**Pelvic Inflammatory Disease (PID)**

\[Slide 2\]

**Learning Objectives**

Upon completion of this content, the learner will be able to:

1.  Describe the epidemiology of PID in the United States.

2.  Describe the pathogenesis of PID.

3.  Discuss the clinical manifestations of PID.

4.  Identify the clinical criteria used in the diagnosis of PID.

5.  List CDC-recommended treatment regimens for PID.

6.  Summarize appropriate prevention counseling messages for a patient
    with PID.

7.  Describe public health measures to prevent PID.

\[Slide 3\]

**Lessons**

I.  Epidemiology: Disease in the U.S.

II. Pathogenesis

III. Clinical manifestations

IV. Diagnosis

V.  Patient management

VI. Prevention

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I.  **Epidemiology: Disease in the U.S.**

    \[Slide 5\]

    A.  Definition: PID is a clinical syndrome associated with ascending
        spread of microorganisms from the vagina or cervix to the
        endometrium, fallopian tubes, ovaries, and contiguous
        structures. PID comprises a spectrum of inflammatory disorders
        including any combination of endometritis (infection of the
        endometrium), salpingitis (infection of the fallopian tubes),
        tubo-ovarian abscess, or pelvic peritonitis (infection of the
        peritoneum). PID may be asymptomatic ("silent") or overt with
        mild to severe symptoms.

        \[Slide 6\]

    B.  Pelvic Inflammatory Disease

        1.  Occurs in approximately 1 million U.S. women annually.

        2.  Annual cost exceeds \$4.2 billion.

        3.  No national surveillance or reporting requirements exist,
            and national estimates are limited by insensitive clinical
            diagnosis criteria.

        4.  Hospitalizations declined through the 1980s and have been
            constant since 1995.

        5.  This trend may be attributable to the increasing rate of
            outpatient treatment rather than an actual decline in the
            incidence of PID.

        6.  The reported number of initial visits to physicians' offices
            for PID declined between 1993 and 1998 and has remained
            unchanged since then.

\[Slide 7\]

Graph: Pelvic Inflammatory Disease\--hospitalization of women 15-44
years of age: United States, 1980-2002

\[Slide 8\]

Graph: Pelvic Inflammatory Disease\--initial visits to physicians'
offices by women 15-44 years of age: United States, 1980-2003

\[Slide 9\]

C.  Risk factors

    1.  Adolescence is a risk factor because of increased age-related
        chlamydia and gonorrhea rates and the presence of cervical
        cellularity (ectopy) which allows for adherence of infectious
        organisms. When gonorrhea and chlamydia are controlled for,
        there is no elevated risk for adolescents.

    2.  History of PID: damaged fallopian tube mucosa may be more
        susceptible to recurrent infection

    3.  History of gonorrhea or chlamydia: increased likelihood of
        recurrent gonorrhea or chlamydia

    4.  Male partners with gonorrhea, chlamydia, or multiple partners

    5.  Current douching: contributes to vaginal flora changes,
        epithelial damage, and disruption of cervical mucous barrier

    6.  Insertion of IUD within the first 21 days of placement; after 21
        days, risk returns to baseline

    7.  Bacterial vaginosis: associated with PID in gynecological
        procedures

    8.  Demographics (socioeconomic status): may be related to access to
        care

    9.  Oral contraceptive use: may increase the risk of cervical
        chlamydial infection because of cervical ectopy, but decreases
        the risk of clinically apparent symptomatic PID (mechanisms
        unclear). Oral contraceptives also cause thickening of cervical
        mucous which may be protective against lower genital tract
        organisms ascending into the upper genital tract.

\[Slide 10\]

Image: Normal cervix with ectopy

\[Slide 11\]

II. **Pathogenesis**

    \[Slide 12\]

    A.  Microbial etiology

        1.  Most cases of PID are polymicrobial.

        2.  Most common pathogens:

            a.  *N. gonorrhoeae*: recovered from cervix in 30%-80% of
                women with PID

            b.  *C. trachomatis*: recovered from cervix in 20%-40% of
                women with PID; recovered from endometrium or tubes in a
                majority of women with cervical chlamydial infection.
                Especially associated with perihepatitis
                (Fitz-Hugh-Curtis syndrome---see Chlamydia module).

            c.  *N. gonorrhoeae* and *C. trachomatis* are present in
                combination in approximately 25%-75% of patients with
                PID; relative prevalence of these and other organisms
                depends on population studied.

