11/14/24, 10\:50 AM Pelvic Inflammatory Disease (PID)

Pelvic In

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Pelvic in
endocervix, a
Estimated incidence\: 1 in 1000 women aged 15-34 diagnosed annually.
Aetiology\:
Sexually transmitted infections (STIs)\: C h l a m y d i a t r a c h o m a t i s (14-35% of cases), N e i s s e r i a g o n o r r h o e a , M y c o p l a s m a
g e n i t a l i u m .
Non-STI bacteria\: Gardnerella vaginalis, anaerobic bacteria.
Risk factors\:
Young age (\<25)
Multiple or new partners
Previous STI or PID
Not using condoms during sex
Instrumentation of the uterus (e.g. abortions, gynaecological procedures, IUD
Symptoms\:
Lower abdominal pain (bilateral/unilateral)
Pain during penetrative sex (deep dyspareunia)
Menstrual changes (post-coital bleeding, inter-menstrual bleeding, menorrhagia)
Abnormal vaginal discharge
Clinical examination\:
Abdominal exam\: tenderness (bilateral/unilateral), guarding, peritonism.
Speculum exam\: mucopurulent cervicitis.
Bimanual exam\: cervical motion tenderness, adnexal tenderness, palpable mass (tubo-ovarian abscess).
Di
cyst complications.
Investigations\:
Bedside\: pregnancy test, urinalysis.
Laboratory\: vaginal swabs (NAAT for chlamydia, gonorrhoea, mycoplasma), MC&S swab, routine HIV and syphilis testing.
Imaging\: transvaginal ultrasound scan (exclude ovarian pathology, detect tubo-ovarian abscess).
Diagnosis\: based on clinical features, risk factors, and exclusion of other diagnoses; a low threshold for diagnosis due to
potential complications.
Management\: antibiotics covering chlamydia, gonorrhoea, and anaerobic bacteria; patient advice includes regular
analgesia and abstaining from sex until treatment completion.
Outpatient\:
First line\: 1g IM ceftriaxone single dose, 100mg oral doxycycline BD 14 days, 400mg oral metronidazole BD 14 days.
Second line\: 400mg oral o
days.
Inpatient\: for systemic illness, no response to outpatient management, intolerance to outpatient management, or tubo-
ovarian abscess.
First line\: 2g IV ceftriaxone OD, 100mg IV/oral doxycycline BD 14 days, 400mg oral metronidazole BD 14 days.
https\://app.geekymedics.com/notebook/2790/ 1/611/14/24, 10\:51 AM Pelvic Inflammatory Disease (PID)
Follow-up\: improvement expected within 72 hours, consider further investigations or inpatient treatment if no
improvement; test of cure for chlamydia, gonorrhoea, and mycoplasma genitalium.
Complications\: chronic pelvic pain, increased risk of ectopic pregnancies, subfertility, tubo-ovarian abscess, pyosalpinx,
hydrosalpinx.
Fitz-Hugh-Curtis syndrome\: liver in
presenting with RUQ pain.
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Introduction

Pelvic in
ascending infection from the endocervix. PID can a
An estimated 1 in 1000 women aged between 15 and 34 are diagnosed with PID every year.

Aetiology

PID can be caused by sexually transmitted infections, including\:
C h l a m y d i a t r a c h o m a t i s (most common, accounts for 14-35% of PID cases)
N e i s s e r i a g o n o r r h o e a
M y c o p l a s m a g e n i t a l i u m
PID can also be caused by non-sexually transmitted bacteria that can be part of the normal vaginal
Gardnerella vaginalis and other anaerobic bacteria.

Risk factors

Risk factors for PID include\:
Young age, especially \<25
Multiple or new partners
Previous history of a sexually transmitted infection or PID
Not using condoms during sex
Instrumentation of the uterus (e.g. abortions, gynaecological procedures such as endometrial biopsies, intrauterine
device

Clinical features

History

Typical symptoms of PID include\:
Lower abdominal pain, which can be bilateral or unilateral
Pain during penetrative sex (deep dyspareunia)
Menstrual changes, such as bleeding after sex (post-coital bleeding), bleeding between periods (inter-menstrual
bleeding) and heavy bleeding (menorrhagia)
Abnormal vaginal discharge
Other important areas to cover in the history include\:
Menstrual history (e.g.
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Sexual history (e.g. when did the patient last have unprotected sexual intercourse, previous sexually transmitted
infections etc.)

