Diagnostic Imaging Pathways - Pelvic Inflammatory Disease (Suspected)

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Population Covered By The Guidance

This pathway provides guidance on the investigation of adult patients with suspected pelvic inflammatory disease.

Date reviewed: August 2014

Date of next review: 2017/2018

Published: November 2014

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Teaching Points


Pelvic Inflammatory Disease (PID)

Centre for Disease Control and Prevention (CDC) Criteria for PID

Minimum Criteria (At least 1 needed for diagnosis)
Additional Criteria (Support for a diagnosis of PID)
Definitive Criteria (Confirm the diagnosis of PID)
Cervical motion tenderness
Uterine tenderness
Adnexal tenderness
Oral temperature > 38.3°C
Abnormal vaginal or cervical discharge
White blood cells on saline wet mount (>10 polymorphonuclear leukocytes per high power field)
Elevated Erythrocyte Sedimentation Rate (> 15mm/hr)
Elevated C-Reactive Protein
Elevated white cell blood count higher than 10,000 cells/ml
Laboratory evidence of Neisseria gonorrhoeae or Chlamydia trachomatis
Histopathologic evidence of endometritis
Imaging showing thickened, fluid tubes, with or without pelvic free fluid or tubo-ovarian complex
Doppler studies suggesting pelvic infection
Intra-abdominal findings consistent with PID on laparoscopy




Imaging in Pelvic Inflammatory Disease (PID)


Computed Tomography (CT)

Magnetic Resonance Imaging (MRI)