        3.  Other microbes include:

            a.  Aerobic Gram-negative rods (e.g., *E. coli*)

            b.  Anaerobes (*Bacteroides* spp., *Prevotella* spp.,
                *Peptostreptococcus* spp.); especially those associated
                with bacterial vaginosis

            c.  Mycoplasmas, ureaplasmas: have been isolated from the
                endometrium and fallopian tubes of women with PID

            d.  Gram-positive organisms (S*treptococcus* spp.)

                \[Slide 13\]

    B.  Pathway of ascendant infection:
        cervicitis→endometritis→salpingitis/oophoritis/tubo-ovarian
        abscess→peritonitis

    C.  Intermittent ascent of microorganisms into the endometrial
        cavity may be a physiological phenomenon. Fate of organisms
        depends on viability, number, pathogenicity, and local defense
        mechanisms.

    D.  The response to ascending organisms is an inflammatory one that
        may lead to scarring of the tubes, subsequent infertility,
        ectopic pregnancy, or chronic pelvic pain. This scarring may
        occur even in women who do not report a history of PID symptoms.

        \[Slide 14\]

        Image: Normal human fallopian tube tissue

        \[Slide 15\]

        Image: *C. trachomatis* infection (PID)

        \[Slide 16\]

III. **Clinical Manifestations**

     \[Slide 17\]

     PID classification: PID may be asymptomatic or subclinical
     (silent), or overt with either moderate or severe symptoms.

     A.  Subclinical, asymptomatic, or "silent PID"

         1.  Occurs approximately 60% of the time; makes diagnosis and
             treatment problematic; women may not seek care

         2.  Atypical presentation may include dyspareunia, irregular
             bleeding, urinary, or gastrointestinal symptoms.

     B.  Symptomatic or overt PID with moderate symptomatology

         1.  Occurs approximately 36% of the time; signs/symptoms
             include lower abdominal pain, cramping, dysuria,
             intermittent or post-coital bleeding, vaginal discharge, or
             fever.

         2.  Uterine tenderness or cervical motion pain are present on a
             pelvic exam in most cases of moderate PID.

     C.  Symptomatic or overt PID with severe symptomatology

         1.  Occurs approximately 4% of the time; patients appear very
             ill with fever, chills, purulent vaginal discharge, nausea,
             vomiting, and elevated white blood cell count (WBC).

         2.  Other laboratory indicators such as erythrocyte
             sedimentation rate (ESR) and C-reactive protein (CRP) may
             also be elevated.

             \[Slide 18\]

     D.  Sequelae

         1.  Approximately 25% of women with a single episode of
             symptomatic PID will experience sequelae, including ectopic
             pregnancy, infertility, or chronic pelvic pain.

         2.  The risk of ectopic pregnancy is increased 6- to10-fold
             after PID.

         3.  Tubal infertility occurs in 8% of women after 1 episode of
             PID, in 20% of women after 2 episodes, and in 50% of women
             after 3 episodes.

\[Slide 19\]

IV. **Diagnosis**

    \[Slide 20\]

    A.  CDC recommends empiric treatment of PID if these minimum
        criteria are met in the absence of any other explanation:

        1.  Uterine/adnexal tenderness (bilateral or unilateral), or

        2.  Cervical motion tenderness

    B.  Acute adnexal tenderness may be the most sensitive sign of upper
        genital tract infection. Under some circumstances, a clinician
        may choose to treat with even less specific finding. The general
        recommendation is to err on the side of over treatment, given
        the high incidence of adverse outcomes with untreated PID.

        \[Slide 21\]

    C.  Additional criteria to increase specificity of PID diagnosis
        (but will decrease sensitivity)

        1.  Temperature \>38.3°C (101° F)

        2.  Abnormal cervical or vaginal mucopurulent discharge

        3.  Presence of WBCs on saline wet prep

        4.  Elevated erythrocyte sedimentation rate (ESR)

        5.  Elevated C-reactive protein (CRP)

        6.  Gonorrhea or chlamydia test positive

            \[Slide 22\]

