Q4 Urgent Caring- Pelvic Inflammatory Disease: Diagnosis and Treatment in Urgent Care

EB Medicine

KidBits: Pelvic Inflammatory Disease in Adolescents

Adolescents are more susceptible to PID for several reasons. Many adolescents are less diligent about using barrier contraception. Additionally, cervical ectropion exposes a large area of columnar epithelial cells, which are less resistant to infection by N gonorrhoeae and C trachomatis.111 Maintain a high level of suspicion for PID in adolescents, as serious sequelae like infertility can develop after a single episode of PID.112 Many clinicians fail to inquire about sexual activity in adolescents and thus fail to consider PID as an etiology for pelvic pain. There are no adjustments for the treatment of the adolescent with PID, and the decision to refer adolescents to the ED should be based on the same criteria as for adult patients.11 

Risk Management Pitfalls for Management of Pelvic Inflammatory Disease

1.“Yes, she could have had PID, but she looked so well that I discharged her and deferred treatment to  primary care.” All patients who have the clinical diagnosis of PID should have empiric therapy started. Initial presentation does not predict progression of the disease and, therefore, should not be used to determine who should have treatment initiated.

  1. “I gave a gram of azithromycin and a shot of ceftriaxone to treat her PID.” There is no single-dose treatment of PID; standard treatment regimens last for 14 days. This particular regimen is used to treat cervicitis in the absence of signs and symptoms of PID; however, even for cervicitis, azithromycin is no longer the medication of choice. Failure to provide adequate duration of appropriate medication places the patient at risk for undertreatment and the development of a resistant organism.
  2. “When she returned for her recheck, I checked her records and saw that she had a negative
    N gonorrhoeae/C trachomatis test, so I stopped her medication and reassured her that she didn’t have PID.” A negative N gonorrhoeae/C trachomatis test cannot be used to rule out the possibility of PID. A cervical N gonorrhoeae/C trachomatis NAAT is a test of lower-tract disease and does not exclude the presence of an upper-tract infection. Additionally, the test does not test for anaerobes that are implicated in PID. 
  3. “She had white blood cells on the urine microscopy, so I treated her for a urinary tract infection even though she had no dysuria.” Patients with PID commonly have white blood cells on urine microscopy. Additionally, uterine tenderness can be mistaken for suprapubic tenderness due to cystitis. Patient risk factors must always be considered, and the presence or absence of dysuria is not diagnostically specific to differentiate PID from a urinary tract infection. 
  4. “She had no fever and a normal white blood cell count, so PID was ruled out.” There are no laboratory tests or imaging modalities that have adequate sensitivity to exclude the diagnosis of PID. Laboratory tests and imaging are typically abnormal only with sicker patients. Over-reliance on laboratory testing will lead to missed diagnoses.
  5. “She came back with continued pain, so I refilled her pain medications.” When a patient fails to show adequate response to treatment, you must first consider the need for parenteral treatment, development of a complication, and infection with a resistant organism. Consider additional testing with cervical culture, which would allow for the identification of a resistant organism. Additionally, strongly consider increased coverage of anaerobic organisms.
  6. “She had clue cells and white blood cells on her wet mount, so I treated her for bacterial vaginosis.” The presence of bacterial vaginosis does not exclude the diagnosis of PID. Bacterial vaginosis can be associated with PID. In some cases, it may be due to direct ascension of anaerobic bacteria, while in other cases it may be secondary to the loss of mucosal immunity secondary to the bacterial overgrowth.
  7. “I told her that her PID was possibly due to an STI. I assumed that she understood that she should avoid any further sexual interactions with her partner.” Patients with a diagnosis of PID should abstain from intercourse until the resolution of therapy and until after the partners have completed empiric treatment. This recommendation is true regardless of the cause of the PID. While it may seem intuitive, it is important to speak to the patient directly about the importance of partner treatment to prevent re-infection.
  8. “When I told her to see her doctor in two days, I assumed she would do it. If she didn’t have a doctor, she should have just come back to Urgent Care.” Most patients with PID should have a clinical response within 48 to 72 hours. Many of the decision points are based on the response to treatment at this repeat visit, especially with regard to the need for imaging, changes in antibiotics, or need for parenteral therapy. Therefore, it is important that the patient has access to and understands the importance of the follow-up appointment.


11.* Workowski KA, Bachman LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-180. (CDC guidelines)

  1. Lee V, Tobin JM, Foley E. Relationship of cervical ectopy to chlamydia infection in young women. J Fam Plann Reprod Health Care. 2006;32(2):104-106. (Prospective; 231 patients)
  2. Gray-Swain MR, Peipert JF. Pelvic inflammatory disease in adolescents. Curr Opin Obstet Gynecol. 2006;18(5):503-510. (Review)

Excerpted from: Pochick K. Pelvic inflammatory disease: diagnosis and treatment in Urgent Care. Evidence-Based Urgent Care. 2023 October;2(10):1-23. Reprinted with permission of EB Medicine.