Nuclear Medicine Imaging



Date of literature search: July 2014

The search methodology is available on request. Email

References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document

  1. Sweet RL. Pelvic inflammatory disease: current concepts of diagnosis and management. Curr Infect Dis Rep. 2012:[Epub ahead of print].(Review article). View the reference
  2. King Edward Memorial Hospital, Perth, Australia, Clinical practice guideline on management of acute pelvic inflammatory disease. [Internet, last updated October 2011; cited 31st July 2014]. View the guideline
  3. Ross J, Judlin P, Nilas L. European guideline for the management of pelvic inflammatory disease. Int J STD AIDS 2007;18(10):662-6. (Evidence based guideline). View the reference
  4. Haggerty CL, Taylor BD. Mycoplasma genitalium: an emerging cause of pelvic inflammatory disease. Infect Dis Obstet Gynecol. 2011;2011:959816. (Review article). View the reference
  5. Wiesenfeld HC, Hillier SL, Meyn LA, Amortegui AJ, Sweet RL. Subclinical pelvic inflammatory disease and infertility. Obstet Gynecol. 2012;120(1):37-43. (Level II evidence). View the reference
  6. Wiesenfeld HC, Sweet RL, Ness RB, Krohn MA, Amortegui AJ, Hillier SL. Comparison of acute and subclinical pelvic inflammatory disease. Sex Transm Dis. 2005;32(7):400-5. (Level I evidence). View the reference
  7. Wiesenfeld HC, Hillier SL, Krohn MA, Amortegui AJ, Heine RP, Landers DV, et al. Lower genital tract infection and endometritis: insight into subclinical pelvic inflammatory disease. Obstet Gynecol. 2002;100(3):456-63. (Level II evidence). View the reference
  8. Kiviat NB, Wolner-Hanssen P, Eschenbach DA, Wasserheit JN, Paavonen JA, Bell TA, et al. Endometrial histopathology in patients with culture-proved upper genital tract infection and laparoscopically diagnosed acute salpingitis. Am J Surg Pathol. 1990;14(2):167-75. (Level II evidence). View the reference
  9. Sellors J, Mahony J, Goldsmith C, Rath D, Mander R, Hunter B, et al. The accuracy of clinical findings and laparoscopy in pelvic inflammatory disease. Am J Obstet Gynecol. 1991;164(1 Pt 1):113-20. (Level II evidence). View the reference
  10. Gradison M. Pelvic inflammatory disease. Am Fam Physician. 2012;85(8):791-6. (Review article). View the reference
  11. Gaitan H, Angel E, Diaz R, Parada A, Sanchez L, Vargas C. Accuracy of five different diagnostic techniques in mild-to-moderate pelvic inflammatory disease. Infect Dis Obstet Gynecol. 2002;10(4):171-80. (Level II evidence). View the reference
  12. Workowski KA, Berman S. Sexually transmitted diseases treatment guidelines. MMWR Recomm Rep. 2010;59(RR-12):1-110. (Evidence based guidelines). View the reference
  13. Ness RB, Soper DE, Holley RL, Peipert J, Randall H, Sweet RL, et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) randomized trial. Am J Obstet Gynecol. 2002;186(5):929-37. (Level I evidence). View the reference
  14. Ness RB, Trautmann G, Richter HE, Randall H, Peipert JF, Nelson DB, et al. Effectiveness of treatment strategies of some women with pelvic inflammatory disease: a randomized trial. Obstet Gynecol. 2005;106(3):573-80. (Level I evidence). View the reference
  15. Cacciatore B, Leminen A, Ingman-Friberg S, Ylostalo P, Paavonen J. Transvaginal sonographic findings in ambulatory patients with suspected pelvic inflammatory disease. Obstet Gynecol. 1992;80(6):912-6. (Level II evidence). View the reference
  16. Boardman LA, Peipert JF, Brody JM, Cooper AS, Sung J. Endovaginal sonography for the diagnosis of upper genital tract infection. Obstet Gynecol. 1997;90(1):54-7. (Level II/III evidence). View the reference
  17. Romosan G, Valentin L. The sensitivity and specificity of transvaginal ultrasound with regard to acute pelvic inflammatory disease: a review of the literature. Arch Gynecol Obstet. 2014;289(4):705-14. (Review article). View the reference
  18. Tukeva TA, Aronen HJ, Karjalainen PT, Molander P, Paavonen T, Paavonen J. MR imaging in pelvic inflammatory disease: comparison with laparoscopy and US. Radiology. 1999;210(1):209-16. (Level I evidence). View the reference
  19. Romosan G, Bjartling C, Skoog L, Valentin L. Ultrasound for diagnosing acute salpingitis: a prospective observational diagnostic study. Hum Reprod. 2013;28(6):1569-79. (Level I evidence). View the reference
  20. Zeger W, Holt K. Gynecologic infections. Emerg Med Clin North Am. 2003;21(3):631-48. (Review article). View the reference
  21. Slap GB, Forke CM, Cnaan A, Bellah RD, Kreider ME, Hanissian JA, et al. Recognition of tubo-ovarian abscess in adolescents with pelvic inflammatory disease. J Adolesc Health. 1996;18(6):397-403. (Level III evidence). View the reference
  22. Taylor KJ, Wasson JF, De Graaff C, Rosenfield AT, Andriole VT. Accuracy of grey-scale ultrasound diagnosis of abdominal and pelvic abscesses in 220 patients. Lancet. 1978;1(8055):83-4. (Level III evidence). View the reference
  23. Landers DV, Sweet RL. Tubo-ovarian abscess: contemporary approach to management. Rev Infect Dis. 1983;5(5):876-84. (Level II/III evidence). View the reference
  24. Lande IM, Hill MC, Cosco FE, Kator NN. Adnexal and cul-de-sac abnormalities: transvaginal sonography. Radiology. 1988;166(2):325-32. (Level III evidence). View the reference
  25. Patten RM, Vincent LM, Wolner-Hanssen P, Thorpe E, Jr. Pelvic inflammatory disease: endovaginal sonography with laparoscopic correlation. J Ultrasound Med. 1990;9(12):681-9. (Level II evidence). View the reference
  26. Varras M, Polyzos D, Perouli E, Noti P, Pantazis I, Akrivis C. Tubo-ovarian abscesses: spectrum of sonographic findings with surgical and pathological correlations. Clin Exp Obstet Gynecol. 2003;30(2-3):117-21. (Level II evidence). View the reference
  27. Adhikari S, Blaivas M, Lyon M. Role of bedside transvaginal ultrasonography in the diagnosis of tubo-ovarian abscess in the emergency department. J Emerg Med. 2008;34(4):429-33. (Level III evidence). View the reference
  28. Timor-Tritsch IE, Lerner JP, Monteagudo A, Murphy KE, Heller DS. Transvaginal sonographic markers of tubal inflammatory disease. Ultrasound Obstet Gynecol. 1998;12(1):56-66. (Level II evidence). View the reference
  29. Ignacio EA, Hill MC. Ultrasound of the acute female pelvis. Ultrasound Q. 2003;19(2):86-98; quiz 108-10. (Review article). View the reference
  30. McClean KL, Sheehan GJ, Harding GK. Intraabdominal infection: a review. Clin Infect Dis. 1994;19(1):100-16. (Review article). View the reference
  31. Gagliardi PD, Hoffer PB, Rosenfield AT. Correlative imaging in abdominal infection: an algorithmic approach using nuclear medicine, ultrasound, and computed tomography. Semin Nucl Med. 1988;18(4):320-34. (Review article). View the reference
  32. Li W, Zhang Y, Cui Y, Zhang P, Wu X. Pelvic inflammatory disease: evaluation of diagnostic accuracy with conventional MR with added diffusion-weighted imaging. Abdom Imaging. 2013;38(1):193-200. (Level II evidence). View the reference
  33. Uslu H, Varoglu E, Kadanali S, Yildirim M, Bayrakdar R, Kadanali A. 99mTc-HMPAO labelled leucocyte scintigraphy in the diagnosis of pelvic inflammatory disease. Nucl Med Commun. 2006;27(2):179-83. (Level II evidence). View the reference
  34. Rachinsky I, Boguslavsky L, Goldstein D, Golan H, Pak I, Katz M, et al. Diagnosis of pyogenic pelvic inflammatory diseases by 99mTc-HMPAO leucocyte scintigraphy. Eur J Nucl Med. 2000;27(12):1774-7. (Level II/III evidence). View the reference

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Transvaginal Ultrasound



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