            Image: Mucopurulent cervical discharge (positive swab test)

        7.  Most women with PID have either mucopurulent cervical
            discharge or evidence of WBCs on wet prep. If there are no
            WBCs found on the wet prep, the diagnosis of PID is
            unlikely.

            \[Slide 23\]

    D.  Other more specific criteria used in diagnosing PID include:

        1.  Endometrial biopsy which shows histopathologic evidence of
            endometritis

        2.  Transvaginal sonography or magnetic resonance imaging (MRI)
            (may demonstrate tubo-ovarian abscess \[TOA\] or thickened
            tubes with or without free pelvic fluid)

        3.  Laparoscopy showing abnormalities consistent with PID.
            Laparoscopy is indicated for:

            a.  Severe peritonitis to exclude ruptured tubal abscess or
                ruptured appendix

            b.  Patients with mild signs in whom the diagnosis is
                unclear

            c.  Patients who fail to respond to antibiotic therapy

            d.  Percutaneous drainage of an abscess

                \[Slide 24\]

V.  **Patient Management**

    \[Slide 25\]

    General PID management considerations

    A.  Regimens must provide coverage of *N. gonorrhoeae*, *C.
        trachomatis*, anaerobes, Gram-negative facultative organisms,
        and streptococci. If bacterial vaginosis is present, anaerobic
        coverage is necessary.

    B.  Treatment should be instituted as early as possible to prevent
        long-term sequelae.

        \[Slide 26\]

    C.  Criteria for hospitalization of women with PID include:

        1.  Inability to exclude surgical emergencies (i.e.,
            appendicitis, ectopic pregnancy)

        2.  Pregnancy

        3.  Non-response to oral therapy. Failure to respond clinically
            to outpatient antimicrobial therapy within 48-72 hours.

        4.  Inability to tolerate an outpatient oral regimen

        5.  Severe illness, nausea and vomiting, or high fever

        6.  Tubo-ovarian abscess

        7.  Current immunodeficiency (HIV infection with low CD4 count,
            immunosuppressive therapy)

            \[Slide 27\]

            Current CDC recommendations for the treatment of PID include
            both parenteral and oral regimens.

    D.  Oral regimens: each of these regimens should be continued for a
        total of 14 days. Patients on oral therapy ideally should be
        followed up within 72 hours, at which time they should show
        substantial clinical improvement. If no improvement, the patient
        should be re-evaluated to confirm the diagnosis and should be
        administered parenteral therapy in either an outpatient or
        inpatient setting.

        1.  CDC-recommended oral regimen A 

            a.  Ofloxacin 400 mg orally 2 times a day for 14 days, OR

            b.  Levofloxacin 500 mg orally 2 times a day for 14 days

                *With or Without*

            c.  Metronidazole 500 mg orally 2 times a day for 14 days

        2.  CDC-recommended oral regimen B

            1.  Ceftriaxone 250 mg IM in a single dose, OR

            2.  Cefoxitin 2 g IM in a single dose and Probenecid 1 g
                orally in a single dose, OR

            3.  Other parenteral third-generation cephalosporin (e.g.,
                Ceftizoxime, Cefotaxime)

            4.  PLUS Doxycycline 100 mg orally 2 times a day for 14 days

                *With or Without*

            5.  Metronidazole 500 mg orally 2 times a day for 14 days

\[Slide 28\]

E.  Follow-up

    1.  Patient should be re-examined within 72 hours and should
        demonstrate substantial clinical improvement (e.g.,
        defervescence; reduction in rebound or direct abdominal
        tenderness; reduction in uterine, adnexal, and cervical motion
        tenderness).

    2.  Patients who do not improve within this period usually require
        hospitalization, additional diagnostic tests, and possible
        surgical intervention.

