Stefanie Biondi, MD


Mallika Singh, MD

Jonathan Kobles, MD



Acute infection of the upper genital tract: uterus (endometritis), fallopian tubes (salpingitis), and ovaries (oophoritis). 

Complications may include progression to perihepatitis (Fitz-Hugh-Curtis syndrome), peritonitis, or tubo-ovarian abscess.


  • Microorganisms compromise the endocervical barrier, allowing for upward migration and infection of the upper genital tract including the uterus, fallopian tubes and ovaries.
  • Approximately 85% of cases occur due to infection of the lower genital tract by sexually transmitted infections including, but not limited to: Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, and Mycoplasma genitalium.
  • Approximately 15% of cases occur due to colonization of the lower genital tract with GI pathogens (Escherichia coli, Bacteroides fragilis, Group B streptococci, and Campylobacter spp) or respiratory pathogens (Haemophilus influenzae, Streptococcus pneumoniae, Group A streptococci, and Staphylococcus aureus). 
  • Very rarely (<1%), PID can be caused by direct extension of GI infection to the upper genital tract (E.g. appendiceal abscess or ruptured diverticulum).
  • PID is uncommon in patients >12 weeks pregnant due to the production of a cervical mucus plug.

Risk Factors:

  • Sexually active individuals aged 15-25
  • Multiple sexual partners or lack of use of barrier contraception
  • History of STI
  • Sexual partner with a history of STI
  • Recent instrumentation of the cervix (E.g., IUD placement, D&C)


  • Lower abdominal/pelvic pain, usually <2 weeks duration
  • Onset of pain is often during menses or shortly after menses
  • Pain worsens with penetrative intercourse or sudden movements
  • Vaginal discharge
  • Systemic symptoms: fevers, chills, nausea, vomiting
  • Heavier than usual vaginal bleeding during periods or irregular vaginal bleeding
  • Right upper quadrant pain which is pleuritic and often radiates to right shoulder can indicate Fitz Hugh Curtis Syndrome aka PID-associated perihepatitis

Diagnosis and Work-up:

The diagnosis of PID is primarily clinical:

  • A Pelvic exam should be offered and performed in any patient with biologically female anatomy presenting with lower abdominal/pelvic pain.
    • Cervical motion tenderness, adnexal tenderness, or uterine tenderness on exam without alternate cause is strongly suggestive of PID and sufficient for establishing diagnosis.
    • Less than half of PID patients have classic findings of STI on pelvic exam such as yellow/green purulent vaginal discharge or cervical friability. Absence of these findings should not exclude PID diagnosis.
  • Other potential findings on physical exam are fever, RUQ tenderness from perihepatitis, or diffuse abdominal tenderness with rebound and guarding from peritonitis.


Labs/Imaging to Consider:

  • STI Testing
      • Chlamydia, gonorrhea, and Mycoplasma genitalium endocervical or self-collected vaginal NAAT testing.
      • Sensitivity for detection of gonorrhea with endocervical NAAT swab is 98% as compared to only 56% specificity with urine NAAT swab.
      • Self-collected vaginal swabs may be more sensitive for diagnosing gonorrhea and chlamydia than health-care performed endocervical swabs and first catch urine samples.
      • Negative G/C does not exclude diagnosis of PID
  • Wet mount of vaginal secretions will show abundant WBCs in PID patients and may demonstrate Trichomonas infection
  • Labs including:
      • CBC 
      • BMP
      • LFTs
      • ESR/CRP
      • Urinalysis 
      • Pregnancy testing
  • Consider abdominal imaging including transvaginal pelvic ultrasound or CT abdomen and pelvis if concern for TOA or peritonitis.
      • Adnexal mass/tenderness on exam or sepsis associated with PID should cause concern for TOA.
      •  PID with CRP>49 or highly elevated WBC count should also cause concern for TOA.
  • Screening for HIV and syphilis


Broad antibiotic coverage is needed to cover Chlamydia trachomatis and Neisseria gonorrhoeae, as well as anaerobic organisms such as Gardnerella vaginalis, enteric gram-negative rods, streptococci, and genital mycoplasmas.

Note that Fitz-Hugh-Curtis peri-hepatitis is present in 4-14% of cases of PID and does not warrant any change in management.

