AIM: To investigate the incidence and high-risk factors associated with the surgical treatment of acute female pelvic inflammatory disease (PID). METHODS: A retrospective analysis was conducted on all inpatients diagnosed with acute female PID, encompassing conditions such as endometritis, salpingitis, tubo-ovarian abscess, ovarian abscess, and pelvic peritonitis, at Dongyang Hospital of Wenzhou Medical University from January 2013 to December 2021. Patients were categorized into two groups: the surgery group (n = 58) and the non-surgery group (n = 399), based on the necessity of surgical intervention (refer to Materials and Methods for surgical indications). Collected data included patient demographics (age, body mass index (BMI)), comorbidities (hypertension, diabetes mellitus), initial laboratory findings upon admission (white blood cell count, absolute neutrophil count, hemoglobin, platelet count, blood urea nitrogen/creatinine, prothrombin time (PT), international normalized ratio (INR), fibrinogen, albumin), surgical records, and postoperative pathology. Univariate and multivariate logistic regression analyses were conducted to ascertain the risk factors associated with the surgical treatment of acute female PID. RESULTS: Out of 457 hospitalized patients with acute female PID, 58 cases (12.7%) required surgical intervention. Univariate and multivariate logistic regression analyses indicated that advancing age correlated with an increased likelihood of surgical intervention in women with acute PID (odds ratio (OR) = 1.052, 95% Confidence Interval (CI) 1.022–1.082, p = 0.001). Additionally, lower serum albumin levels upon admission were associated with a heightened risk of surgery (OR = 0.913, 95% CI 0.859–0.970, p = 0.003), while elevated fibrinogen levels amplified the risk of surgical intervention in these patients (OR = 1.193, 95% CI 1.008–1.411, p = 0.04). CONCLUSIONS: Elderly women diagnosed with acute PID, especially those presenting with abscess formation, should undergo prompt surgical intervention if they display high-risk factors such as low albumin levels and elevated fibrinogen levels upon admission.