Pelvic inflammatory disease differential diagnosis

Pelvic inflammatory disease Microchapters

Home

Patient Information

Overview

Historical Perspective

Pathophysiology

Causes

Differentiating Pelvic Inflammatory Disease from other Diseases

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Criteria

History and Symptoms

Physical Examination

Laboratory Findings

MRI

Ultrasound

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Pelvic inflammatory disease differential diagnosis On the Web

Most recent articles

cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Pelvic inflammatory disease differential diagnosis

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Pelvic inflammatory disease differential diagnosis

CDC on Pelvic inflammatory disease differential diagnosis

Pelvic inflammatory disease differential diagnosis in the news

Blogs on Pelvic inflammatory disease differential diagnosis

to Hospitals Treating Pelvic inflammatory disease

Risk calculators and risk factors for Pelvic inflammatory disease differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:  Seyedmahdi Pahlavani, M.D. [2]

## Overview[edit | edit source]

Pelvic inflammatory disease must be differentiated from ectopic pregnancy, ovarian torsion, ovarian cyst hemorrhage, ruptured ovarian cysts, appendicitis, endometriosis, diverticulitis and urinary tract infection.

## Differentiating Pelvic inflammatory disease from other Diseases[edit | edit source]

Disease | Findings

|

Ectopic pregnancy | History of missed menses, positive pregnancy test, ultrasound reveals an empty uterus and may show a mass in the fallopian tubes.[1]
Appendicitis | Pain localized to the right iliac fossa, vomiting, abdominal ultrasound sensitivity for diagnosis of acute appendicitis is 75% to 90%.[2]
Rupturedovarian cyst | Usually spontaneous, can follow history of trauma; mild chronic lower abdominal discomfort may suddenly intensify, ultrasound is diagnostic.[3]
Ovarian cyst torsion | Present with acute severe unilateral lower quadrant abdominal pain, nausea and vomiting, tender adnexal mass palpated in 90%, ultrasound is diagnostic.[4]
Hemorrhagic ovarian cyst | Presents with localized abdominal pain, nausea and vomiting. Hypovolemic shock may be present; abdominal tenderness and guarding are physical exam findings, ultrasound is diagnostic.[4]
Endometriosis | Present with cyclic pain that is exacerbated by onset of menses and during the luteal phase; dyspareunia, transvaginal ultrasound is suggestive, laparoscopic exploration is diagnostic.[4]
Diverticulitis | Present with bowel symptoms in older women
Acute cystitis | Features with increased frequency and urgency, dysuria, and suprapubic pain.[5][6]

Diseases | Diagnostic tests | Physical Examination | Symptoms | Past medical history | Other Findings

|
|
|
|
|

Urinalysis | Urine Culture | Gold Standard  | Fever | Tenderness | Discharge | Inguinal Lymphadenopathy | Hematuria | Pyuria | Frequency | Urgency | Dysuria
Urethritis |

* Positive leukocyte esterase test or >10 WBCs
* Mucous threads in the morning urine

| \-  |

Gram stain & Mucoid or purulent discharge

| \+  | \-  | Urethral discharge | \+  | \-  | \+  | \-  | \-  | \+  |

* Prior STDs
* Urinary tract infections
* New sexual partner
* Recent intercourse
* Recent catheterization

* Purulent discharge may suggest gonorrhoea
* Exclusive dysuria suggest Chlamydia
* Painful genital ulcers with dysuria suggest HSV

Pyelonephritis |

* Leukocytes

* Positive nitrite

| Identifies causative bacteria | Imaging and culture | \+  | Flank or costovertebral angle | \+  | \+  | \+  | \+  | \-  | \-  | \+  |

* History of pyelonephritis
* Recent history of hospitalisation
* Nephrolithiasis
* Immunosupression

* Costovertebral angle tenderness
* Patient is in acute distress
* Look for obstructive causes

Cystitis |

* Positive nitrite

* Positive leukocyte esterase

* WBCs

* RBCs

| >100,000CFU/mL  | Urine culture | \+  | Suprapubic  | \-  | \+  | \+  | \+  | \+  | \+  | \+  |