Inpatient treatment:

  • Criteria for inpatient treatment:
      • Pregnancy with PID
      • Severe PID (temperature greater than 101F , WBC count > 15,000, elevated ESR or CRP, sepsis associated with PID)
      • Suspected abscess associated with PID
      • Inability to tolerate oral medications due to vomiting, lack of adherence,etc.
      • Lack of improvement in symptoms after 72 hrs of outpatient treatment
  • Preferred inpatient treatment regimen:
      • IV Ceftriaxone 1g every 24 hours PLUS
      • IV or PO doxycycline 100mg every 12 hours PLUS
      • IV or PO metronidazole 500mg every 12 hours

Outpatient treatment: 

  • Criteria for outpatient treatment: 
      • None of the above inpatient criteria (ie sepsis, pregnancy) 
      • Patient demonstrates capability to adhere to outpatient regimen
      • Patient understands and has ability to return to care for worsening symptoms or lack of improvement within 72 hrs of initiating antibiotics
  • Preferred outpatient treatment regimen:
      • Ceftriaxone 500mg IM single dose PLUS
      • Doxycycline 100mg PO twice daily x 14 days PLUS
      • Metronidazole 500 mg PO twice daily x 14 days


  • If untreated, PID can lead to infertility, ectopic pregnancies, chronic pelvic pain, and recurrent tubo-ovarian abscesses.
  • Due to the high risk of these sequelae in untreated patients, there should be a low threshold to treat patients with adnexal, uterine, or CMT for PID.

Tubo-Ovarian Abscess


  • A tubo-ovarian abscess is a complex infectious/inflammatory mass consisting of agglutinated pelvic organs (fallopian tube, ovary, and/or adjacent bowel/bladder) with surrounding collection of purulence.
  • TOAs are typically polymicrobial, containing enteric flora and genital flora, and are most commonly a complication of pelvic inflammatory disease (PID). 

Risk factors:

  • Recent diagnosis of PID: One third of patients hospitalized for PID are found to have TOA.
  • Sexually active individuals, aged 15-25,  presence of multiple sexual partners, recent oocyte retrieval, and/or lack of use of barrier contraception.
  • TOA in a postmenopausal patient can be associated with GYN or GI malignancy.


  • TOA develops from the spread of a polymicrobial PID infection to the fallopian tube, causing salpingitis and pyosalpinx. The edema of the infected fallopian tube can lead to tissue necrosis resulting in adherence to surrounding structures such as the ovary/bladder. Purulent exudate causes these structures to coalesce into a walled-off infection/abscess.
  • Less often, a polymicrobial infection/abscess of the fallopian tube/ovary can result iatrogenically from egg retrieval procedures, or from seeding of the pelvic structures with GI flora from erosions of the GI tract by GI malignancies, pelvic malignancies, or GI infections (ex., ruptured diverticulitis).


  • Symptoms of TOA are similar to PID if the abscess has not ruptured and may include lower abdominal pain, fever, chills, dyspareunia, vaginal discharge.
  • Sepsis and signs of peritonitis may be symptoms of a ruptured TOA.


  • If the patient meets clinical criteria for the diagnosis of PID (cervical motion tenderness, lower abd pain) and the patient has adnexal mass/adnexal tenderness on exam or signs of peritonitis/sepsis, a diagnosis of TOA should be considered.
  •  Labs to obtain:
    • Typical PID labs (Endocervical chlamydia, gonorrhea, and Mycoplasma genitalium NAAT testing, wet mount, pregnancy test, UA, offer HIV/syphilis screening)
    • Pre-op labs (CBC, BMP, T&S, coags)
    • ESR, CRP 
    • Blood cultures
    • VBG
  • Patients with PID and a CRP >49 with /elevated WBC and ESR have a high likelihood of having a TOA.
  • Imaging to obtain: 
    • TVUS is an appropriate first step in patients with concern for TOA.
    • CT abdomen pelvis with IV contrast is more sensitive than transvaginal ultrasound (TVUS) for detecting TOA and better for planning of potential IR-guided drainage of the TOA.


