Ojeda-Fournier, Haydee MD; Akers, M. Jason MD
Pelvic inflammatory disease (PID) is infection and inflammation of the upper female genital tract including the uterus, fallopian tubes, and ovaries. A wide range of organisms has been implicated in the pathogenesis of this condition. The clinical findings can vary markedly, and there is no single finding pathognomonic for this condition. The same holds true for the imaging findings. Because of the wide spectrum of clinical and imaging findings, the diagnosis of PID is sometimes difficult to make and the disease may remain unrecognized.1 The sequelae of PID are significant, and therefore, treatment is often empiric even with minimal suspicion of this condition. The following 2 cases depict the classic clinical picture, which is encountered in outpatient settings and in the emergency department. The imaging findings in these 2 cases comprise the spectrum of disease manifestations by computed tomography (CT) and ultrasound (US). A brief review of PID and imaging characteristics follows.
A 21-year-old woman G5 P5 with medical history significant for multiple culture positive episodes of PID presented to the emergency department with a 2-day history of left lower quadrant abdominal pain, chills, and vaginal discharge. Physical examination revealed temperature of 97.6°F and blood pressure 104/60. Physical examination demonstrated tenderness to palpation in the left lower quadrant and left adnexal tenderness on bimanual exam. There was no cervical motion tenderness. Speculum examination revealed purulent discharge from the cervical os. Laboratory analysis revealed a white blood cell (WBC) count of 8300 cells/μL with 55.4% neutrophils and an absolute neutrophil count of 4600 cells/μL. Qualitative B-HCG was negative. Because of nonspecific physical examination and vague clinical picture, a CT of the abdomen and pelvis was obtained to further evaluate. Figure 1 demonstrates a cyst/follicle in the left ovary and enhancement of the fallopian tubes. The uterus has a congested appearance with a fluid filled endometrial canal. There is minimal free pelvic fluid. Although the spectrum of imaging findings is nonspecific and subtle, PID was suggested and this correlated to the clinical diagnosis. It was then suggested based on this clinical information that additional differential consideration for the cyst/follicle in the left ovary includes tubo-ovarian abscess.
Based on the patient's history of multiple prior episodes of culture positive PID, current clinical presentation, and subsequent imaging findings, empiric treatment was started with 250 mg ceftriaxone IM and 100 mg doxycycline PO while in the emergency department and 14 days of doxycycline 100 mg PO twice per day after discharge. The final results of the endocervical swab showed no Chlamydia trachomatis or Neisseria gonorrhoeae, although the microbiology from 7 months earlier and multiple others had been positive for both chlamydia and gonorrhoeae.
A 22-year-old woman G2/P2 presented to the emergency department with a 1-week history of lower abdominal pain, nausea, and vomiting. The medical history was significant for recurrent PID and several previous microbiology studies positive for both gonorrhea and chlamydia. She presents with pain that was identical to her last episode of PID and complained of vaginal discharge. On physical examination, she has suprapubic pain that does not lateralize and has yellow thick discharge from the cervical os. Temperature was 100.5°F. Laboratory analysis demonstrated WBC 21,300 per microliter, with BAND of 16.0%. No other serology was obtained, and at the time of evaluation, the results from the cervical swab were not available.
There was a short debate as to the utility of imaging, and after consultation with gynecology, a CT of the abdomen and pelvis was obtained. Figure 2 demonstrated a lobulated rim enhancing fluid collection in the left pelvis measuring 7.8 × 6.0 cm. At this window level, only the thicker septations are noted in the periphery of the mass. The endometrial lining of the uterine cavity demonstrates enhancement. Findings are compatible with tubo-ovarian abscess. A second simple loculated fluid collection more superiorly in the pelvis (Fig. 3) was thought to represent a peritoneal inclusion cyst, likely the sequelae of previous infections. Ultrasound was performed to better characterize the complex fluid collection and assess the ovaries. In the left adnexal region (Fig. 4), there is a large thick walled complex fluid collection with fluid/fluid levels and an increased color flow in the periphery (Fig. 5). The left ovary was not identified.
The patient was admitted and treated initially with IV doxycycline, metronidazole, and cefazolin. On the second hospital day, when the symptoms had not improved, her medications were changed to clindamycin, gentamicin, and ampicillin. The patient was discharged on hospital day number 5, afebrile and asymptomatic, with instructions to complete a 2-week course of doxycycline 100 mg PO twice per day. In the meantime, the microbiology results demonstrated positive amplified DNA probe for N. gonorrhoeae and negative C. trachomatis.