* Recent catheterisation
* Pregnancy
* recent intercourse
* Diabetes
* Personal or family history of UTI
* Known abnormality of the urinary tract
* BPH or HIV

* Imaging studies help differentiate the various types
* May acompany back pain, nausea, vomiting and chills

Prostatitis |

* 10-20 leukocytes for acute and chronic bacterial subtypes

| Identifies causative bacteria (in bacterial subtypes)  |

Urine culture

| \+  | \-  | \-  | \-  | \-  | \+  | \+  | \+  | \+  |

* Urogenital disorders
* Recent catheterization or other genitourinary instrumentation
* History of UTIs

* In acute prostatitis, palpation reveals a tender and enlarged prostate[1][3]
* In chronic prostatitis, palpation reveals a tender and soft (boggy) prostate[1]
* A prostate massage should never be done in a patient with suspected acute prostatitis, since it may induce sepsis

Bacterial Vulvovagintis | \-  | \-  |

Gram stain & Culture of discharge

| \+  | \-  | Vaginal discharge | \+  | \-  | \-  | \-  | \-  | \+  |

* Number and type of sexual partners (new, casual, or regular)
* Prior STDs
* Previous history of symptomatic BV in female partner (in homosexual women)

* Fishy odor from the vagina (Whiff test)
* Thin, white/gray homogeneous vaginal discharge
* Microscopy (wet prep) and vaginal pH
* Clue cells

Cervicitis | \-  | \-  | culture for gonococcal cervicitis  | \+  | Cervical  |

endocervical exudate

| \-  | \-  | \+  | \-  | \-  | \+  |

* Abnormal vaginal bleeding after intercourse or after menopause
* Abnormal vaginal discharge
* Painful sexual intercourse
* Pressure or heaviness in the pelvis

* Purulent or mucopurulent endocervical exudate

* Sustained endocervical bleeding easily induced by a cotton swab

* >10 WBC in vaginal fluid, in the absence of trichomoniasis, may indicate endocervical inflammation caused specifically by C. trachomatis or N. gonorrhea

Epididymitis |

* Hematuria may be seen

| \+  | Culture | \+  |

Testicular & Suprapubic

| +/- urethral discharge | \+  | \+  | \-  | \+  | \+  | \+  |

* Scrotal pain: starts gradually, is usually unilateral and localized posterior to the testis
* Scrotal swelling
* Scrotal wall erythema
* Constitutional symptoms: feeling warm, chills, nausea and vomiting

* Ultrasound in patients with acute testicular pain to assess for testicular torsion
* If equivocal do surgical exploration

Syphilis (STD)  | \-  | \-  | Darkfield microscopy | +/-  | \-  | \-  | \+  | \-  | \-  | \-  | \-  | \-  |

* History of STD
* HIV
* Immunosupression
* Previous history of chancre

* May be asymptomatic
* Painless chancre in primary syphilis
* Secondary syphilis may have generalised features and condylomata lata
* Tertiary syphilis can have neurosyphilis, cardiovascular syphilis and gummas

| Clinical Features  | Physical Examination  | Diagnostic Findings

|
|
|

Endometriosis |

* Dysmenorrhea
* Dyspareunia
* Infertility
* Common in women between 25 to 35 years

* Nodules in the posterior fornix
* Adnexal masses
* Fixed retroverted uterus
* Lateral displacement of the cervix

* Increased serum cancer antigen-125
* Nodules of the recto vaginal septum and hypoechoic, vascular mass on MRI
* Laproscopic visualization confirms the diagnosis

Adenomyosis[7] |

* Abnormal uterine bleeding
* Dysmenorrhea
* Common in women aged 40 and 50 years

* Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of gestation

* Asymmetric thickening of the myometrium on MRI

Submucous uterine leiomyomas[8] |

* Menorrhagia
* Pelvic pressure and pain
* Infertility
* Peak age of onset 25 to 44 years of age