  • Unstable patients with concern for ruptured TOA:
    • Initiate broad spectrum IV antibiotics and obtain GYN consult as the patient will require emergent exploratory laparotomy with washout and drainage and excision of the abscess.
  • Stable patients with TOA confirmed on imaging should be initiated on appropriate antibiotics with GYN consultation and admission. 
  • Management depends on a variety of factors:
    • Ideal antibiotic choice for all stable TOA patients: 
      • IV Ceftriaxone 1g every 24 hours PLUS
      • IV or PO doxycycline 100mg every 12 hours PLUS
      • IV or PO metronidazole 500mg every 12 hours
    • If the patient is stable, premenopausal, and TOA <7cm with no signs of rupture, the patient should be admitted for IV antibiotics and monitoring. 
      • Patients may require IR-guided drainage of abscess if they fail to improve on IV antibiotics.
    • If the patient is stable, premenopausal, with a TOA >7cm, the patient should be admitted for IV antibiotics and non-emergent surgical or IR-guided drainage of the abscess.
    • If the patient is stable, postmenopausal, with TOA of any size without signs of rupture, the patient should be admitted for surgical exploration/drainage of the TOA as it may be associated with a malignancy.


  • Suspect PID in any sexually active person with a cervix presenting with lower abdominal pain, abnormal uterine bleeding or new vaginal discharge.
  • PID remains primarily a clinical diagnosis.
  • Patients with uterine tenderness, cervical motion tenderness, or adnexal tenderness without alternate cause (E.g. ectopic pregnancy or ovarian torsion) should be treated empirically for PID.
  • Consequences of untreated PID can include future ectopic pregnancies, infertility, chronic pelvic pain, and recurrent tubo-ovarian abscesses.
  • Patients diagnosed with PID should be evaluated for possible TOA if demonstrated to have:
    • adnexal mass or adnexal tenderness on exam, be concerned for TOA and consider imaging.
    • CRP>49, elevated WBCs, and elevated ESR.
  • A septic patient with PID may have a ruptured TOA which is a surgical emergency requiring broad spectrum antibiotics and early consultation for surgical or interventional treatment.


  1. Ross J, Chacko M. Pelvic inflammatory disease: Clinical manifestations and diagnosis. UpToDate. 2022 April. 
  2. Gynecologic infection. Hoffman B.L., & Schorge J.O., & Halvorson L.M., & Hamid C.A., & Corton M.M., & Schaffer J.I.(Eds.), (2020). Williams Gynecology, 4e. McGraw Hill. 
  3. Jennings LK, Krywko DM. Pelvic Inflammatory Disease. [Updated 2022 Jun 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: 
  4. Cook RL, Hutchison SL, Østergaard L, Braithwaite RS, Ness RB. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Intern Med. 2005 Jun 7;142(11):914-25. doi: 10.7326/0003-4819-142-11-200506070-00010. PMID: 15941699. 
  5. Wang PY, Zhang L, Wang X, Liu XJ, Chen L, Wang X, Wang B. Fitz-Hugh-Curtis syndrome: clinical diagnostic value of dynamic enhanced MSCT. J Phys Ther Sci. 2015 Jun;27(6):1641-4. doi: 10.1589/jpts.27.1641. Epub 2015 Jun 30. PMID: 26180288; PMCID: PMC4499951. 
  6. Belgi R. Epidemiology, clinical manifestations, and diagnosis of tubo-ovarian abscess. UpToDate. 2022 February. 
  7. Jackson SL, Soper DE. Pelvic inflammatory disease in the postmenopausal woman. Infect Dis Obstet Gynecol. 1999;7(5):248-52. doi: 10.1002/(SICI)1098-0997(1999)7:5<248::AID-IDOG8>3.0.CO;2-V. PMID: 10524671; PMCID: PMC1784753. 
  8. Ribak R, Schonman R, Sharvit M, Schreiber H, Raviv O, Klein Z. Can the Need for Invasive Intervention in Tubo-ovarian Abscess Be Predicted? The Implication of C-reactive Protein Measurements. J Minim Invasive Gynecol. 2020 Feb;27(2):541-547. doi: 10.1016/j.jmig.2019.04.027. Epub 2019 Aug 31. PMID: 31479751. 
  9. Kairys N, Roepke C. Tubo-Ovarian Abscess. [Updated 2022 Jun 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: 
  10. CDC 2021 STI Treatment Guidelines, PID and TOA.