Pelvic inflammatory disease (PID) is a common gynaecological condition and an important cause of reproductive morbidity among women of reproductive age. It encompasses inflammatory disorders of the upper female genital tract, including endometritis, salpingitis, oophoritis, tubo-ovarian abscess, and pelvic peritonitis. PID primarily results from ascending infection from the lower genital tract, with Chlamydia trachomatis and Neisseria gonorrhoeae being important causative organisms[1]. Polymicrobial infections involving anaerobic and facultative bacteria also contribute to its pathogenesis. Delayed diagnosis and inadequate treatment may lead to tubal infertility, ectopic pregnancy, chronic pelvic pain, and recurrent pelvic infections, emphasizing the importance of early recognition and appropriate management [2,3].The diagnosis of PID remains challenging because of its variable and frequently nonspecific clinical presentation. Common symptoms include lower abdominal pain, abnormal vaginal discharge, fever, menstrual irregularities, and dyspareunia, while clinical examination may reveal cervical motion tenderness, uterine tenderness, and adnexal tenderness. However, these manifestations overlap with other gynaecological and abdominal conditions, including ectopic pregnancy, ovarian cysts, endometriosis, and acute appendicitis. Patients with mild or early-stage disease may also present with minimal symptoms despite underlying pelvic inflammation. Consequently, clinical assessment alone may not adequately establish the diagnosis or determine the extent of disease involvement [4–6].Ultrasonography is a valuable imaging modality in the evaluation of suspected PID because of its widespread availability, noninvasive nature, cost-effectiveness, and absence of ionizing radiation. Both transabdominal and transvaginal ultrasonography provide information regarding pelvic structures, with transvaginal ultrasonography offering improved visualization of the fallopian tubes and adnexa. Characteristic sonographic findings include thickened and dilated fallopian tubes, hydrosalpinx, pyosalpinx, tubo-ovarian complexes, tubo-ovarian abscesses, and pelvic free fluid. Colour Doppler ultrasonography may additionally demonstrate increased vascularity associated with active inflammation. These findings assist in evaluating disease extent, identifying complications, and excluding alternative pelvic pathologies [7–9].The ultrasonographic appearance of PID varies according to the stage and severity of infection. Acute salpingitis may demonstrate thickened tubal walls and the characteristic cogwheel sign, whereas chronic tubal inflammation may exhibit hydrosalpinx and the beads-on-a-string sign. Three-dimensional transvaginal ultrasonography may further assist in the characterization of tubal abnormalities, particularly hydrosalpinx. Nevertheless, ultrasonographic findings may be absent or nonspecific during early disease, and a normal examination does not exclude PID. Therefore, imaging findings should be interpreted alongside clinical manifestations and examination findings [8,10–12].The correlation between clinical findings and ultrasonographic abnormalities is particularly important because symptom severity may not consistently reflect the extent of pelvic inflammation. Patients with significant adnexal pathology may present with mild symptoms, whereas those with pronounced clinical manifestations may demonstrate limited sonographic abnormalities. Previous investigations have highlighted the usefulness of ultrasonography in identifying inflammatory changes, although variations in diagnostic performance emphasize the importance of combining clinical assessment with imaging findings [9,11,12].Therefore, the present study was undertaken to evaluate the role of ultrasonography in pelvic inflammatory disease and assess its correlation with clinical findings.

