Pelvic inflammatory disease
Citation, DOI & article data
Pelvic inflammatory disease (PID) is a broad term that encompasses a spectrum of infection and inflammation of the upper female genital tract, resulting in a range of abnormalities.
The highest incidence is seen among sexually-active women in their teens, with 75% of cases being under 25 years of age. In the United States, approximately 1 million females are thought to be afflicted with pelvic inflammatory disease per year, and nearly 275,000 of them are believed to be hospitalized 7.
More common presentations include acute pelvic pain (of variable intensity), cervical motion tenderness, vaginal discharge, fever, dyspareunia, and leukocytosis. Right upper quadrant pain from perihepatitis in Fitz-Hugh-Curtis syndrome is possible.
Pelvic inflammatory disease is defined as an acute clinical syndrome associated with ascending spread of micro-organisms, unrelated to pregnancy or surgery. The infection generally ascends from the vagina or cervix (cervicitis) to the endometrium (endometritis), then to the fallopian tubes (salpingitis, hydrosalpinx, pyosalpinx), and then to and/or contiguous structures (oophoritis, tubo-ovarian abscess, peritonitis).
It can result from a number of causative organisms:
Pelvic inflammatory disease is usually bilateral, except when it is caused by the direct extension of an adjacent inflammatory process such as appendiceal, diverticular, or post-surgical abscesses.
Imaging features are often non-specific but are disproportionate to what may be apparent from symptoms. If imaged early (e.g. during the cervicitis stage), there may be no finding. If imaged very late, there may be an adnexal mass-like region with surrounding inflammatory change, and the fallopian tube and ovary may not be distinguished.
Other associated findings include 7:
soft-tissue stranding and infiltration of pelvic floor fascial planes
thickening of uterosacral ligaments
Ultrasound is usually the first imaging ordered in a case of lower abdominal pain.
Early findings in PID include 12 :
indistinct uterine margins
echogenic pelvic fat
fallopian tube thickening
Few non-specific findings include 8:
fluid in cul-de-sac
fluid in endometrial cavity
increased ovarian volumes
increased thickness and vascularity of the endometrium
In the most severe cases, ultrasound may show adnexal masses with a heterogeneous echo-pattern.
Some sonographic signs associated with tubal inflammation include:
thickened/dilated fallopian tubes
incomplete septa in the tube
fluid collection within the tubes (hydrosalpinx)
increased vascularity around the tube on color Doppler
the fat around the tube may be echogenic and there may be a small amount of reactive free fluid in the pelvis
echogenic fluid in the tube (pyosalpinx)
results from adhesions causing tubal obstruction
tubular adnexal "mass"
fallopian tube thickening of >5 mm with enhancing wall: has high specificity of 95%
indistinct uterine border
thickening of the uterosacral ligaments
complex free fluid in the pouch of Douglas (cul-de-sac)
pelvic fat stranding or haziness
lymph nodes in the para-aortic and paracaval regions often become prominent due to infection draining into lymphatics along the course of the gonadal veins
May show an ill-defined adnexal mass containing fluid with various signal intensities:
T1: if there is proteinaceous debris in a dilated tube, then it may have increased T1 signal
T1+C (Gd): wall and surrounding tissues may enhance
Treatment and prognosis
In the absence of complications, pelvic inflammatory disease is often treated conservatively with education, antibiotics, and partner tracing.
infertility due to tubal adhesions
consider in a patient without risk factors for PID and/or a patient in whom a course of antibiotics did not resolve the PID
- 1. Sam JW, Jacobs JE, Birnbaum BA. Spectrum of CT findings in acute pyogenic pelvic inflammatory disease. Radiographics. 22 (6): 1327-34. doi:10.1148/rg.226025062 - Pubmed citation
- 2. Tukeva TA, Aronen HJ, Karjalainen PT et-al. MR imaging in pelvic inflammatory disease: comparison with laparoscopy and US. Radiology. 1999;210 (1): 209-16. Radiology (full text) - Pubmed citation
- 3. Rezvani M, Shaaban AM. Fallopian tube disease in the nonpregnant patient. Radiographics. 31 (2): 527-48. doi:10.1148/rg.312105090 - Pubmed citation
- 4. Horrow MM. Ultrasound of pelvic inflammatory disease. Ultrasound Q. 2004;20 (4): 171-9. Ultrasound Q (link) - Pubmed citation
- 5. Kaakaji Y, Nghiem HV, Nodell C et-al. Sonography of obstetric and gynecologic emergencies: Part II, Gynecologic emergencies. AJR Am J Roentgenol. 2000;174 (3): 651-6. AJR Am J Roentgenol (full text) - Pubmed citation
- 6. Tinkanen H, Kujansuu E. Doppler ultrasound studies in pelvic inflammatory disease. Gynecol. Obstet. Invest. 1992;34 (4): 240-2. - Pubmed citation
- 7. Lalwani N, Patel S, Ha KY et-al. Miscellaneous tumour-like lesions of the ovary: cross-sectional imaging review. Br J Radiol. 2012;85 (1013): 477-86. Br J Radiol (full text) - doi:10.1259/bjr/92819127 - Free text at pubmed - Pubmed citation
- 8. Amirbekian S, Hooley RJ. Ultrasound Evaluation of Pelvic Pain. Radiol. Clin. North Am. 2014;52 (6): 1215-1235. doi:10.1016/j.rcl.2014.07.008 - Pubmed citation
- 9. Revzin MV, Mathur M, Dave HB, Macer ML, Spektor M. Pelvic Inflammatory Disease: Multimodality Imaging Approach with Clinical-Pathologic Correlation. (2016) Radiographics : a review publication of the Radiological Society of North America, Inc. 36 (5): 1579-96. doi:10.1148/rg.2016150202 - Pubmed
- 10. Revzin MV, Moshiri M, Katz DS, Pellerito JS, Mankowski Gettle L, Menias CO. Imaging Evaluation of Fallopian Tubes and Related Disease: A Primer for Radiologists. (2020) Radiographics : a review publication of the Radiological Society of North America, Inc. 40 (5): 1473-1501. doi:10.1148/rg.2020200051 - Pubmed
- 11. Jennings L, Jennings KD, Jennings. Pelvic Inflammatory Disease. (2021) . doi: - Pubmed
- 12. Horrow M, Rodgers S, Naqvi S. Ultrasound of Pelvic Inflammatory Disease. Ultrasound Clinics. 2007;2(2):297-309. doi:10.1016/j.cult.2007.08.008