PID - Pelvic inflammatory disease
- 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.
- 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.
|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.
|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 is clinical, and as severity can vary (from asymptomatic to severe), a low threshold of suspicion is necessary.
- 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, as below, supports the diagnosis, but STIs are not detected in the majority of cases.
|NAAT plus culture|
|M. genitalium||Endocervical swab||NAAT|
NAAT – Nucleic Acid Amplification Test
Clinician collected specimens is recommended. However self collection can be used if patient declines speculum and bimanual.
- 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.
|Principal Treatment Options|
Mild to moderate:
|Ceftriaxone 500mg in 2mL of 1% lignocaine IMI, or 500 mg IV, stat
Metronidazole 400mg PO, BD for 14 days
Azithromycin 1g PO, stat
Doxycycline 100mg PO, BD for 14 days
|Ceftriaxone 2g IV, daily
Cefotaxime 2g IV, TDS
Azithromycin 500mg IV, daily
Metronidazole 500mg IV, BD
- 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
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
- 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 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:
100% of people diagnosed with PID have had investigations for gonorrhoea and chlamydia.