study was designed to evaluate the role of ultrasonography in pelvic inflammatory disease (PID) and its correlation with clinical findings. Women presenting with symptoms suggestive of PID were evaluated clinically and through pelvic ultrasonography.A total of 130 women aged 18–45 years with clinically suspected pelvic inflammatory disease were included in the proposed study. Eligible patients were selected using a consecutive sampling technique. Inclusion Criteria 1. Women aged 18–45 years with clinically suspected PID. 2. Patients presenting with lower abdominal pain, abnormal vaginal discharge, fever, dyspareunia, or menstrual irregularities. 3. Patients with cervical motion tenderness, uterine tenderness, or adnexal tenderness. 4. Patients willing to participate and provide informed consent. Exclusion Criteria 1. Pregnant women or patients with suspected ectopic pregnancy. 2. Patients with known gynaecological malignancies. 3. Patients with confirmed alternative causes of acute abdominal pain. 4. Patients with recent pelvic surgery or trauma. 5. Patients unwilling to participate. Data Collection and Clinical Evaluation Detailed demographic information, menstrual and reproductive history, presenting complaints, duration of symptoms, and previous history of PID were recorded using a structured proforma. General physical, abdominal, and pelvic examinations were performed, with particular attention to lower abdominal tenderness, cervical motion tenderness, uterine tenderness, adnexal tenderness, and abnormal vaginal discharge. Ultrasonographic Examination All patients underwent transabdominal ultrasonography, supplemented by transvaginal ultrasonography wherever clinically appropriate. The uterus, fallopian tubes, ovaries, adnexa, and pouch of Douglas were systematically examined. Sonographic findings, including tubal thickening, hydrosalpinx, pyosalpinx, tubo-ovarian complex, tubo-ovarian abscess, adnexal masses, and pelvic free fluid, were documented. Colour Doppler examination was performed wherever indicated to assess inflammatory vascular changes. Correlation of Clinical and Ultrasonographic Findings Clinical symptoms and examination findings were correlated with ultrasonographic abnormalities. Patients were categorized according to the presence or absence of sonographic findings suggestive of PID. Associations between lower abdominal pain, fever, vaginal discharge, cervical motion tenderness, uterine tenderness, adnexal tenderness, and ultrasonographic abnormalities were evaluated. Outcome Measures Primary Outcome: To assess the spectrum of ultrasonographic abnormalities in clinically suspected PID and their correlation with clinical findings.Secondary Outcomes: To identify associated pelvic complications and evaluate the relationship between individual clinical manifestations and ultrasonographic abnormalities. Statistical Analysis Data were compiled in Microsoft Excel and analyzed using appropriate statistical software. Categorical variables were expressed as frequencies and percentages, while continuous variables were presented as mean ± standard deviation. Associations between clinical and ultrasonographic findings were assessed using the Chi-square test or Fisher's exact test, as appropriate. The independent t-test or Mann–Whitney U test was used for continuous variables where applicable. A p-value of less than 0.05 was considered statistically significant.

A total of 130 patients with clinically suspected pelvic inflammatory disease (PID) were included in the study.The majority of patients belonged to the 26–30-year age group (31.5%), followed by 18–25 years (24.6%). Most patients were married (83.1%) and multiparous (46.2%). A previous history of PID was reported in 26.2% of patients (Table 1).Lower abdominal pain was the most common presenting symptom (90.8%), followed by abnormal vaginal discharge (72.3%), fever (47.7%), menstrual irregularities (36.9%), dyspareunia (33.1%), and dysuria (22.3%). On clinical examination, lower abdominal tenderness was the most frequent finding (81.5%), followed by cervical motion tenderness (70.8%), adnexal tenderness (60.0%), abnormal cervical discharge (55.4%), and uterine tenderness (49.2%) (Table 2).Ultrasonographic findings suggestive of PID were observed in 105 patients (80.8%), while 25 (19.2%) had no significant abnormality. Pelvic free fluid was the most common finding (43.1%), followed by thickened fallopian tubes (36.9%), increased vascularity on colour Doppler (32.3%), endometrial thickening (26.9%), and hydrosalpinx (22.3%). Tubo-ovarian abscess was identified in 10.0% of patients (Table 3).Abnormal vaginal discharge (76.2% vs. 56.0%, p = 0.043) and fever (53.3% vs. 