PID - Pelvic inflammatory disease

PID | Acute salpingitis | Adnexitis | Pelvic perionitis |

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

SymptomsComments/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.

  • 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.

 

InfectionSite/SpecimenTest
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.

Clinician collected |
Self-collection

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.

Management

Principal Treatment Options
SituationRecommended

Mild to moderate:

Outpatient treatment

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
Doxycycline 100mg PO, BD for 14 days

Severe

Inpatient treatment

Ceftriaxone 2g IV, daily
OR
Cefotaxime 2g IV, TDS
PLUS
Azithromycin 500mg IV, daily
PLUS
Metronidazole 500mg IV, BD

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

SituationRecommended
Complicated infection Seek specialist advice.
Pregnant women
pregnancy
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.
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.

Last Updated: Monday, 27 June 2016