Population Covered By The Guidance
This pathway provides guidance on the investigation of adult patients with suspected pelvic inflammatory disease.
Lead Researcher: Manusha Ratnayake
Experts & Contributors: Emmeline Lee, Jenny McCloskey
Date reviewed: August 2014
Date Published: November 2014
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- The diagnosis of PID is mainly made on clinical grounds with the use of imaging not commonly indicated
- Ultrasound is an accepted modality for the investigation of clinically suspected PID where patients are classified as being systemically unwell/severe symptoms and are refractory to treatment or where tubo-ovarian abscess is suspected. CT/Laparoscopy are rarely indicated
- Sub-clinical PID is a clinically distinct entity
- Before initiating treatment microbiological aetiology should always be attempted to be ascertained
- N.gonorrhoeae and C.trachomatis are the main microbiological aetiologies for PID but there is now a growing acknowledgement of the contribution M.genitalium to PID
Date of literature search: July 2014
The search methodology is available on request. Email
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Sweet RL. Pelvic inflammatory disease: current concepts of diagnosis and management. Curr Infect Dis Rep. 2012:[Epub ahead of print].(Review article). View the reference
- King Edward Memorial Hospital, Perth, Australia, Clinical practice guideline on management of acute pelvic inflammatory disease. [Internet, last updated October 2011; cited 31st July 2014]. View the guideline
- Ross J, Judlin P, Nilas L. European guideline for the management of pelvic inflammatory disease. Int J STD AIDS 2007;18(10):662-6. (Evidence based guideline). View the reference
- Haggerty CL, Taylor BD. Mycoplasma genitalium: an emerging cause of pelvic inflammatory disease. Infect Dis Obstet Gynecol. 2011;2011:959816. (Review article). View the reference
- Wiesenfeld HC, Hillier SL, Meyn LA, Amortegui AJ, Sweet RL. Subclinical pelvic inflammatory disease and infertility. Obstet Gynecol. 2012;120(1):37-43. (Level II evidence). View the reference
- Wiesenfeld HC, Sweet RL, Ness RB, Krohn MA, Amortegui AJ, Hillier SL. Comparison of acute and subclinical pelvic inflammatory disease. Sex Transm Dis. 2005;32(7):400-5. (Level I evidence). View the reference
- Wiesenfeld HC, Hillier SL, Krohn MA, Amortegui AJ, Heine RP, Landers DV, et al. Lower genital tract infection and endometritis: insight into subclinical pelvic inflammatory disease. Obstet Gynecol. 2002;100(3):456-63. (Level II evidence). View the reference
- Kiviat NB, Wolner-Hanssen P, Eschenbach DA, Wasserheit JN, Paavonen JA, Bell TA, et al. Endometrial histopathology in patients with culture-proved upper genital tract infection and laparoscopically diagnosed acute salpingitis. Am J Surg Pathol. 1990;14(2):167-75. (Level II evidence). View the reference
- Sellors J, Mahony J, Goldsmith C, Rath D, Mander R, Hunter B, et al. The accuracy of clinical findings and laparoscopy in pelvic inflammatory disease. Am J Obstet Gynecol. 1991;164(1 Pt 1):113-20. (Level II evidence). View the reference
- Gradison M. Pelvic inflammatory disease. Am Fam Physician. 2012;85(8):791-6. (Review article). View the reference
- Gaitan H, Angel E, Diaz R, Parada A, Sanchez L, Vargas C. Accuracy of five different diagnostic techniques in mild-to-moderate pelvic inflammatory disease. Infect Dis Obstet Gynecol. 2002;10(4):171-80. (Level II evidence). View the reference
- Workowski KA, Berman S. Sexually transmitted diseases treatment guidelines. MMWR Recomm Rep. 2010;59(RR-12):1-110. (Evidence based guidelines). View the reference
- Ness RB, Soper DE, Holley RL, Peipert J, Randall H, Sweet RL, et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) randomized trial. Am J Obstet Gynecol. 2002;186(5):929-37. (Level I evidence). View the reference
- Ness RB, Trautmann G, Richter HE, Randall H, Peipert JF, Nelson DB, et al. Effectiveness of treatment strategies of some women with pelvic inflammatory disease: a randomized trial. Obstet Gynecol. 2005;106(3):573-80. (Level I evidence). View the reference