Pelvic inflammatory disease is infection and inflammation that involves the cervix, uterus, fallopian tubes, and ovaries. In severe cases, adjacent pelvic structures including fat, fascial planes, small bowel, large bowel, and the peritoneum can become infected and inflamed. According to the Center for Disease Control (CDC), 1 million women experience acute PID per year and 150 will die of the disease itself or complications from PID (http://www.cdc.gov/std/PID/). Risk factors are the same as for any other sexually transmitted disease and include unprotected intercourse, multiple sexual partners, high frequency of intercourse, race, low socioeconomic status, prior episodes of sexually transmitted disease, and PID.1 Other risk factors that are debated to be a significant cause of PID include surgical instrumentation, use of intrauterine device, douching, cigarette smoking, and substance abuse.1-3
Pelvic inflammatory disease can present clinically with a wide spectrum of findings ranging from vague and nonspecific symptoms that are difficult to distinguish from other abdominal and pelvic pathology to the classic manifestation that includes pelvic pain, cervical motion tenderness, and pelvic mass.4 Constitutional symptom including fever, malaise, nausea, and vomiting are nonspecific and may be seen with PID. No single clinical finding is sufficiently sensitive or specific to be considered pathognomonic.
The pathogens responsible for PID are also widely variable. The sexually transmitted infections, specifically C. trachomatis and N. gonorrhoeae, are the most commonly implicated microbial organism, with chlamydia accounting for up to 40% of cases.1,3,4 In addition, aerobic and anaerobic, gram positive and negative organism, normal vaginal flora, viruses, tuberculosis, mycoplasma, and other atypical organism have been implicated as causative agents.3,4
Ultrasound should be the first line imaging modality in imaging the premenopausal female pelvis. The advantages of US include lower cost, portability, and lack of ionizing radiation. The main disadvantages are that it provides limited evaluation of the remainder of the abdomen and pelvis and is dependant on the operator and the patient's body habitus. Ultrasound findings of PID are often subtle and nonspecific and include mild enlargement or indistinctness of the uterus and ovaries, increased echogenicity of the fat in the pelvis, fluid in the endometrial canal, and/or free fluid in the cul-de-sac. More specific US findings include complex fluid collections, thickened fallopian tube wall >5mm, fluid filled fallopian tubes, and frank tubo-ovarian abscess.5 The utility of Doppler evaluation remains controversial;2 color Doppler correlates with hyperemia and is another tool that can be useful as is demonstrated in Figure 5.
The CT findings of PID can also be very subtle. This point is nicely illustrated in Figure 1, where the imaging diagnosis was nearly missed because the appearance of a young and menstruating uterus on CT can be very similar. Computed tomography was obtained in case 1 to exclude other pathology in the abdomen and pelvis, which can have similar clinical presentation. Early in the disease, the only clues can be edema in the pelvic fat planes, nonspecific free pelvic fluid, and fluid in the endometrial canal.6 Enlargement and increased number of ovarian follicles (the so-called "polycystic" appearance) is also considered a reliable finding of infection and inflammation by both US, CT, and MRI. Endometrial, ovarian, and fallopian tube enhancement is seen in the more advanced case of PID. The extreme of the spectrum, as in US, is the presence of tubo-ovarian abscess and other complex fluid collections.6 As with US, no CT finding is pathognomonic for PID. Computed tomography is often the first imaging modality used because of its wide availability and its ability to give an overview of the entire abdomen and pelvis to exclude other etiologies in the differential diagnosis such as appendicitis or diverticulitis. Computed tomography is of limited value in evaluating the ovaries, fallopian tubes, and endometrium, which are better interrogated with transvaginal ultrasound.5
No pathognomonic MRI finding has been documented. As with CT and US, tubal-ovarian abscess, dilated fluid filled tubes, increased number of ovarian cyst and free fluid in the pelvis are the characteristic findings at MRI.7 MRI, however, provides excellent soft tissue resolution and is the most sensitive imaging modality to evaluate for tissue water content (ie, inflammation). Magnetic resonance imaging has the advantage of being highly sensitive to water signal so that subtle fluid in the fallopian tubes or free fluid in the pelvis can be readily assessed. The current use of MRI is in the prevention of unnecessary laparoscopy in difficult or indeterminate cases of PID.7 Limitations of MRI include its relative expense, limited availability, and imaging time constraints that typically limit the examination to 1 specific anatomic location.
