Laparoscopy, once considered the diagnostic gold standard for PID, is now thought to lack sufficient sensitivity for the diagnosis.²⁵

In a study by Gaitain comparing various means of diagnosing PID, conclusions were that clinical diagnosis has an 87% sensitivity, while laparoscopy has 81% sensitivity and 100% specificity.26

Therefore, given the invasiveness of laparoscopy, it is now utilized as a diagnostic means only for those patients who follow an atypical course and fail to respond to aggressive inpatient parenteral therapy.

The decision of whether to add metronidazole to cover bacterial vaginosis and other anaerobic organisms is also widely debated.

While any patient with concomitant bacterial vaginosis or trichomonas infection should be treated with a course of metronidazole, the addition of this therapy in other patients is based on their risk of infection with an anaerobic organism.

Those at risk include patients with a pelvic abscess and those with a history of gynecological instrumentation in the 3 weeks preceding infection.¹⁵

Adherence to the 14-day antibiotic regimen is difficult for many patients, and research has focused on how to achieve better compliance with the antibiotic regimen.

One double-blind, randomized, control study compared the efficacy of combining a single dose of IM ceftriaxone followed by 14-days of either twice daily doxycycline or once a day azithromycin. In this study, once daily azithromycin proved superior, with a cure rate of 90%, compared with 72% in twice daily doxycycline.²⁷ The results are attributed in part to the fact that fewer than 70% of patients completed the doxycycline course as prescribed.

However, the CDC has not yet added azithromycin to its recommended regimens, as more studies are first needed to confirm this finding.

Conclusion

Pelvic inflammatory disease affects hundreds of thousands of women each year and is a leading cause of abdominal pain in women presenting to the emergency department.

The diagnosis is largely a clinical one, and practitioners must maintain a low threshold for diagnosing and treating PID, as empiric therapy will lessen the serious complications related to untreated disease.

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