- Cacciatore B, Leminen A, Ingman-Friberg S, Ylostalo P, Paavonen J. Transvaginal sonographic findings in ambulatory patients with suspected pelvic inflammatory disease. Obstet Gynecol. 1992;80(6):912-6. (Level II evidence). View the reference
- Boardman LA, Peipert JF, Brody JM, Cooper AS, Sung J. Endovaginal sonography for the diagnosis of upper genital tract infection. Obstet Gynecol. 1997;90(1):54-7. (Level II/III evidence). View the reference
- 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(4):705-14. (Review article). View the reference
- Tukeva TA, Aronen HJ, Karjalainen PT, Molander P, Paavonen T, Paavonen J. MR imaging in pelvic inflammatory disease: comparison with laparoscopy and US. Radiology. 1999;210(1):209-16. (Level I evidence). View the reference
- Romosan G, Bjartling C, Skoog L, Valentin L. Ultrasound for diagnosing acute salpingitis: a prospective observational diagnostic study. Hum Reprod. 2013;28(6):1569-79. (Level I evidence). View the reference
- Zeger W, Holt K. Gynecologic infections. Emerg Med Clin North Am. 2003;21(3):631-48. (Review article). View the reference
- Slap GB, Forke CM, Cnaan A, Bellah RD, Kreider ME, Hanissian JA, et al. Recognition of tubo-ovarian abscess in adolescents with pelvic inflammatory disease. J Adolesc Health. 1996;18(6):397-403. (Level III evidence). View the reference
- Taylor KJ, Wasson JF, De Graaff C, Rosenfield AT, Andriole VT. Accuracy of grey-scale ultrasound diagnosis of abdominal and pelvic abscesses in 220 patients. Lancet. 1978;1(8055):83-4. (Level III evidence). View the reference
- Landers DV, Sweet RL. Tubo-ovarian abscess: contemporary approach to management. Rev Infect Dis. 1983;5(5):876-84. (Level II/III evidence). View the reference
- Lande IM, Hill MC, Cosco FE, Kator NN. Adnexal and cul-de-sac abnormalities: transvaginal sonography. Radiology. 1988;166(2):325-32. (Level III evidence). View the reference
- Patten RM, Vincent LM, Wolner-Hanssen P, Thorpe E, Jr. Pelvic inflammatory disease: endovaginal sonography with laparoscopic correlation. J Ultrasound Med. 1990;9(12):681-9. (Level II evidence). View the reference
- Varras M, Polyzos D, Perouli E, Noti P, Pantazis I, Akrivis C. Tubo-ovarian abscesses: spectrum of sonographic findings with surgical and pathological correlations. Clin Exp Obstet Gynecol. 2003;30(2-3):117-21. (Level II evidence). View the reference
- Adhikari S, Blaivas M, Lyon M. Role of bedside transvaginal ultrasonography in the diagnosis of tubo-ovarian abscess in the emergency department. J Emerg Med. 2008;34(4):429-33. (Level III evidence). View the reference
- Timor-Tritsch IE, Lerner JP, Monteagudo A, Murphy KE, Heller DS. Transvaginal sonographic markers of tubal inflammatory disease. Ultrasound Obstet Gynecol. 1998;12(1):56-66. (Level II evidence). View the reference
- Ignacio EA, Hill MC. Ultrasound of the acute female pelvis. Ultrasound Q. 2003;19(2):86-98; quiz 108-10. (Review article). View the reference
- McClean KL, Sheehan GJ, Harding GK. Intraabdominal infection: a review. Clin Infect Dis. 1994;19(1):100-16. (Review article). View the reference
- Gagliardi PD, Hoffer PB, Rosenfield AT. Correlative imaging in abdominal infection: an algorithmic approach using nuclear medicine, ultrasound, and computed tomography. Semin Nucl Med. 1988;18(4):320-34. (Review article). View the reference
- Li W, Zhang Y, Cui Y, Zhang P, Wu X. Pelvic inflammatory disease: evaluation of diagnostic accuracy with conventional MR with added diffusion-weighted imaging. Abdom Imaging. 2013;38(1):193-200. (Level II evidence). View the reference
- Uslu H, Varoglu E, Kadanali S, Yildirim M, Bayrakdar R, Kadanali A. 99mTc-HMPAO labelled leucocyte scintigraphy in the diagnosis of pelvic inflammatory disease. Nucl Med Commun. 2006;27(2):179-83. (Level II evidence). View the reference
- Rachinsky I, Boguslavsky L, Goldstein D, Golan H, Pak I, Katz M, et al. Diagnosis of pyogenic pelvic inflammatory diseases by 99mTc-HMPAO leucocyte scintigraphy. Eur J Nucl Med. 2000;27(12):1774-7. (Level II/III evidence). View the reference
Pathway User Guide
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
|---|---|---|
 |
None | 0 |
 |
Minimal | < 1 millisieverts |
 |
Low | 1-5 mSv |
 |
Medium | 5-10 mSv |
 |
High | >10 mSv |
Disclaimer
Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.