24.0%, p = 0.008) were significantly more frequent among USG-positive patients compared with USG-negative patients. However, lower abdominal pain (p = 0.209), menstrual irregularities (p = 0.137), dyspareunia (p = 0.121), and dysuria (p = 0.398) showed no statistically significant association with ultrasonographic positivity (Table 4, Figure 1).All evaluated clinical examination findings were significantly associated with ultrasonographic positivity. Lower abdominal tenderness (86.7% vs. 60.0%, p = 0.002), cervical motion tenderness (77.1% vs. 44.0%, p = 0.001), and adnexal tenderness (66.7% vs. 32.0%, p = 0.002) were significantly more frequent among USG-positive patients. Similarly, uterine tenderness (54.3% vs. 28.0%, p = 0.018) and abnormal cervical discharge (60.0% vs. 36.0%, p = 0.030) showed significant associations (Table 5, Figure 2). Correlation analysis demonstrated weak positive associations between clinical findings and ultrasonographic positivity. Among presenting symptoms, fever showed the strongest association (φ = 0.231, p = 0.008), followed by abnormal vaginal discharge (φ = 0.181, p = 0.043). Among examination findings, cervical motion tenderness demonstrated the strongest association (φ = 0.291, p = 0.001), followed by adnexal tenderness (φ = 0.286, p = 0.002) and lower abdominal tenderness (φ = 0.277, p = 0.002). Uterine tenderness (φ = 0.211, p = 0.018) and abnormal cervical discharge (φ = 0.190, p = 0.030) also showed significant positive associations (Table 6, Figure 3). Table 1. Distribution of Patients According to Demographic and Clinical Characteristics (N = 130) Parameter Number (n) Percentage (%) Age group (years) 18–25 32 24.6 26–30 41 31.5 31–35 29 22.3 36–40 18 13.8 41–45 10 7.7 Marital status Married 108 83.1 Unmarried 22 16.9 Parity Nulliparous 28 21.5 Primiparous 42 32.3 Multiparous 60 46.2 Previous history of PID Present 34 26.2 Absent 96 73.8 Table 2. Distribution of Patients According to Presenting Symptoms and Clinical Examination Findings (N = 130) Clinical finding Number (n) Percentage (%) Presenting symptoms Lower abdominal pain 118 90.8 Abnormal vaginal discharge 94 72.3 Fever 62 47.7 Menstrual irregularities 48 36.9 Dyspareunia 43 33.1 Dysuria 29 22.3 Clinical examination findings Lower abdominal tenderness 106 81.5 Cervical motion tenderness 92 70.8 Adnexal tenderness 78 60.0 Uterine tenderness 64 49.2 Abnormal cervical discharge 72 55.4 Table 3. Distribution of Patients According to Ultrasonographic Findings (N = 130) Ultrasonographic finding Number (n) Percentage (%) Thickened fallopian tubes 48 36.9 Hydrosalpinx 29 22.3 Pyosalpinx 21 16.2 Tubo-ovarian complex 24 18.5 Tubo-ovarian abscess 13 10.0 Pelvic free fluid 56 43.1 Endometrial thickening/heterogeneity 35 26.9 Increased vascularity on colour Doppler 42 32.3 Overall USG findings Positive for findings suggestive of PID 105 80.8 No significant USG abnormality 25 19.2 Table 4. Association Between Presenting Symptoms and Ultrasonographic Findings Suggestive of PID (N = 130) Clinical symptom USG Positive (n = 105) USG Negative (n = 25) p-value Statistical Test Lower abdominal pain 97 (92.4%) 21 (84.0%) 0.209 Fisher's exact test Abnormal vaginal discharge 80 (76.2%) 14 (56.0%) 0.043 Chi-square test Fever 56 (53.3%) 6 (24.0%) 0.008 Chi-square test Menstrual irregularities 42 (40.0%) 6 (24.0%) 0.137 Chi-square test Dyspareunia 38 (36.2%) 5 (20.0%) 0.121 Chi-square test Dysuria 25 (23.8%) 4 (16.0%) 0.398 Fisher's exact test Table 5. Association Between Clinical Examination Findings and Ultrasonographic Findings Suggestive of PID (N = 130) Clinical finding USG Positive (n = 105) USG Negative (n = 25) p-value Statistical Test Lower abdominal tenderness 91 (86.7%) 15 (60.0%) 0.002 Chi-square test Cervical motion tenderness 81 (77.1%) 11 (44.0%) 0.001 Chi-square test Adnexal tenderness 70 (66.7%) 8 (32.0%) 0.002 Chi-square test Uterine tenderness 57 (54.3%) 7 (28.0%) 0.018 Chi-square test Abnormal cervical discharge 63 (60.0%) 9 (36.0%) 0.030 Chi-square test Table 6. Correlation Between Clinical Findings and Ultrasonographic Positivity in Patients with Suspected PID (N = 130) Clinical parameter Phi coefficient (φ) p-value Statistical Test Lower abdominal pain 0.118 0.209 Phi coefficient with Fisher's exact test Abnormal vaginal discharge 0.181 0.043 Fever 0.231 0.008 Menstrual irregularities 0.131 0.137 Dyspareunia 0.137 0.121 Dysuria 0.076 0.398 Lower abdominal tenderness 0.277 0.002 Cervical motion tenderness 0.291 0.001 Adnexal tenderness 0.286 0.002 Uterine tenderness 0.211 0.018 Abnormal cervical discharge 0.190 0.030

