Background Information
Definition
PID refers to the ascending infection of the upper genital tract from the endocervix
PID is an umbrella term that covers one or more of the following:
- Endometritis — inflammation and infection of the uterus
- Salpingitis — inflammation of the fallopian tubes
- Parametritis — inflammation of the parametrium, the connective tissue of the pelvic floor
- Oophoritis — inflammation of the content of one or both ovaries
- Tubo-ovarian abscess — due to complex infection of the adnexae
- Pelvic peritonitis — inflammation of the peritoneum.
Causes
Most commonly caused by STIs:
- Chlamydia trachomatis – most common (14-35%)
- Neisseria gonorrhoea
- Mycoplasma genitalium
Risk Factors
Risk factors related to sexual behaviour:
- <25 y/o
- Not using condoms
- <15 y/o at onset of sexual activity
- Multiple sexual partners
- Recent new sexual partner (<3 months)
- Previous PID
- History of STI in the women / sexual partner
Recent uterus instrumentation from:
- Termination of pregnancy
- Insertion of IUDIntrauterine device (only increases risk for first 3 weeks after insertion)
- Hysteroscopy / hysterosalpingography
- IVFIn vitro fertilisation
Clinical Features
Symptoms:
- Lower abdominal / pelvic pain (typically bilateral)
- Deep dyspareunia
- Abnormal vaginal bleeding
- Secondary dysmenorrhoea
Signs:
- Adnexal tenderness
- Vaginal / cervical discharge (often purulent)
- Cervical motion tenderness
Cervical motion tenderness is assessed during bimanual pelvic examination by gently moving the cervix from side to side or back and forth with the examining fingers.
Cervical motion tenderness is most classically associated with PID, indicating inflammation of the pelvic organs (e.g. fallopian tubes, ovaries, surroundign structures)
- Systemic upset (fever, nausea, vomiting, malaise)
Complications
- ↑ Risk of ectopic pregnancy
- InfertilityPID is a cause of tubal factor infertility Salpingitis → scarring and adhesions → obstruction of fallopian tubes
- Chronic pelvic pain
- Tubo-ovarian abscess
- Perihepatitis (Fitz-Hugh-Curtis syndromeDue to infection spread into the peritoneal cavity. Characteristed by inflammation of the liver capsule → RUQ pain +/- right shoulder tip referred pain Particularly associated with Chlamydia trachomatis )
Diagnosis
Diagnostic Criteria
PID is a clinical diagnosis.
BASHH recommends considering a diagnosis of PID and offering treatmnet in:
- Any <25 y/o women, with
- Recent onset, bilateral lower abdominal pain, and
- Local tenderness on bimanual examination
If PID is suspected clinically, antibiotics should not be delayed while awaiting laboratory test results.
Investigations
If PID is suspected clinically, antibiotics should not be delayed while awaiting laboratory test results.
Consider the following tests (not needed for diagnosis):
| Test | Notes |
|---|---|
| Pregnancy test | To exclude ectopic pregnancy |
| Blood tests | ↑ Leukocyte / CRP / ESR may support diagnosis |
| Vaginal swabs for chlamydia + gonorrhoea + Mycoplasma genitalium | -ve Swab does not rule out PID |
| STI screen | Including HIV, hepatitis serology, and syphilis serology |
| Vaginal smear microscopy | Good -ve predictive value (absence of pus cells means PID is unlikely) |
In any female of reproductive age, a urinary pregnancy test should always be done initially to rule out ectopic pregnancy.
It is a quick bedside test and can rule out potentially life-threatening ruptured ectopic pregnancy.
Management
BASHH recommends a low threshold for empirical PID treatment due to:
- Lack of definitive diagnostic criteria, and
- Delaying treatment is likely to increase risk of long-term complications
Patient should be advised to attend local specialist sexual health service if hospital admission is not needed.
Urgent Hospital Admission Criteria
- Clinically severe disease
- Pregnant women
- Tubo-ovarian abscess suspected
- Pelvic peritonitis suspected
- Surgical emergency cannot be excluded (e.g. suspected acute appendicitis, ovarian torsion)
- No response to oral therapy
General Advice / Conservative Management
- Paracetamol and/or ibuprofen for symptom relief
- Avoid unprotected sexual intercourse until patient and partner(s) have completed treatment and follow-up
- Routine removal of an IUDIntrauterine device is NOT necessary
- IUDIntrauterine device can remain in situ if there are mild-to-moderate symptoms + clinically improving within 48-72 hours of starting antibiotics
- Removal of IUDIntrauterine device is indicated if severe symptoms at presentation, or NOT clinically improving after antibiotics
Antibiotic Therapy
Outpatient Management
1st line: triple therapy (to cover chlamydial and gonococcal infection):
- IM ceftriaxone 1g single dose, PLUS
- Oral doxycycline 100mg BD for 14 days, PLUS
- Oral metronidazole 400mg BD for 14 days
If Mycoplasma genitalium +ve: oral moxifloxacin 400mg OD for 14 days
2nd line regimen:
- IM ceftriaxone 1g single dose, PLUS
- Oral azithromycin 1g per week for 14 days
Inpatient Management
Principle:
- IV antibiotics until 24 hours after clinical improvement
- Then, switch to oral antibiotics
Regimen (either of the following):
- IV ceftriaxone + IV doxycycline followed by oral doxycycline 100mg BD + oral metronidazole 400mg BD for 14 days
- IV clindamycin + IV gentamicin followed by oral clindamycin / doxycycline + metronidazole for 14 days
Follow Up
- Review within 72 hours after starting antibiotics
- Consider further review 2-4 weeks after completion of antibiotics
- Advice on future use of barrier method of contraception
Test of cure indicated if:
- +ve initial test for gonorrhoea / chlamydia / Mycoplasma genitalium
- Persistent symptoms after completing antibiotics
- Initial test results showing unknown antibiotic sensitivity or resistance (for gonorrhoea / Mycoplasma genitalium)
- Persistent / recurrent infection
- Poor compliance with antibiotic / treatment not tolerated
Management of Sexual Partners
Offer contact tracing + STI screeningOffer screening for chlamydia and gonorrhoea. If the woman has confirmed Mycoplasma genitalium infection → offer screening for Mycoplasma genitalium as well + treatment for:
- Current partners
- Recent (<6 months) partners
Whilst waiting for results, offer male partners doxycycline 100mg BD for 1 week
References
NICE CKS Pelvic Inflammatory Disease
BASHH Pelvic Inflammatory Disease 2019