Pelvic inflammatory disease differential diagnosis

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

Overview

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

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.
Appendicitis	Pain localized to the right iliac fossa, vomiting, abdominal ultrasound sensitivity for diagnosis of acute appendicitis is 75% to 90%.
Rupturedovarian cyst	Usually spontaneous, can follow history of trauma; mild chronic lower abdominal discomfort may suddenly intensify, ultrasound is diagnostic.
Ovarian cyst torsion	Present with acute severe unilateral lower quadrant abdominal pain, nausea and vomiting, tender adnexal mass palpated in 90%, ultrasound is diagnostic.
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.
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.
Diverticulitis	Present with bowel symptoms in older women
Acute cystitis	Features with increased frequency and urgency, dysuria, and suprapubic pain.

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	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	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	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	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