In the present study of 130 patients, the majority belonged to the 26–30-year age group (31.5%), followed by 18–25 years (24.6%). Most patients were married (83.1%), and 46.2% were multiparous. A previous history of PID was reported in 26.2%. Similarly, Naaz et al. [13], in their study of 200 women, reported the highest prevalence of PID among women aged 25–29 years (40.0%), followed by 20–24 years (29.0%). Fernandez et al. [14] reported a mean age of 32 years among 42 women evaluated for suspected hydrosalpinx. These findings indicate that pelvic inflammatory conditions predominantly affect women of reproductive age.Lower abdominal pain was the most common presenting symptom in the present study (90.8%), followed by abnormal vaginal discharge (72.3%), fever (47.7%), and menstrual irregularities (36.9%). Lower abdominal tenderness (81.5%) and cervical motion tenderness (70.8%) were the predominant examination findings. Fernandez et al. [14] reported pelvic pain in 67% of patients, infertility in 36%, and pelvic mass in 21%. Similarly, Ujaddughe et al. [15] evaluated 1,599 women presenting with pelvic pain and identified PID, uterine fibroids, and ovarian cysts among the underlying abnormalities. These findings emphasize the importance of pelvic pain as a presenting symptom while highlighting the need for imaging to differentiate PID from other pelvic conditions.In the present study, ultrasonographic abnormalities suggestive of PID were identified in 105 patients (80.8%), while 25 (19.2%) had no significant abnormalities. Pelvic free fluid was the most common finding (43.1%), followed by thickened fallopian tubes (36.9%), increased Doppler vascularity (32.3%), and hydrosalpinx (22.3%). Rahman [16], in a study of 45 women, reported bulky uterus associated with PID in 15.56%, hydrosalpinx in 2.22%, and normal ultrasonographic findings in 20.0%. Ujaddughe et al. [15] reported normal ultrasonographic findings in 30.58% and PID in 4.19% of 1,599 patients. The higher frequency of PID-related abnormalities in the present study may reflect the inclusion of patients specifically suspected of having PID.In the present study, thickened fallopian tubes were observed in 36.9% of patients, hydrosalpinx in 22.3%, and pyosalpinx in 16.2%. Fernandez et al. [14] reported hydrosalpinx in 45% of patients using three-dimensional transvaginal ultrasonography compared with 38% using conventional two-dimensional ultrasonography. Surgical confirmation was obtained in 14 of 19 operated patients (74%). Rahman [16] reported hydrosalpinx in 2.22% of women undergoing infertility evaluation. These differences may be attributed to variations in study populations and imaging techniques. The findings highlight the usefulness of ultrasonography in identifying tubal inflammatory changes.Tubo-ovarian complex was identified in 18.5% of patients in the present study, while tubo-ovarian abscess was observed in 10.0%. Ujaddughe et al. [15] reported tubo-ovarian abscess in 0.13% of women presenting with pelvic pain. The higher proportion in the present study may be related to the inclusion of clinically suspected PID cases rather than patients with pelvic pain from various causes. These findings demonstrate the importance of ultrasonography in identifying complications associated with pelvic inflammation.In the present study, abnormal vaginal discharge was more frequent among patients with positive ultrasonographic findings than those with negative findings (76.2% vs. 56.0%; reported p = 0.043). Similarly, fever was observed in 53.3% and 24.0%, respectively (reported p = 0.008). Rahman [16] reported 77.78% clinical–sonographic agreement for bulky uterus associated with PID. Ujaddughe et al. [15] found that initial clinical differential diagnoses were accurate in only 26.14% of patients. These findings emphasize the limitations of clinical symptoms alone and support the complementary role of ultrasonography in evaluating suspected PID. In the present study, cervical motion tenderness was observed in 77.1% of USG-positive patients compared with 44.0% of USG-negative patients (reported p = 0.001). Adnexal tenderness was present in 66.7% versus 32.0% (reported p = 0.002), while lower abdominal tenderness was observed in 86.7% versus 60.0% (reported p = 0.002). The strongest positive associations were observed for cervical motion tenderness (φ = 0.291), adnexal tenderness (φ = 0.286), and lower abdominal tenderness (φ = 0.277). Rahman [16] demonstrated 77.78% agreement between clinical and sonographic findings for bulky uterus associated with PID, while Ujaddughe et al. [15] highlighted discrepancies between clinical and ultrasonographic diagnoses. These findings support the combined use of clinical examination and ultrasonography for evaluating pelvic inflammatory abnormalities.