    3.  Some experts recommend rescreening for *C. trachomatis* and *N.
        gonorrhoeae* after completion of therapy, if initially positive.
        The optimal time period for rescreening is 4-6 weeks.

        \[Slides 29-30\]

F.  Parenteral regimens

    1.  CDC-recommended parenteral regimen A

        a.  Cefotetan 2 g IV every 12 hours, OR

        b.  Cefoxitin 2 g IV every 6 hours

        c.  PLUS Doxycycline 100 mg orally every 12 hours

    2.  CDC-recommended parenteral regimen B

        a.  Clindamycin 900 mg IV every 8 hours

            1.  PLUS Gentamicin loading dose IV or IM (2 mg/kg),
                followed by maintenance dose (1.5 mg/kg) every 8 hours.
                Single daily gentamicin dosing may be used.

    3.  Continue either of these regimens for at least 24 hours after
        substantial clinical improvement, then complete a total of 14
        days therapy with

        a.  Doxycycline (100 mg orally twice a day) with regimen A or
            with

        b.  Doxycycline (100 mg orally twice a day) or Clindamycin (450
            mg orally 4 times a day), if using regimen B.

            \[Slide 31\]

    4.  Alternative parenteral regimens

        1.  Ofloxacin 400 mg IV every 12 hours, OR

        2.  Levofloxacin 500 mg IV once daily

            *With or Without*

        3.  Metronidazole 500 mg IV every 8 hours, OR

        4.  Ampicillin/Sulbactam 3 g IV every 6 hours

        5.  PLUS Doxycycline 100 mg orally or IV every 12 hours

            \[Slide 32\]

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VI. **Prevention**

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    A.  Screening

        1.  Screening recommendations

            a.  Prevention of chlamydial infection by screening and
                treating at-risk women reduces the incidence of PID.

            b.  CDC screening recommendations for chlamydia include:
                annual screening for sexually active women age 25 and
                under; screening of at-risk women over age 25; pregnant
                women in the first trimester or at the first prenatal
                visit if after the first trimester; and any patient
                diagnosed with another STD.

            c.  Some specialists recommend screening and treating women
                with bacterial vaginosis prior to surgical abortion or
                hysterectomy.

\[Slides 34-35\]

B.  Partner management

    1.  Male sex partners of women with PID should be examined and
        treated if they had sexual contact with the patient during the
        60 days preceding onset of the patient's symptoms.

    2.  Male partners of women who have PID caused by *C. trachomatis*
        or *N. gonorrhoeae* are often asymptomatic. Sex partners should
        be treated empirically with regimens effective against both of
        these infections, regardless of the apparent etiology of PID or
        pathogens isolated from the infected woman.

    3.  The evaluation and treatment of partners is imperative because
        of the risk for reinfection and the strong likelihood of
        gonococcal or chlamydial infection in the sex partner.

\[Slide 36\]

C.  Reporting

    1.  Report cases to the local STD program in states where PID
        reporting is mandated. Laws and regulations in all states
        require that persons with gonorrhea or chlamydia be reported to
        public health authorities by clinicians, labs, or both. Check
        with your state or local health department for reporting
        requirements in your area.

\[Slide 37\]

D.  Patient counseling and education should cover the nature of the
    disease, transmission issues, and risk reduction.

    1.  Nature of the infection

        a.  PID may be silent or overt with moderate or severe symptoms.

        b.  A history of having had PID increases the risk for
            developing PID.

        c.  The sequelae of PID are severe and include ectopic
            pregnancy, chronic pelvic pain, and infertility.

    2.  Transmission issues

        a.  Gonorrhea and chlamydia are efficiently transmitted from
            males to females via vaginal intercourse.

        b.  Patients should abstain from intercourse until therapy is
            completed and until they and their sex partners no longer
            have symptoms.

    3.  Risk reduction

> The clinician should:

a.  Assess the patient's behavior-change potential.

b.  Develop individualized risk-reduction plans with the patient for
    lasting results.

c.  Discuss prevention strategies (abstinence, monogamy with an
    uninfected partner, condoms, limit number of sex partners, etc.).

d.  Latex condoms, when used consistently and correctly, can reduce the
    risk of transmission of chlamydia and gonorrhea.