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Imaging in Pelvic Inflammatory Disease (PID)
Transvaginal Ultrasound
If imaging is required to aid the diagnosis of suspected PID, ultrasound should be the first modality used.
- The diagnosis of PID is mainly made on clinical grounds with the use of imaging not commonly indicated
- Where PID is the primary diagnosis it should be presumptively treated as such but before initiating treatment appropriate microbiological testing should be completed to accurately elucidate the relevant organisms contributing to the diagnosis of PID
Ultrasound
- The use of ultrasound in the investigation of PID is an accepted modality where imaging is thought to be required to assist in making the diagnosis
- In one study using transvaginal sonography the presence of thickened fluid filled tubes was found to have a sensitivity of 85 percent and specificity of 100 percent for PID when compared to endometrial biopsy as the reference standard. Other studies assessing the diagnostic accuracy of US in PID have given sensitivities ranging from 30 percent to 85 percent. ,, A recent literature review of sonographic features used to assess PID similarly found thick fluid filled tubes the most accurate feature with a sensitivity of 100 percent. The identification of thickened, fluid filled tubes sonographically detected is considered a definitive criteria for the diagnosis of PID by the CDC
- In another study comparing MRI with US and laparoscopy, US was found to have a sensitivity of 81 percent and specificity of 78 percent in the detection of acute PID
- US can be useful for sonographically assessing for the presence of PID and also to assist in deciding to proceed to diagnostic laparoscopy
- US also has been used in the assessment for Tubo-Ovarian Abscess (TOA) which is considered a serious complication of PID, associated with a high morbidity. TOAs have been reported to occur in up to a third of women hospitalized with PID. , The studies assessing US for TOA have sensitivities ranging from 56 percent to 93 percent and specificities of 86 percent to 98 percent. , TOAs should not be confused with a tubo-ovarian complex which is considered an inflammatory pelvic mass without the presence of pus within a defined cavity, here the ovarian and tubal structures can still be recognized
- The typical features of a TOA are as following ,,
- Adnexal mass of varying echogenicity with septations, debris and irregular margins
- Pyosalpinx
- Loculated or speckled, echogenic fluid located in the cul-de-sac
- Loss of normal boundaries that delineate the fallopian tube and ovary due to oedematous and pus filled tissue
- In the following study, these sonographic features were identified in patients with acute PID and chronic PID
- Incomplete septum of the tubal wall was present in 92 percent of cases either chronic or acute, this was found to be the best indicator of tubal inflammatory disease and indicative of an oedematous and tortuous tube
- In acute disease, thickening of walls was present in 100 percent of cases and in cross section the presence of a cogwheel structure was present in 86 percent of cases
- In chronic disease thin walls were present in 97 percent of cases
- Information for consumers about ultrasound InsideRadiology
Computed Tomography (CT)
- CT has a limited role in the assessment of PID due radiation exposure in a predominantly younger age group
- It can be helpful to differentiate between conditions that may mimic PID like appendicitis where its efficacy is proven, however it is generally rarely used due to the aforementioned radiation exposure
- CT has been used to diagnose TOA where US has been inconclusive with sensitivities ranging from 78 percent – 100 percent in the literature ,
- Information for consumers about CT InsideRadiology
Magnetic Resonance Imaging (MRI)
- In clinical practice MRI is rarely used to assist in the diagnosis of PID mainly from a logistical perspective
- MRI is diagnostically more accurate than US for the assessment of PID. MR was found to have a sensitivity of 95 percent and specificity of 89 percent compared to US with a sensitivity of 81 percent and specificity of 78 percent
- These results were further confirmed in a recent study assessing MRI and PID where conventional MR imaging was 90.7 percent sensitive and 93.3 percent specific in the assessment of PID. The addition of diffusion weighted imaging increased the diagnostic accuracy to a sensitivity of 91.2 percent and specificity of 98.4 percent
- Information for consumers about MRI InsideRadiology
Nuclear Medicine Imaging
- Nuclear medical imaging is another modality that is rarely used, but available for the assessment of PID. Similar to MRI the use of nuclear imaging is limited by logistical and clinical considerations
- Scintigraphy using leucocytes labelled with 99mTc hexamethylpropylenamine oxime (99mTc-HMPAO) was used to assess the ability to detect patients with acute PID. In this study a sensitivity of 100 percent and specificity of 90 percent was achieved in the detection of PID
- In a similar study using 99mTc-HMAPO to assist in diagnosing TOA caused by PID, a sensitivity of 100 percent and specificity of 91.6 percent was achieved
- Limitations with integrating these imaging modalities into clinical practice include the requirement for repeat scan protocols, local expertise, radiation exposure and availability of resources
- Information for consumers about Nuclear Medicine InsideRadiology
Imaging in Pelvic Inflammatory Disease (PID)
CT/Laparoscopy
Rarely indicated but may be of use where diagnostic uncertainty exists or clinical deterioration progresses.
