PID - Pelvic inflammatory disease

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.

NAAT – Nucleic Acid Amplification Test

Specimen collection

Clinician collected specimens is recommended. However self collection can be used if patient declines speculum and bimanual.

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.

* 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
Complicated infection	Seek specialist advice.
Pregnant women Aciclovir B3 Hydrocortisone A Amoxycillin A Imiquimod B1 Azithromycin B1 Itraconazole B3 Benzathine Penicillin A Ivermectin B3 Bioallethrin B2 Lignocaine A Cefotaxime B1 Metronidazole B2 Ceftriaxone B1 Permethrin B2 Ciprofloxacin B3 Piperonyl butoxide  B3 Clindamycin A Podophyllotoxin D Clotrimazole A Probenecid B2  Doxycycline D Procaine Penicillin  A Erythromycin A Tinidazole B3 Famciclovir B1 Valaciclovir B3 Fluconazole D     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.
Allergy to principal treatment choice	Seek specialist advice.

• 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:
  • Chlamydia
  • Gonorrhoea
  • M. genitalium.

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:

• Gonorrhoea
• Chlamydia
• M. genitalium.