 Welcome to emergency medicine video. In this segment we will discuss pelvic inflammatory disease. In particular, we will focus on signs and symptoms, diagnosis and treatment in the emergency department. PID is a spectrum of infections of the female upper reproductive tract. It is generally initiated from ascending infection from the cervix, or cervicitis. It can include selpinggitis if the fallopian tubular involved, endometritis if the uterus is involved, tubal ovarian abscess if abscesses are formed, and can extend to pelvic peritonitis. In rare cases, it can even spread and become a perihepatitis. Apart from the infection, PID can also cause infertility, while the scarring of the tube will increase ectopic pregnancy risk later on. It can also cause chronic pain in patients. In terms of bacteria, the most common bacteria include nasiria gonorrhea and chlamydia trachomatis. These two bacteria often contribute to the cervicitis. When the cervicitis is not treated, it then spreads to the upper tract with involvement of other bacteria, causing a PID. The risk factors for PID include multiple sexual partners, previous STDs, presence of an IUD particularly right after insertion, or any other procedures involving the uterine cavity. In terms of the symptoms, depending on the extent of the PID, the patient might have different symptoms. With just cervicitis, so not PID, the patients may not have any symptoms at all, or they may complain of increased discharge. Once the disease has spread to the upper tract, the patients can present with lower abdominal pain. In patients with a tubal ovarian abscess, their pain might be more localized through the location of the abscess. Other symptoms might include abnormal discharge, vaginal bleeding, or postcoido bleeding. Due to the infection, they may also have systemic symptoms such as fever, nausea, or malaise. Frank peritonitis is rare in a late finding. Let's move on to signs on physical exams. On physical examination, as you can deduce, the patient might have a fever, be tachycardic, and might appear toxic. She may have abdominal pain and peritoneal signs if there is peritonitis. If there is a perihepatitis, her right upper quadrant might be tender. On pelvic exam, the tenderness might localize to the anexa if there is a tubal ovarian abscess, and might be palpated. There should also be purulent discharge on pelvic exam and cervical motion tenderness. Let's move on to diagnosis. Typically, we would do swabs during the pelvic exam. In terms of lab tests, we can include inflammatory markers such as white blood cell count. If we worry about perihepatitis, then LFTs would be drawn as well. A pregnancy test should also be done. In terms of imaging, an ultrasound is done for tubal ovarian abscess. It is also done in patients whose findings on physical examination might be unclear. Ultrasound will also diagnose other ovarian pathologies such as torsion and rupturovarian cysts. These two can also give a very similar clinical picture as pelvic inflammatory disease or tubal ovarian abscess. In the emergency department, often the swabs will not yield the results in a timely manner. Since there are many complications for PID, we often treat patients with a very low threshold. If we see a patient with lower abdominal tenderness with cervical motion tenderness in a patient at risk for STDs, we often do not wait for the culture results to return to start treatment in this patient. Let's move on to treatment for PID. Antibiotics are given to treat pelvic inflammatory disease. Depending on the local resistance, medications can include the following. Third generation cephalosporin, metronidazole, gentamycin, doxycycline, oazethromycin. It is best to check local guidelines for the specific regimen. What if the patient has an IUD? After the initiation of antibiotics, the IUD would be removed after about 24 to 48 hours. Who do we admit? Patients who have tubal ovarian abscess will be admitted to ensure the abscess resolved with antibiotics. If not, surgery might be needed. As you can imagine, those with peritonitis and perihepititis will also need to be admitted as well. In terms of follow-up, patients' partners will need to be tested for STD and patients are also instructed to return to the hospital if their symptoms worsen. Here are the main points for PID. Cervicitis are often asymptomatic and therefore are very hard to pick out. Based on where is involved, the presenting symptoms for PID can vary. We should have a very low threshold to treat patients because of the terrible complications that PID can have. If we're worried about a tubal ovarian abscess or any other ovarian pathology, ultrasound is the imaging test of choice. We hope you enjoyed this. Thank you for watching.