The role of laparoscopy: Laparoscopy has been the gold standard in the diagnosis of PID. This is the ultimate imaging study, as direct visualization of the female pelvic organs is performed. Obviously, this procedure is expensive and invasive and carries the risk associated with general anesthesia and surgery. The sensitivity and specificity rate of laparoscopy are 50% and 85%, respectively; when only visualization is used. The addition of biopsy improves the sensitivity and specificity of these procedure.1
The CDC recommends that empiric treatment be initiated when a patient with risk factors for sexually transmitted disease presents with uterine/adnexal tenderness or cervical motion tenderness.8 Additional criteria not necessary to initiate therapy include the following: temperature 101° F, cervical/vaginal discharge, WBCs in vaginal secretions, elevated ESR and C-reactive proteins, and microbiology positive for gonorrhoeae and chlamydia. The following are the CDC recommended oral regimen for treatment: Regimen A-ofloxacin 400 mg twice per day for 14 days or levofloxacin 500 mg once per day for 14 days with or without metronidazole 500 mg twice per day for 14 days and Regimen B-ceftriaxone 250 mg IM in a single dose or cefoxitin 2 g IM in a single dose and probenecid 1 g orally administered concurrently in a single dose or other parenteral third-generation cephalosporin (eg, ceftizoxime or cefotaxime) plus doxycycline 100 mg orally twice a day for 14 days with or without metronidazole 500 mg orally twice a day for 14 days.8 If there is no improvement, then consideration is given to intravenous therapy either as an inpatient or outpatient. There are several CDC recommended parenteral regimens (A and B and an alternative regimen) which can be used: Regimen A-cefotetan 2 g IV every 12 hours or cefoxitin 2 g IV every 6 hours plus doxycycline 100 mg orally or IV every 12 hours; Regimen B-clindamycin 900 mg IV every 8 hours plus gentamicin loading dose IV or IM (2 mg/kg of body weight), followed by a maintenance dose (1.5 mg/kg) every 8 hours (single daily dosing may be substituted); Alternative Parenteral Regimen-ofloxacin 400 mg IV every 12 hours or levofloxacin 500 mg IV once daily with or without metronidazole 500 mg IV every 8 hours or ampicillin/sulbactam 3 g IV every 6 hours plus doxycycline 100 mg orally or IV every 12 hours.8 No large clinical trials are available to document the efficacy of this or any regimen.1,2,8 Likewise, there are no trials that demonstrate improved efficacy of inpatient versus outpatient or parenteral versus oral therapy. As illustrated in case 2, often the antibiotic treatment used is aimed to cover general abdominal processes.
The sequelae of recurrent PID is well documented and include infertility, ectopic pregnancy, chronic pelvic pain, and, as previously stated, a small risk of death.1,8 The likelihood of these complications increase with the number of episodes of PID. There are significant economic implications, and the sequela of this condition is irreversible.1
Pelvic inflammatory disease is a commonly encountered process with serious complications and challenging clinical and imaging findings. An awareness of the spectrum of imaging findings is important when correlating diagnostic data to the clinical presentation.
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3. Simms I, Stephenson JM. Pelvic inflammatory disease epidemiology: what do we know and what do we need to know? Sex Transm Infect. 2000;76:80-87.
4. Barrett S, Taylor C. A review on pelvic inflammatory disease Int J STD AIDS. 2005;16:715-721.
5. Horrow MM. Ultrasound of pelvic inflammatory disease Ultrasound Q. 2004;204:171-179.
6. Sam JW, Jacobs JE, Birnbaum BA. Spectrum of CT findings in acute pyogenic pelvic inflammatory disease Radiographics. 2002;226:1327-1334.
7. Tukeva TA, et al. MR imaging in pelvic inflammatory disease: comparison with laparoscopy and US Radiology. 1999;210:209-216.
8. Workowski KA, Levine WC. Sexually Transmitted Diseases Treatment Guidelines. MMWR, Center for Disease Control and Prevention. 51 (RR06); May 10, 2002:1-80.
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