**CASE STUDY**

\[Slide 39\]

Jane Wheels is a 24-year-old married female who presents to her nurse
practitioner reporting lower abdominal pain, cramping, slight fever, and
dysuria of 4 days duration.

**History**

-   24-year-old P 1001, LMP 2 weeks ago (regular without dysmenorrhea)

-   She uses oral contraceptives (for 2 years).

-   She reports a gradual onset of symptoms of lower bilateral abdominal
    discomfort, dysuria (no gross hematuria), abdominal cramping, and a
    slight low-grade fever in the evenings for 4 days. Discomfort has
    gradually worsened.

-   Denies GI disturbances or constipation. Denies vaginal discharge.
    Took Tylenol for fever x 3.

-   Jane states that she is happily married in a mutually monogamous
    relationship and plans another pregnancy in about 6 months. Husband
    does not use condoms. Reports that they engage in sexual intercourse
    approximately 2 times per week---no oral or rectal sex.

-   Cooperative and good historian. Non-smoker, exercises regularly, no
    appetite changes, no travel outside the U.S., and no history of
    STDs. Reports occasional yeast infections. Douches regularly after
    menses and intercourse. Reports douching last this morning.

\[Slide 40\]

**Physical exam**

-   Vital signs: blood pressure 104/72, pulse 84, temperature 38°C,
    weight 132

-   Neck, chest, breast, heart, and musculoskeletal exam within normal
    limits. No flank pain on percussion. No CVA tenderness.

-   On abdominal exam the patient reports tenderness in the lower
    quadrants with light palpation. Several small inguinal nodes
    palpated bilaterally.

-   Normal external genitalia without lesions or discharge.

-   Speculum exam reveals minimal vaginal discharge with a small amount
    of visible cervical mucopus.

-   Bimanual exam reveals uterine and adnexal tenderness as well as pain
    with cervical motion. Uterus anterior, midline, smooth and not
    enlarged.

\[Slide 41\]

1.  What should be included in the differential diagnosis?

Correct responses include the following:

-   Urinary tract infection--Dysuria and abdominal tenderness can be
    consistent with a UTI.

-   Vaginitis\--Ms. Wheels' history of douching this morning could
    account for the minimal vaginal discharge noted on exam, so
    vaginitis cannot be ruled out.

-   Pelvic inflammatory disease (PID)--While the clinical
    characteristics of patients with PID depend on the etiologic agent
    involved, CDC's minimum criteria for a presumptive diagnosis of PID
    (uterine/adnexal or cervical motion tenderness) have been met.

-   Pregnancy--Pregnancy or ectopic pregnancy should be ruled out in any
    woman of reproductive age with Ms. Wheels' symptoms.

    1.  Which laboratory tests should be performed or ordered?

Correct responses include the following:

-   Vaginal saline wet mount with pH\--This would assist in diagnosing
    vaginitis, which may not be obvious given her douching history.
    Also, the presence of WBCs on saline microscopy increases the
    specificity of PID diagnosis.

-   Gonorrhea culture--This would be appropriate given the presumptive
    diagnosis of PID.

-   Urine C/S--This would be appropriate given the history of dysuria
    and lower abdominal tenderness.

-   Nucleic acid amplification test (NAAT) for chlamydia--A sensitive
    NAAT would be the first choice for diagnosing chlamydia.

-   CBC with sedimentation rate and C-reactive protein--An elevated
    erythrocyte sedimentation rate and elevated C-reactive protein
    increases the specificity of PID diagnosis. However, these tests may
    not be indicated, may not be available, or may be too expensive.

-   Pregnancy test--A sensitive pregnancy test to rule out ectopic
    pregnancy is necessary.

\[Slide 42\]

**Laboratory**

Results of office diagnostics:

-   Urine pregnancy test: negative

-   Urine dip stick for nitrates: negative

-   Vaginal saline wet mount: vaginal pH was 4.5. Microscopy showed WBCs
    \>10 per HPF, no clue cells, no trichomonads and the KOH wet mount
    was negative for budding yeast and hyphae.

3\. What is the presumptive diagnosis?

