PID - Pelvic inflammatory disease
Overview
- A syndrome comprising a spectrum of inflammatory disorders of the upper female genital tract, including any combination of endometritis, salpingitis, tubo-ovarian abscess and pelvic peritonitis.
- Clinical presentation varies widely in both severity and symptomatology.
- Prompt treatment is essential to prevent long term sequelae.
Possible causes
- Polymicrobial
- Up to 70% of cases have an unidentified cause
- STIs (e.g. Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium implicated)
- Vaginal facultative bacteria are a possible cause and other vaginal bacteria have also been implicated
- Disruption of the cervical epitheliumand facilitates change in cervicovaginal environment allowing vaginal bacteria to ascend to the upper genital tract.
Clinical presentation
Symptoms | Comments/Considerations |
---|---|
Lower pelvic pain |
Typically bilateral, may worsen with movement and may localise to one side. Pain described like period pain in character and distribution. Pain may refer to upper right quadrant. |
Dyspareunia | Deep |
Vaginal/cervical discharge | Intermenstrual, post-coital bleeding or Menorrhagia may occur |
Vaginal bleeding | Intermenstrual, postcoital and menorrhagia |
Fever, nausea, vomiting | Indicates severe infection. Absence of these symptoms does not exclude a diagnosis of PID. |
Diagnosis
Diagnosis is clinical, and as severity can vary (from asymptomatic to severe), a low threshold of suspicion is necessary.
- Examination is important to make an accurate diagnosis.
- New onset of pelvic pain among women <25 years is highly predictive of PID (with exclusion of surgical emergencies).
- Rapid response to appropriate antibiotic treatment is highly predictive of PID.
- Risks include: recent partner change, partner with STI or symptoms of an STI, recent uterine instrumentation or pregnancy
- Exclude ectopic pregnancy and surgical emergencies e.g. appendicitis
- The presence of STI supports the diagnosis, but no organism is identified in 70% of cases.
Infection | Site/Specimen | Test |
---|---|---|
Gonorrhoea |
Endocervical swab |
NAAT plus culture |
Chlamydia | Endocervical swab | NAAT |
M. genitalium | Endocervical swab | NAAT |
NAAT – Nucleic Acid Amplification Test
Specimen collection
Clinician collected specimens is recommended. However self collection can be used if patient declines speculum and bimanual.
Urethral swabs for microscopy should be collected when the patient has not urinated for at least 1 hour and only if the patient has frank urethral discharge. Squeeze the urethra to express the discharge and collect on urethral swab. It is not necessary to insert the swab into the urethra. Vaginal swab: instruct the patient to insert the swab into the vagina like a tampon and then remove and place into the transport tube. Rectal swab: instruct the patient to insert the swab into the anal canal 2-4cms and then remove and place into the transport tube. FPU (First pass urine): Collect approximately 20 ml (1/3 of the standard urine jar) of the first part of the urine stream in a specimen jar at the time you are consulting the patient. The patient does not need to have held their urine for more than 20 minutes prior to specimen collection. A midstream urine (MSU) or early morning specimen (i.e. first void urine) are not required for NAAT. Click here for information on how to describe self-collection technique to a patient.Clinician collected for NAAT/culture/microscopy
Rectal swabs should be collected by inserting a sterile swab 2-4cms into the anal canal and moving the swab gently side to side for 10-20 seconds.
Pharyngeal swabs should be collected from the tonsils and oropharynx.
High vaginal swab of vaginal discharge smeared onto a glass slide, air dried and sent for microscopy. Swab inserted into transport medium for culture.Self-collection of samples for NAAT testing
Investigations
- All women of reproductive age with new onset abdominal pain should have the following investigations
- Urine pregnancy test and, if positive, urgent pelvic ultrasound
- Testing for STIs as indicated in diagnosis
- Urinalysis – the presence of nitrites or leucocytes plus prominent symptoms of dysuria and frequency makes UTI a possible differential diagnosis
- Bimanual examination is necessary to elicit cervical motion tenderness and adnexal or uterine tenderness. However, although a bimanual is ideal, the inability to perform a bimanual should not alter making a provisional diagnosis and commencing treatment. Positive predictive value of pain on bimanual is non-specific whereas the absence of pain has a high negative predictive value.
- Speculum examination allows for visualisation of the cervix. The presence of mucopurulent discharge supports the diagnosis of PID.
- Pelvic ultrasound is useful to detect alternative causes of pain, if the diagnosis is uncertain. In PID, the pelvic ultrasound may be normal or may show indicators of pelvic inflammation. Transvaginal ultrasound is preferred.
Management
Principal Treatment Options | |
---|---|
Situation | Recommended |
Mild to moderate: Outpatient treatment |
Ceftriaxone 500mg in 2mL of 1% lignocaine IMI, or 500 mg IV, stat PLUS |
Severe Inpatient treatment |
Ceftriaxone 2g IV, daily OR Cefotaxime 2g IV, TDS PLUS Azithromycin 500mg IV, daily PLUS Metronidazole 500mg IV, BD |
* If M.genitalium confirmed 2 weeks of Moxifloxacin 400mg daily for 14 days
Treatment advice
- Begin treatment immediately with provisional diagnosis, without waiting for test results.
- For patients who may be non-adherent to doxycycline, consider replacing with azithromycin 1g PO, as a further single dose 1 week later.
- Remove intrauterine device (IUD) if no response to treatment in 48-72 hours.
- Consider admission if:
- diagnosis uncertain
- a surgical emergency cannot be excluded
- suspicion or definitive diagnosis of a pelvic abscess
- severe illness or no response to outpatient medicine
- intolerance to oral therapy
- pregnancy.
Other immediate management
- Patient to avoid sexual intercourse for a week following treatment or until symptomatically better
- Rest and simple analgesia where required (non-steroidal anti-inflammatory medications, paracetamol)
- Prophylactic Candida infection treatment may be commenced
- Contact tracing
- Provide patient with factsheet.
Special treatment situations
Situation | Recommended | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Complicated infection | Seek specialist advice. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Pregnant women
For more information go to the Therapeutic Goods Association's Prescribing medicines in pregnancy database and/or seek specialist advice. ![]() |
If pregnant or breastfeeding, avoid doxycycline and use azithromycin regimen i.e for mild to moderate infection: Ceftriaxone 500mg in 2mL of 1% lignocaine IMI, or 500 mg IV, stat PLUS Metronidazole 400mg PO, BD for 14 days PLUS Azithromycin 1g PO, stat PLUS Azithromycin 1g PO, stat, 1 week later. |
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Allergy to principal treatment choice | Seek specialist advice. |
Contact Tracing
- Current sexual partners should be treated to cover chlamydia (and gonorrhoea if likely) immediately, irrespective of test results.
- Where organism is isolated, refer to relevant STI guideline for contact tracing recommendations:
See Australasian Contact Tracing Manual - PID for more information
Follow up
Follow up provides an opportunity to:
- Review at day 3 to assess response to treatment
- Further review at 1-2 weeks to ensure adequate clinical response to treatment, compliance testing and treatment of sexual contacts, repeat pregnancy test, if clinically indicated
For test of cure (TOC) and retesting advice see:
Auditable outcomes
100% of people diagnosed with PID have had investigations for gonorrhoea and chlamydia.