Clinical examination

If PID is suspected, abdominal, speculum, and bimanual examinations are required. Microscopy can also be considered if
suspecting Neisseria gonorrhoea.
Patients with severe symptoms should have a set of basic observations (vital signs) recorded. Severe PID may cause a
fever.
Typical abdominal examination may include\:
Abdominal tenderness (unilateral or bilateral)
Guarding
Peritonism & rebound tenderness\: in cases of severe PID
Speculum examination may show mucopurulent cervicitis (pustular discharge from the cervix).
Typical bimanual examination may include\:
Cervical motion tenderness
Adnexal tenderness (unilateral or bilateral)
Palpable mass (if a tubo-ovarian abscess has formed)

Di

Di
Ectopic pregnancy
Urinary tract infection
Acute appendicitis
Diverticulitis
Endometriosis
Complications of an ovarian cyst (e.g. torsion or rupture)

Investigations

Bedside investigations

Relevant bedside investigations include\:
Pregnancy testing\: to rule out an ectopic pregnancy
Urinalysis\: to exclude urinary tract infection

Laboratory investigations

Relevant laboratory investigations include\:
Vaginal swabs\: chlamydia, gonorrhoea and mycoplasma genitalium nucleic acid ampli
MC&S swab of cervical discharge (for gonorrhoea culture, but will also detect other bacteria)
Routine HIV and syphilis testing
Patients admitted to hospital with PID will have routine blood tests, including a full blood count (neutrophilia) and
in

Imaging

A transvaginal ultrasound scan can be performed to exclude ovarian pathology, free
suspicion of a tubo-ovarian abscess. A pyosalpinx is the presence of pus in the fallopian tube. Salpingitis is an infection in
the tube.
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Ultrasound is also helpful when considering other diagnoses (e.g. ectopic pregnancy in the context of a positive pregnancy
test).

Diagnosis

There is no single test to diagnose PID. The diagnosis is based on clinical judgement according to clinical features, risk
factors and consideration of other di
There is a low threshold for diagnosis as the consequences of delaying treatment can have signi

Management

PID is managed with antibiotics. The type of antibiotics used and the route of administration depend on the severity of the
illness. The antibiotic regimen is designed to cover chlamydia, gonorrhoea, and anaerobic bacteria.
The
treatment with moxi
Patients should be advised to use regular analgesia and abstain from sexual contact until the antibiotic course has been
completed (usually two weeks) and their partner has also completed their course of antibiotics.

Outpatient management

First line outpatient antibiotic treatment is\:
1g intramuscular ceftriaxone single dose
100mg oral doxycycline twice daily for fourteen days
400mg oral metronidazole twice daily for fourteen days
Second line outpatient antibiotic treatment is\:
400mg oral o
400mg oral moxi

Inpatient management

Inpatient management is reserved for patients with systemic illness, no response to outpatient management, intolerance
to outpatient management (e.g. vomiting), or evidence of a tubo-ovarian abscess.
First line inpatient antibiotic treatment is\:
2g intravenous ceftriaxone once daily
100mg intravenous OR oral doxycycline twice daily for fourteen days
400mg oral metronidazole twice daily for fourteen days
Intravenous therapy should be continued for 24 hours after clinical improvement. The patient can then switch to oral
therapy.
Partner noti
Current male partners should be treated as a contact of PID with 100mg oral doxycycline twice daily for seven days
All partners over the last six months should be contacted and tested for chlamydia and gonorrhoea.
If the patient tests positive for mycoplasma genitalium, the current partners should be tested and, if positive, treated.

Follow up

Clinical symptoms should improve within 72 hours of treatment. If symptoms have not improved, consider arranging further
investigations, switching to inpatient treatment or making an alternative diagnosis
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A test of cure is required\:
If positive for chlamydia, a repeat test is recommended 3 to 5 weeks after completing treatment if the patient is still
experiencing symptoms or you suspect poor treatment compliance
If positive for gonorrhoea, a test of cure is recommended 2 weeks after completing treatment
If positive for mycoplasma genitalium, a test of cure is recommended 5 weeks after completing treatment

Complications

If left untreated, PID can have several long-term complications including\:
Chronic pelvic pain (even after treatment)
Increased risks of future ectopic pregnancies
Subfertility (due to scarring caused by infections)
Abscesses in the ovaries and fallopian tubes (tubo-ovarian abscess) and pus (pyosalpinx) or
fallopian tubes
Fitz-Hugh-Curtis syndrome
Fitz-Hugh-Curtis syndrome is in
typically associated with chlamydia and can present with right upper quadrant pain.

References

British Association of Sexual Health and HIV. U n i t e d K i n g d o m N a t i o n a l G u i d e l i n e f o r t h e M a n a g e m e n t o f P e l v i c
I n
Oxford University Press. O x f o r d H a n d b o o k o f G e n i t o u r i n a r y M e d i c i n e , H I V , A n d S e x u a l H e a l t h . rd
3 edition.

Reviewer

Dr Najia Aziz
Consultant in Sexual and Reproductive Health

Related notes

Bacterial Vaginosis
Bartholin’s Cyst
Syphilis

Test yourself

Contents

Introduction
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Aetiology
Risk factors
Clinical features
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