This patient meets the minimum criteria for a presumptive diagnosis of
PID. The presence of WBCs on the saline microscopy increases the
specificity of that diagnosis. Minimum criteria, in the absence of a
competing diagnosis, justify presumptive treatment.

4\. How should this patient be managed?

Given the clinical presentation of the patient, it is reasonable to
consider oral or IM outpatient treatment for PID if she can return for
follow-up in 48-72 hours.

5\. What is an appropriate CDC-recommended therapeutic regimen for Ms.
Wheels?

Correct responses include the following:

-   Ofloxacin 400 mg orally twice a day for 14 days PLUS metronidazole
    500 mg orally twice a day for 14 days

-   Cefoxitin 2 g IM plus probenecid 1 g orally plus doxycycline 100 mg
    orally twice a day for 14 days

-   Ceftriaxone 250 mg IM once plus doxycycline 100 mg orally twice a
    day for 14 days

The chosen regimen should cover the polymicrobial nature of PID
(gonorrhea, chlamydia, and anaerobes) as the etiologic agent is often
unknown at the time of treatment initiation. The results of the cervical
cultures are not always predictive of the organisms implicated in upper
genital tract disease. The organisms involved in bacterial vaginosis
play a role in some cases of PID.

The first regimen is more difficult to tolerate (GI problems) and is far
more expensive then the second one. However, anaerobic coverage is
superior.

\[Slide 43\]

**Partner Management**

Sex partner: Joseph (spouse)

First exposure: 4 years ago

Last exposure: 1 week ago

Frequency: 2 times per week (vaginal only)

6\. How should Joseph be managed?

Joseph should be evaluated and treated for gonorrhea and chlamydia. Male
sex partners of women with PID should be examined and treated if they
had sexual contact with the patient during the 60 days preceding the
onset of symptoms in the patient. Partner evaluation and treatment are
imperative because of the risk for reinfection and the strong likelihood
of gonococcal or chlamydial infection in the sex partner.

Male partners of women who have PID caused by *C. trachomatis* and/or
*N. gonorrhoeae* are often asymptomatic. Therefore sex partners should
be treated empirically with regimens effective against both of these
infections, regardless of the apparent etiology of PID or pathogens
isolated from the infected woman.

\[Slide 44\]

**Follow Up**

On follow up 3 days later, Jane was improved clinically. The culture for
gonorrhea was positive. The nucleic acid probe (DNA-probe) for chlamydia
was negative.

Joseph came in with Jane at follow-up. He was asymptomatic but did admit
to a \"one-night stand\" while traveling. He was treated. They were
offered HIV testing which they accepted.

7\. Who is responsible for reporting this case to the local health
department?

Laws and regulations in all states require that persons with gonorrhea
or chlamydia be reported to public health authorities by clinicians,
laboratories, or both. Check with your state or local health department
for reporting requirements in your area.

8\. What are appropriate prevention counseling recommendations for this
patient?

Correct responses include the following:

-   A history of PID increases the risk for developing a future episode
    of PID.

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-   Patients should abstain from intercourse until therapy is completed
    and until they and their sex partners no longer have symptoms.

-   Latex condoms, when used correctly and consistently, can reduce the
    risk of transmission of chlamydia and gonorrhea.

-   Sexually active women age 25 years of age and younger should be
    screened annually for chlamydia.

-   Douching increases the risk of PID because it contributes to vaginal
    flora changes, epithelial damage, and disruption of the cervical
    mucous barrier, all of which can increase the likelihood of
    developing PID.

-   Discuss individual risk reduction strategies, including monogamy
    with an uninfected partner and correct and consistent use of
    condoms.