Ultrasonography demonstrated findings suggestive of pelvic inflammatory disease in 80.8% of patients, with pelvic free fluid (43.1%), thickened fallopian tubes (36.9%), and hydrosalpinx (22.3%) being prominent abnormalities. Cervical motion tenderness, adnexal tenderness, and lower abdominal tenderness showed positive associations with ultrasonographic findings. Ultrasonography is a valuable adjunct to clinical examination for evaluating pelvic inflammation and identifying complications. LIMITATIONS The study was limited by its single-centre design, relatively small sample size (N = 130), and absence of an independent diagnostic reference standard. Additionally, ultrasonography may fail to detect early or mild PID, potentially underestimating the extent of pelvic inflammation.

1. Simms I, Stephenson JM, Mallinson H, Peeling RW, Thomas K, Gokhale R, et al. Risk factors associated with pelvic inflammatory disease. Sex Transm Infect. 2006;82(6):452-457. 2. Workowski KA, Bachmann LH, Chan PA, Johnston CM, Muzny CA, Park I, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187. 3. Haggerty CL, Taylor BD. Mycoplasma genitalium: an emerging cause of pelvic inflammatory disease. Infect Dis Obstet Gynecol. 2011;2011:959816. 4. Gaitán 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):171-180. 5. Revzin MV, Mathur M, Dave HB, Macer ML, Spektor M. Pelvic inflammatory disease: multimodality imaging approach with clinical-pathologic correlation. Radiographics. 2016;36(5):1579-1596. 6. Cicchiello LA, Hamper UM, Scoutt LM. Ultrasound evaluation of gynecologic causes of pelvic pain. Obstet Gynecol Clin North Am. 2011;38(1):85-114. 7. Swayne LC, Love MB, Karasick SR. Pelvic inflammatory disease: sonographic-pathologic correlation. Radiology. 1984;151(3):751-755. 8. 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. 9. Taipale P, Tarjanne H, Ylostalo P. Transvaginal sonography in suspected pelvic inflammatory disease. Ultrasound Obstet Gynecol. 1995;6(6):430-434. 10. Hammon, D.M., Pelvic inflammatory disease.InnovAiT, 2024. 17(8): p. 373-377 11. 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):705-714. 12. Molander P, Sjöberg J, Paavonen J, Cacciatore B. Transvaginal power Doppler findings in laparoscopically proven acute pelvic inflammatory disease. Ultrasound Obstet Gynecol. 2001;17(3):233-238. 13. Naaz F, Khan N, Mastan A. Risk factors of pelvic inflammatory disease: a prospective study. Int J Herbal Med. 2016;4(4):129-33. 14. Fernandez CM, Levine EM, Tam T. Enhancing diagnostic accuracy: three-dimensional sonographic diagnosis of hydrosalpinx in pelvic inflammatory disease. J Diagn Med Sonogr. 2024;87564793241297940. 15. Ujaddughe O, et al. Evaluation of common ultrasound findings in female patients who present with pelvic pain at Irrua Specialist Teaching Hospital (ISTH), Edo State, Nigeria. J Exp Clin Anat. 2024;21(2):287-94. 16. Rahman S. Use of trans-vaginal ultrasound to diagnose and treat infertility and its performance. Open J Radiol. 2023;13(3):167-83.