity of transvaginal ultrasound with regard
to acute pelvic inflammatory disease: a review of the literature. Arch Gynecol Obstet 2014;
289:705.

27. Sellors J, Mahony J, Goldsmith C, et al. The accuracy of clinical findings and laparoscopy in
pelvic inflammatory disease. Am J Obstet Gynecol 1991; 164:113.

28. Livengood CH 3rd, Hill GB, Addison WA. Pelvic inflammatory disease: findings during
inpatient treatment of clinically severe, laparoscopy-documented disease. Am J Obstet
Gynecol 1992; 166:519.

29. Peipert JF, Boardman LA, Sung CJ. Performance of clinical and laparoscopic criteria for the
diagnosis of upper genital tract infection. Infect Dis Obstet Gynecol 1997; 5:291.

30. Miettinen AK, Heinonen PK, Laippala P, Paavonen J. Test performance of erythrocyte
sedimentation rate and C-reactive protein in assessing the severity of acute pelvic
inflammatory disease. Am J Obstet Gynecol 1993; 169:1143.

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GRAPHICS

Differential diagnosis for pelvic inflammatory disease

Diagnosis Suggestive features

Ectopic pregnancy History of missed menses, positive pregnancy test

Ovarian cyst rupture/torsion Sudden onset of severe pain

Endometriosis Cyclical or chronic pain

Cystitis Urinary frequency and/or dysuria

Appendicitis Pain localized to the right iliac fossa, vomiting

Diverticulitis Bowel symptoms in older women

Irritable bowel syndrome Generalized abdominal pain, constipation, diarrhea

Functional pain Other causes have been excluded

Graphic 102246 Version 1.0

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Contributor Disclosures
Jonathan Ross, MD Grant/Research/Clinical Trial Support: Janssen [HIV (educational support)].
Consultant/Advisory Boards: GlaxoSmithKlein [Gonorrhea, Mycoplasma genitalium [Development of new
antimicrobials)]; Hologic [Mycoplasma genitalium (diagnostics)]. Equity Ownership/Stock Options:
GlaxoSmithKlein; AstraZeneca. Mariam R Chacko, MD Nothing to disclose Jeanne Marrazzo, MD, MPH,
FACP, FIDSA Grant/Research/Clinical Trial Support: Merck [Vaginitis (etonogestrel/ethinyl estradiol vaginal
ring)]; Entasis [Gonorrhea treatment (Investigational drug)]; Cepheid [STD diagnosis (Investigational drug)].
Consultant/Advisory Boards: BioFire Diagnostics [Vaginitis (diagnostic testing strategies)]. Other Financial
Interest: Gilead [Data and Safety Monitoring Board member]. Allyson Bloom, MD Nada que revelar

Las divulgaciones de los colaboradores son revisadas por conflictos de intereses por el grupo editorial.
Cuando se encuentran, se abordan examinando a través de un proceso de revisión multinivel y a través de
los requisitos para que se proporcionen referencias para respaldar el contenido. Se requiere el contenido de
referencia apropiado de todos los autores y debe cumplir con los estándares de evidencia de UpToDate.

Política de conflicto de intereses

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