**TEST QUESTIONS**

1.  In the United States the number of hospitalized cases of PID is
    decreasing. What is the most likely reason for this decrease?

    a.  Decrease in reporting of PID

    b.  Increase in prevention messages

    c.  **Increase in outpatient treatment of PID**

    d.  Decreased incidence of PID

2.  PID is associated with ascending spread of microorganisms to the
    upper genital tract. The fate of these organisms depends on all of
    the following factors **except**:

    a.  Pathogenicity of organisms

    b.  Host defense mechanisms

    c.  **Length of vagina**

    d.  Viability of organisms

3.  All of the following are risk factors associated with PID
    **except**:

    a.  Adolescence

    b.  **Number of past pregnancies**

    c.  Douching

    d.  History of having an STD

4.  Which of the following is **not** related to the increased risk of
    PID related to douching?

    a.  Vaginal flora changes

    b.  **Cervical cellularity**

    c.  Epithelial damage

    d.  Disruption of cervical mucous barrier

5.  The most common etiologic agent associated with PID is:

    a.  *N. gonorrhoeae*

    b.  *C. trachomatis*

    c.  Mycoplasmas

    d.  **PID is usually polymicrobial**

6.  The most common clinical presentation of PID is:

    a.  Severe pain

    b.  **No pain**

    c.  Profuse vaginal discharge

    d.  Fever, chills, and cramping

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6.  All of the following are potential sequelae of untreated PID
    **except:**

    a.  Ectopic pregnancy

    b.  Tubal infertility

    c.  Chronic pelvic pain

    d.  **Decreased ovulation**

7.  The majority of cases of PID are:

    a.  Symptomatic with moderate symptomatology

    b.  Symptomatic with severe symptomatology

    c.  Caused by a single organism

    d.  **Subclinical**

8.  What is the most sensitive sign of upper genital tract infection?

    a.  Cervical motion tenderness

    b.  Abdominal pain

    c.  Fever

    d.  **Adnexal tenderness**

9.  Which of the following statements about PID is true?

    a.  **It is a preventable cause of infertility.**

    b.  It is an infection of the lower reproductive tract.

    c.  Clinicians should "under diagnose" rather than "over diagnose"
        PID.

    d.  Diagnosis of PID always requires hospitalization.

10. CDC-recommended criteria for hospitalization of women with PID
    include all of the following except:

    a.  Non-response to therapy

    b.  **Adolescence**

    c.  Tubo-ovarian abscess

    d.  Pregnancy

11. CDC recommends empiric treatment for PID if which of these criteria
    are present?

    a.  Bloody discharge and fever

    b.  **Uterine/adnexal tenderness and cervical motion tenderness**

    c.  Fever and supra pubic pain

    d.  WBCs and clue cells on wet prep examination

12. The CDC recommendation for parenteral treatment of PID includes a
    cephalosporin plus which of the following?

    a.  Clindamycin

    b.  Metrodidazole

    c.  **Doxycycline**

    d.  Ofloxacin

13. Which of the following is a CDC-recommended oral treatment regimen
    for PID?

    a.  Azithromycin 500 mg once

    b.  Ofloxacin 400 mg 2 times a day for 10 days

    c.  **Ofloxacin 400 mg 2 times a day for 14 days**

    d.  Metronidazole 2 g once

14. After completion of parenteral therapy for PID, one should continue
    oral therapy to complete a total of \_\_\_\_\_days of therapy?

    a.  7

    b.  **14**

    c.  21

    d.  28

15. PID prevention strategies include which of the following?

    a.  Chlamydia screening of all sexually active women ages 25 and
        under on an annual basis

    b.  Screening and treating women with bacterial vaginosis prior to
        surgical abortion or hysterectomy

    c.  Encouraging abstinence, monogamy with an uninfected partner,
        condom use, and limiting number of sex partners

    d.  **All of the above**

16. Patient education regarding PID should include which of the
    following messages?

    a.  PID may be silent or have moderate to severe symptoms.

    b.  Consequences of PID may include ectopic pregnancy, infertility,
        and pelvic pain.

    c.  Having a history of PID increases the risk for subsequent PID.

    d.  **All of the above.**

17. Management of sex partners of women with PID includes which of the
    following strategies?

    a.  **Partners should be examined and treated if they had sexual
        contact with the patient during the 60 days preceding onset of
        her symptoms.**

    b.  Only partners who are symptomatic and who are current partners
        should be treated.

    c.  Partners do not need to be treated if they were not the last
        reported sex partner of the patient.

    d.  All partners should be treated for chlamydia only.

18. Which of the following statements is true?

    a.  PID reporting is mandated in all states.

    b.  Routine screening for *C. trachomatis* is not recommended.

    c.  **Latex condoms can reduce the risk of transmission of gonorrhea
        and chlamydia.**

    d.  The sequelae of PID may include chronic neurologic symptoms.

