Pediatric Pelvic Inflammatory Disease

Pelvic Inflammatory Disease (PID)“Abdominal pain” is ubiquitous in the pediatric acute care setting. It’s list of potential causes are extensive and diverse. We have discussed many of these causes from acute (ex, appendicitis, intussusception, pancreatitis) to chronic (ex, CRAP). We have also discussed causes that don’t reside in the abdomen (ex, pneumonia, strep pharyngitis, ovarian torsion, testicular torsion). There is another cause that deserves attention, even if we would rather not have to think about it in the pediatric population.  Let us take minute to ensure we are not overlooking Pediatric Pelvic Inflammatory Disease:

 

Pelvic Inflammatory Disease: Basics

  • In the US, prevalence of sexually transmitted infections (STIs) are highest among adolescents and young adults.
  • Pelvic Inflammatory Disease (PID) is a significant complication of untreated STIs in women.
  • ~70% of PID diagnoses among teenagers are made in the ED. [Trent, 2011]
  • PID is a spectrum of inflammatory disorders of the upper female genital tract and includes:
    • Endometritis
    • Salpingitis
    • Tubo-ovarian abscess
    • Pelvic peritonitis
  • Risk Factors for developing PID:
    • Adolescents
    • New or multiple sex partners
    • Inconsistent use of condoms
    • Prior history of STDs or PID [Kreisel, 2017; Trent, 2008]
    • Vaginal douching
    • IUD use [Viberga, 2005]
  • Upper tract infections increase risk of: [Rein, 2000]
    • Ectopic Pregnancy
    • Infertility
    • Pelvic Adhesions and Chronic Pelvic Pain

 

Pelvic Inflammatory Disease: The Dx

  • The diagnosis is primarily clinical!
  • There is a wide variance in presenting signs and symptoms. [Workowski, 2015]
  • A low threshold needs to be maintained for diagnosing PID. [CDC.gov]
  • For sexually active females, presumptive diagnosis can be made for those with: [Workowski, 2015]
    • Risk for STIs presenting with pelvic / lower abdominal pain and no clear alternative diagnosis AND one or more of the following:
      • Cervical Motion Tenderness
      • Uterine Tenderness
      • Adnexal Tenderness
    • The following add support for the diagnosis:
      • Fever (>101°F / >38.3°C)
      • Mucopurulent cervical discharge or friability
      • Wet prep with abundant WBC

 

Pelvic Inflammatory Disease: The Bugs

  • We always consider:
    • Chlamydia trachomatis
    • Neisseria gonorrhea
    • Rates of these two being the primary culprits are declining. [Workowski, 2015]
  • There are others though:
    • Often polymicrobial [Haggerty, 2006]
      • Mycoplasma genitalium
      • High levels of bacterial vaginosis
      • Haemophilus influenzae
      • Gram positive and negative anaerobic bacteria
    • Important to remember that Chlamydia and Gonorrhea testing may be negative even with clinically apparent PID.
    • More than 50% of PID cases had no organism found. [Solomon, 2017]
    • So… if you were thinking of just checking Chlamydia/Gonorrhea DNA probes from urine sample, you will be missing some patients with PID.

 

Pelvic Inflammatory Disease: Treatment

  • Currently, it is recommended that broad antibiotic coverage be used for PID. [Workowski, 2015]
  • Unfortunately, ~30% of patients diagnosed with PID received inadequate Tx (often using cervicitis therapy regimens). [Solomon, 2017]
  • Some possible regimens:
    • Cefotetan 2 g IV q 12 hr AND Doxycycline 100mg PO/IV q 12 hr
    • Ampicillin/Sulbactam 3 g IV q 6 hrs AND Doxycycline 100mg PO/IV q 12 hr
    • Ceftriaxone 250 mg IM x 1 AND Doxycycline 100mg PO BID x 14 days
    • Metronidazole 500 mg PO BID x 14 days can also be added.

 

Moral of the Morsel

  • Don’t ignore it! in adolescent females, regardless of whether we want to deal with it or not, PID is a common condition.
  • Keep a low threshold! If the sexually active female has pelvic/abdominal pain without another explanation, you must have PID on your DDx.
  • Don’t rely solely on testing. Chlamydia and Gonorrhea testing may be negative.
  • Don’t treat like it is cervicitis. Doxycycline for 14 days is needed for PID.

 

References

Kreisel K1, Torrone E1, Bernstein K1, Hong J1, Gorwitz R1. Prevalence of Pelvic Inflammatory Disease in Sexually Experienced Women of Reproductive Age – United States, 2013-2014. MMWR Morb Mortal Wkly Rep. 2017 Jan 27;66(3):80-83. PMID: 28125569. [PubMed] [Read by QxMD]

Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015 Jun 5;64(RR-03):1-137. PMID: 26042815. [PubMed] [Read by QxMD]

Balamuth F1, Zhang Z, Rappaport E, Hayes K, Mollen C, Sullivan KE. RNA Biosignatures in Adolescent Patients in a Pediatric Emergency Department With Pelvic Inflammatory Disease. Pediatr Emerg Care. 2015 Jul;31(7):465-72. PMID: 26125533. [PubMed] [Read by QxMD]

Trent M1, Ellen JM, Frick KD. Estimating the direct costs of pelvic inflammatory disease in adolescents: a within-system analysis. Sex Transm Dis. 2011 Apr;38(4):326-8. PMID: 21057380. [PubMed] [Read by QxMD]

Trent M1, Chung SE, Forrest L, Ellen JM. Subsequent sexually transmitted infection after outpatient treatment of pelvic inflammatory disease. Arch Pediatr Adolesc Med. 2008 Nov;162(11):1022-5. PMID: 18981349. [PubMed] [Read by QxMD]

Haggerty CL1, Ness RB. Epidemiology, pathogenesis and treatment of pelvic inflammatory disease. Expert Rev Anti Infect Ther. 2006 Apr;4(2):235-47. PMID: 16597205. [PubMed] [Read by QxMD]

Viberga I1, Odlind V, Lazdane G, Kroica J, Berglund L, Olofsson S. Microbiology profile in women with pelvic inflammatory disease in relation to IUD use. Infect Dis Obstet Gynecol. 2005 Dec;13(4):183-90. PMID: 16338777. [PubMed] [Read by QxMD]

Rein DB1, Kassler WJ, Irwin KL, Rabiee L. Direct medical cost of pelvic inflammatory disease and its sequelae: decreasing, but still substantial. Obstet Gynecol. 2000 Mar;95(3):397-402. PMID: 10711551. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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1 Response

  1. June 18, 2017

    […]  Make sure to talk to patients about pregnancy, get a urine or serum b-HCG, and screen for PID. The American Academy of Pediatrics has guidelines for screening for STIs in adolescents. […]

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