Management of gonococcal pelvic inflammatory disease.

Abstract

Information that has become available since 1974 on the management of pelvic infections unrelated to abortions, the puerperium, or pelvic surgery, with an emphasis on those associated with Neisseria gonorrhoeae are summaried. Attention is directed to both diagnosis (clinical, bacteriologic) and therapy (hospitalized patients, outpatients, indications for hospitalization, and IUDs). Most investigators classify acute pelvic inflammatory disease (PID) as gonococcal or nongonococcal on the basis of the presence or absence of N. gonorrhoeae in cervical specimens. As compared with patients who have nongonococcal pelvic inflammatory disease, patients who have gonococcal disease are often younger, more likely to have elevated temperatures, and more often experience pain in the first 10 days of the menstrual cycle. It is not possible to differentiate gonogoccal from nongonococcal pelvic inflammatory disease without the aid of laboratory tests. N. gonorrhoeae can be isolated from the cervix in 20-80% of acute PID. Much of the variation can be explained by differences in the prevalences of gonorrhea in different populations. In populations with high prevalence of gonorrhea, most cases of acute PID are associated with gonorrheal infection. Where gonorrhea is less common, N. gonorrhoeae is isolated from the cervix in fewer than half of cases of acute PID. Neisseria gonorrhoeae can be demonstrated in the fallopian tube or peritoneal cavity of 8-70% of patients with PID whose cervical cultures yield N. gonorrhoeae. When N. gonorrhoeae is isolated from the lower genital tract of a patient who has acute pelvic inflammatory disease, causal significance is appropriately ascribed to that organism. The use of gram staining of cervical specimens to diagnose uncomplicated gonorrhea in women has been discouraged due to low sensitivity and specificity compared with cultures on selective medium. Comparative evaluation of studies of therapy of acute pelvic inflammatory disease is hampered by differences in criteria for diagnosis of cases, in indications for hospitalization and surgical treatment, in durations of therapy and follow-up, and in criteria for cure. The information available is insufficient to justify recommending a change in the 1974 schedules for therapy of hospitalized patients. Results of 2 studies of treatment of outpatients with PID are summarized in a table. Cunningham et al. reported satisfactory bacteriologic and clinical cure rates for gonococcal PID after use of the currently recommended treatment schedules. McCormack et al. obtained satisfactory results with a 5-day course of spectinomycin HCI administered to a small number of patients. Sweet recommended that hospitalization be considered for all patients with acute PID, as is the practice of many facilities in Sweden. It is now clearly documented that users of IUDs have a 3-9 fold greater risk of developing PID as compared with nonusers. All patients treated for acute PID should be followed closely to monitor their responses to therapy. Controlled therapeutic trials of acute PID should ensure similarity of case definition and identification of "cure."