So what are the clinical features of pelvic inflammatory disease?
By and large, you're talking about a clinical diagnosis,
and we physicians are rather imprecise
in how we make this diagnosis.
Our positive predictive value is between 65% and 90%
compared with the gold standard of laparoscopy.
Furthermore, many episodes go undiagnosed
because the women have PID,
but they don't have symptoms,
or their symptoms are rather mild.
So the bottomline is a good physician
should have his/her antenna up
because the diagnosis may be very, very subtle.
As a result, we often need to use empirical treatment.
So the classic clinical picture
would be a woman who has abdominal pain,
right lower quadrant,
left lower quadrant,
or bilateral lower abdominal pain.
And all patients who present like that to an emergency department
should have a pelvic examination.
And on a pelvic exam,
one of the classic finding would be cervical motion tenderness.
With the least motion of the cervix,
this often produces excruciating pain in the woman being examined.
And it would be prudent for the physician
doing the pelvic exam to warn the woman
that he or she is going to move the cervix,
and it's important for the woman to mention
whether this is very painful or not.
The other thing that you might expect would be
white blood cells in vaginal secretions.
And if a woman has no white cells in vaginal secretions
and no cervical discharge
she probably doesn't have PID.
However, bacterial vaginosis is a marker,
and certainly a test for Neisseria gonorrhoeae or Chlamydia trachomatis
is an indication for emperical treatment.
Most of the patients have a temperature
that is greater than 38 degrees Celsius,
but some patients are afebrile.
Some ancillary test that we often use would be testing for
an elevated erythrocyte sedimetation rate (sed rate)
or C-reactive protein.
All of these are indications for empirical treatment for PID.
When the diagnosis still remains in doubt,
or if our empirical regimen, whatever we've chosen,
hasn't seem to work,
then, that may be an indication for a laparoscopy.
And so generally that's for failure of emperical therapy
or patients who have a history of PID
and negative tests for gonorrhea, chlamydia or bacterial vaginosis.
Those are the ones that probably do need a laparoscopy.