for CT
- The diagnosis of PID is mainly made on clinical grounds with the use of imaging not commonly indicated
- Where PID is the primary diagnosis it should be presumptively treated as such but before initiating treatment appropriate microbiological testing should be completed to accurately elucidate the relevant organisms contributing to the diagnosis of PID
Ultrasound
- The use of ultrasound in the investigation of PID is an accepted modality where imaging is thought to be required to assist in making the diagnosis
- In one study using transvaginal sonography the presence of thickened fluid filled tubes was found to have a sensitivity of 85 percent and specificity of 100 percent for PID when compared to endometrial biopsy as the reference standard. Other studies assessing the diagnostic accuracy of US in PID have given sensitivities ranging from 30 percent to 85 percent. ,, A recent literature review of sonographic features used to assess PID similarly found thick fluid filled tubes the most accurate feature with a sensitivity of 100 percent. The identification of thickened, fluid filled tubes sonographically detected is considered a definitive criteria for the diagnosis of PID by the CDC
- In another study comparing MRI with US and laparoscopy, US was found to have a sensitivity of 81 percent and specificity of 78 percent in the detection of acute PID
- US can be useful for sonographically assessing for the presence of PID and also to assist in deciding to proceed to diagnostic laparoscopy
- US also has been used in the assessment for Tubo-Ovarian Abscess (TOA) which is considered a serious complication of PID, associated with a high morbidity. TOAs have been reported to occur in up to a third of women hospitalized with PID. , The studies assessing US for TOA have sensitivities ranging from 56 percent to 93 percent and specificities of 86 percent to 98 percent. , TOAs should not be confused with a tubo-ovarian complex which is considered an inflammatory pelvic mass without the presence of pus within a defined cavity, here the ovarian and tubal structures can still be recognized
- The typical features of a TOA are as following ,,
- Adnexal mass of varying echogenicity with septations, debris and irregular margins
- Pyosalpinx
- Loculated or speckled, echogenic fluid located in the cul-de-sac
- Loss of normal boundaries that delineate the fallopian tube and ovary due to oedematous and pus filled tissue
- In the following study, these sonographic features were identified in patients with acute PID and chronic PID
- Incomplete septum of the tubal wall was present in 92 percent of cases either chronic or acute, this was found to be the best indicator of tubal inflammatory disease and indicative of an oedematous and tortuous tube
- In acute disease, thickening of walls was present in 100 percent of cases and in cross section the presence of a cogwheel structure was present in 86 percent of cases
- In chronic disease thin walls were present in 97 percent of cases
- Information for consumers about ultrasound InsideRadiology
Computed Tomography (CT)
- CT has a limited role in the assessment of PID due radiation exposure in a predominantly younger age group
- It can be helpful to differentiate between conditions that may mimic PID like appendicitis where its efficacy is proven, however it is generally rarely used due to the aforementioned radiation exposure
- CT has been used to diagnose TOA where US has been inconclusive with sensitivities ranging from 78 percent – 100 percent in the literature ,
- Information for consumers about CT InsideRadiology
Magnetic Resonance Imaging (MRI)
- In clinical practice MRI is rarely used to assist in the diagnosis of PID mainly from a logistical perspective
- MRI is diagnostically more accurate than US for the assessment of PID. MR was found to have a sensitivity of 95 percent and specificity of 89 percent compared to US with a sensitivity of 81 percent and specificity of 78 percent
- These results were further confirmed in a recent study assessing MRI and PID where conventional MR imaging was 90.7 percent sensitive and 93.3 percent specific in the assessment of PID. The addition of diffusion weighted imaging increased the diagnostic accuracy to a sensitivity of 91.2 percent and specificity of 98.4 percent
- Information for consumers about MRI InsideRadiology
Nuclear Medicine Imaging
- Nuclear medical imaging is another modality that is rarely used, but available for the assessment of PID. Similar to MRI the use of nuclear imaging is limited by logistical and clinical considerations
- Scintigraphy using leucocytes labelled with 99mTc hexamethylpropylenamine oxime (99mTc-HMPAO) was used to assess the ability to detect patients with acute PID. In this study a sensitivity of 100 percent and specificity of 90 percent was achieved in the detection of PID
- In a similar study using 99mTc-HMAPO to assist in diagnosing TOA caused by PID, a sensitivity of 100 percent and specificity of 91.6 percent was achieved
- Limitations with integrating these imaging modalities into clinical practice include the requirement for repeat scan protocols, local expertise, radiation exposure and availability of resources
- Information for consumers about Nuclear Medicine InsideRadiology