**RESOURCES**

**Publications**

1.  Cates W, et al. Sexually transmitted diseases, pelvic inflammatory
    disease and infertility: an epidemiologic update. Epi Rev 1990;
    12:190-220.

2.  Cates W, Wasserheit JN. Genital chlamydia infections: epidemiology
    and reproductive sequelae. Am J Ob Gyn 1991; 164(6):1771-1781.

3.  CDC. Pelvic inflammatory disease: guidelines for prevention and
    management. MMWR 1991; 40(RR-5):1-21.  Available from URL:
    [[http://www.cdc.gov/mmwr/preview/mmwrhtml/00031002.htm]{.underline}](http://www.cdc.gov/mmwr/preview/mmwrhtml/00031002.htm).

4.  CDC. Sexually transmitted diseases treatment guidelines 2002. MMWR
    2002;51 (RR-6). Available from URL:
    [[http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5106a1.htm.]{.underline}](http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5106a1.htm)

5.  Holmes KK, Sparling PF, Mardh P-A, Lemon SM, Stamm WE, Piot P,
    Wasserheit JN (editors). Sexually transmitted diseases, 3rd ed. New
    York (NY): McGraw-Hill, 1999.

6.  Landers DV, Sweet RL, editors. Pelvic inflammatory disease. New York
    (NY): Springer; 1997.

7.  Expert committee on pelvic inflammatory disease. Pelvic inflammatory
    disease: research directions in the 1990s. Sex Trans Dis 1991;
    18(1):46-64.

8.  Paavonen J, et al. Prevalence and manifestations of endometritis
    among women with cervicitis. Am J Obstet Gynecol 1985; 152:280.

9.  Peterson HB, Walker CK, Kahn JG, Washington AE, Eschenbach DA,
    Faro S. Pelvic inflammatory disease: key treatment issues and
    options. JAMA 1991; 266(18):2605-2611.

10. Walker CK, Kahn JG, et al. Pelvic inflammatory disease:
    meta-analysis of antimicrobial regimen efficacy. J Infect Dis 1993;
    168:969-78.

11. Washington AE, Katz P. Cost of and payment source for pelvic
    inflammatory disease: trends and projections, 1983 through 2000.
    JAMA 1991; 266(18):2565-2569.

12. Westrom L, et al. Pelvic inflammatory disease and fertility: a
    cohort study of 1844 women with laparoscopically verified disease
    and 657 control women with normal laparoscopic results. Sex Trans
    Dis 1992; 19(4):185-192.

13. Wolner-Hanssen P, Kiviat NB, Holmes KK. Atypical pelvic inflammatory
    disease: subacute, chronic, or subclinical upper genital tract
    infection in women. In: Holmes KK, Mardh P-A, Sparling PF, Wiesner
    PJ, Cates W, Lemon SM, Stamm WE (editors). Sexually transmitted
    diseases, 2nd ed. New York (NY): McGraw-Hill, 1990; 615-620.

14. Weinstock H, Berman S, Cates W Jr. Sexually transmitted diseases
    among American youth: incidence and prevalence estimates, 2000.
    Persp Sex Reprod Hlth 2004; 36 (1): 6-10.

**Websites and Other Resources**

1.  CDC, Division of STD Prevention:
    [www.cdc.gov/std](http://www.cdc.gov/std)

2.  National Network of STD/HIV Prevention Training Centers:
    <http://depts.washington.edu/nnptc/>

3.  2002 CDC STD Treatment Guidelines (including downloadable version
    for Palm devices): <http://www.cdc.gov/STD/treatment/>

4.  CDC National STD Hotline: 800-227-8922 or 800-342-2437

    a.  En Español: 800-344-7432

    b.  TTY for the Deaf and Hard of Hearing: 800-243-7889

5.  CDC National Prevention Information Network (NPIN):
    [www.cdcnpin.org](http://www.cdcnpin.org/)

6.  American Social Health Association (ASHA):
    [www.ashastd.org](http://www.ashastd.org/)