Clinical presentation


The clinical diagnosis of PID is based on the presence of lower abdominal pain, usually bilateral, combined with either adnexal tenderness or cervical excitation on vaginal examination (Fig. 42.1). A comprehensive medical history and examination including an accurate menstrual and sexual history may help to reach a diagnosis. A pelvic examination is essential and a speculum examination is necessary both to enable appropriate swabs to be taken and also to exclude foreign bodies in the vagina such as retained tampons. The poor specificity and associated low positive predicative value of this approach (65-90%) is justified because a delay in antibiotic therapy of even a few days leads to a large increase in the risk of impaired fertility [10]. The risks of giving antibiotics to a woman who turns out not to have PID are low, although important differential diagnoses first need to be excluded.

Essential features

Lower abdominal pain (usually bilateral) or

Adnexal tenderness or

Cervical motion tenderness

Other clinical features can support a diagnosis of PID but are not essential before starting empirical therapy:

• intermenstrual or post coital bleeding - resulting from endometritis and cervicitis

• deep dyspareunia

• abnormal vaginal discharge - indicating lower genital tract infection

• fever - non-specific and usually only present in moderate to severe PID

• nausea/vomiting - may occur in severe PID but is more commonly associated with appendicitis.

PID caused by gonorrhoea presents more acutely and is more severe compared to chlamydial PID [11]. It is worth remembering that for every woman presenting with clinical features of PID there are two others who are asymptomatic.

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