* Mobile uterus with an irregular contour

* Transvaginal ultrasound will demonstrate the presence of myomas

Pelvic Inflammatory disease[9] |

* Seen in patients with history of sexually transmitted disease
* History of multiple sexual partners
* Common in women younger than 25 years of age

* Abdominal tenderness
* Acute cervical motion, uterine, and adnexal tenderness
* Visualization of purulent endocervical discharge

* Positive Nucleic acid amplification tests for Chlamydia trachomatis and N. gonorrhoeae
* Gram negative diplococci on gram stain

Pelvic congestion Syndrome[10] |

* Shifting lower abdominal pain
* Deep dyspareunia
* Post-coital pain
* Exacerbation of pain after prolonged standing

* Bimanual tenderness
* Cervical motion tenderness

* Pelvic varicosities on ultrasound with reduced blood flow

## References[edit | edit source]

1. ↑ Morin L, Cargill YM, Glanc P (2016). "Ultrasound Evaluation of First Trimester Complications of Pregnancy". J Obstet Gynaecol Can. 38 (10): 982–988. doi:10.1016/j.jogc.2016.06.001. PMID 27720100.
2. ↑ Balthazar EJ, Birnbaum BA, Yee J, Megibow AJ, Roshkow J, Gray C (1994). "Acute appendicitis: CT and US correlation in 100 patients". Radiology. 190 (1): 31–5. doi:10.1148/radiology.190.1.8259423. PMID 8259423.
3. ↑ Bottomley C, Bourne T (2009). "Diagnosis and management of ovarian cyst accidents". Best Pract Res Clin Obstet Gynaecol. 23 (5): 711–24. doi:10.1016/j.bpobgyn.2009.02.001. PMID 19299205.
4. ↑ 4.0 4.1 4.2 Bhavsar AK, Gelner EJ, Shorma T (2016). "Common Questions About the Evaluation of Acute Pelvic Pain". Am Fam Physician. 93 (1): 41–8. PMID 26760839.
5. ↑ W. E. Stamm (1981). "Etiology and management of the acute urethral syndrome". Sexually transmitted diseases. 8 (3): 235–238. PMID 7292216. Unknown parameter `|month=` ignored (help)
6. ↑ W. E. Stamm, K. F. Wagner, R. Amsel, E. R. Alexander, M. Turck, G. W. Counts & K. K. Holmes (1980). "Causes of the acute urethral syndrome in women". The New England journal of medicine. 303 (8): 409–415. doi:10.1056/NEJM198008213030801. PMID 6993946. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
7. ↑ Parker JD, Leondires M, Sinaii N, Premkumar A, Nieman LK, Stratton P (2006). "Persistence of dysmenorrhea and nonmenstrual pain after optimal endometriosis surgery may indicate adenomyosis". Fertil Steril. 86 (3): 711–5. doi:10.1016/j.fertnstert.2006.01.030. PMID 16782099.CS1 maint: Multiple names: authors list (link)
8. ↑ Donnez J, Donnez O, Matule D, Ahrendt HJ, Hudecek R, Zatik J; et al. (2016). "Long-term medical management of uterine fibroids with ulipristal acetate". Fertil Steril. 105 (1): 165–173.e4. doi:10.1016/j.fertnstert.2015.09.032. PMID 26477496.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
9. ↑ Ross J, Judlin P, Jensen J, International Union against sexually transmitted infections (2014). "2012 European guideline for the management of pelvic inflammatory disease". Int J STD AIDS. 25 (1): 1–7. doi:10.1177/0956462413498714. PMID 24216035.CS1 maint: Multiple names: authors list (link)
10. ↑ Rozenblit AM, Ricci ZJ, Tuvia J, Amis ES (2001). "Incompetent and dilated ovarian veins: a common CT finding in asymptomatic parous women". AJR Am J Roentgenol. 176 (1): 119–22. doi:10.2214/ajr.176.1.1760119. PMID 11133549.CS1 maint: Multiple names: authors list (link)

Template:WH Template:WS