PELVIC INFLAMMATORY DISEASE
Introduction
Pelvic inflammatory disease (PID) is a clinical syndrome in women resulting from
infection of the usually sterile upper genital tract.
The diagnosis encompasses the following entities, either in isolation or combination: 1
●
Endometritis, (including postpartum)
●
Salpingitis
●
Tubo-ovarian abscess
●
Pelvic cellulitis/ peritonitis
●
Chorioamnionitis and intra-amniotic syndrome
PID presents in two principle forms:
●
Sexually acquired:
♥
Note that some terminology reserves the term PID exclusively for
sexually
acquired infection.
●
Non-sexually acquired:
♥
pregnancy.
Often secondary to gynaecological surgery or complications of
PID is an important condition to recognise and treat, as significant complications such
as infertility or ectopic pregnancy may ensue.
Pathophysiology
Organisms:
Sexually acquired:
●
N. gonorhoeae.
●
C. trachomatis, (now the most common STD cause of PID in Australia).
●
Mycoplasma genitalium.
Non-sexually acquired:
●
Polymicrobial with both aerobic and anaerobic organisms.
Note that, even with sexually transmitted infections the resultant upper tract infection
is usually polymicrobial with mixed STD pathogens and endogenous flora, and
hence empirical treatment will need to be broad-spectrum and include cover for
anaerobic pathogens. 1
Risk factors:
There are two predominant predisposing factors:
1.
Sexually transmitted disease, (STD)
2.
Mechanical disruption of the cervical barrier, including:
●
Childbirth
●
Instrumentation:
♥
IUDs
♥
Termination of pregnancy
♥
Dilation and curettage.
♥
Septic abortions (secondary to non-medical/ non-aseptic
pregnancy termination).
attempts at
Complications:
There is a high incidence of significant sequelae in untreated PID, including:
●
Chronic infection with chronic pelvic pain.
●
Infertility, the risk of this increases with the number of episodes of PID.
●
Increased risk of ectopic pregnancy.
●
Fitz-Hugh-Curtis syndrome:
♥
Rarely patients may present with RUQ pain, due to Fitz-Hugh-Curtis
syndrome, although this is usually an incidental finding in patients
with PID.
♥
It is due to a perihepatitis and a focal peritonitis secondary to the
spread of inflammatory peritoneal fluid to the sub-phrenic and subdiaphragmatic spaces.
♥
Other causes of biliary tract disease will need to be excluded before
this diagnosis is made.
Clinical Features
The diagnosis of PID is imprecise. It is usually based on a combination of:
●
Known risk factors
●
The clinical presentation
●
Investigations
Important point of history:
1.
Abdominal or pelvic pain.
2.
Assess for risk factors:
●
Sexual activity
●
Recent childbirth
●
Recent instrumentation.
3.
Abnormal vaginal discharge.
4.
Dyspareneunia
Important point of examination:
1.
Fever:
●
This may indicate more severe disease, but its absence does not
exclude PID.
2.
PV examination:
Mucopurulent discharge:
●
slide
The presence of muco/purulent discharge (or the presence of WBCs on
microscopy), is a sensitive marker for PID.
If the discharge appears normal and there are no WBCs seen on a wet
preparation, then PID is a less likely diagnosis.
Adnexal tenderness:
●
3.
This is the most sensitive examination finding, but has extremely low
sensitivity.
Cervical motion tenderness (cervical “excitation”).
●
There is tenderness on cervical “rocking” toward the side of the
pathology.
Investigations
Blood tests:
1.
FBE
2.
CRP
3.
U&Es/ glucose.
4.
Beta HCG
●
with
The possibility of ectopic pregnancy must always be considered in the
differential diagnosis of any female of child bearing age who presents
pelvis pain and/ or abnormal bleeding.
●
PID is uncommon in pregnancy, but has significant implications if
present.
Urine:
●
To help rule out UTI as a differential diagnosis
PCR testing:
Urine and/or swabs For:
●
N. gonorhoeae
●
C. trachomatis.
●
M. genitalium (if available).
Microbiology:
●
Cervical cultures for N. gonorhoeae or C. trachomatis, (useful for antibiotic
sensitivity testing, which PCR testing will not be able to assess).
Ultrasound:
Ultrasound may detect suggestive but non-specific features of PID such as free fluid
in the Pouch of Douglas.
It is more useful in more severe disease, where it can detect significant complications
such as tubo-ovarian abscess.
It is also useful to help rule out other causes of pelvic pain such as complicated
ovarian cysts, (torsion or hemorrhage).
Laparoscopy:
This has traditionally been taken as the ultimate the gold standard investigation.
It has a specificity that approaches 100 %, however, it cannot diagnose early/ milder
disease and so sensitivity is only around 50- 80 %.
It is useful in unwell patients, when diagnosis is uncertain or in the setting of acute,
recurrent or chronic abdominal pain of uncertain diagnosis.
Management
1.
Analgesia:
●
Simple oral analgesia is usually sufficient, occasionally titrated opioid
may be
require for more severe cases.
2.
Foreign material:
●
removed as
3.
It is vital that any IUCD or retained products of conception be
soon as possible.
Antibiotics:
Non-sexually acquired pelvic inflammatory disease: 1
For mild to moderate infection, use:
●
Amoxycillin + clavulanate 875 + 125 mg orally, 12-hourly for 14 days
Plus
●
Doxycycline 100 mg orally, 12-hourly for 14 days
Plus either:
●
Azithromycin 1 g orally, as a single dose 1 week later (azithromycin
should be
used in pregnancy or breastfeeding)
Or
●
Doxycycline 100 mg orally, 12-hourly for 14 days.
For severe disease (related to pregnancy/ surgery and unlikely to be
sexually acquired):
●
Amoxy/ampicillin 2 grams IV, 6-hourly
Plus
●
Gentamicin 4 to 6 mg/kg IV, daily (adjust dose for renal function)
Or
●
Ceftriaxone 2 grams IV, daily
Plus
●
Metronidazole 500 mg IV, 12-hourly.
Continue until there is substantial clinical improvement, then use oral
amoxicillin + clavulanate plus doxycycline (as for mild to moderate infection
above) to complete at least 2 weeks of treatment.
Sexually acquired pelvic inflammatory disease: 1
Early empirical treatment of sexually acquired pelvic inflammatory disease is
important because it reduces complications such as infertility.
Infection is usually initiated by Chlamydia trachomatis and/or Neisseria
gonorrhoeae, and possibly Mycoplasma genitalium, although other organisms
from the endogenous vaginal flora may subsequently be involved.
Sexual partners should be examined, investigated and treated empirically.
For mild to moderate infection, use:
●
Ceftriaxone 500 mg IM or IV, as a single dose (for gonorrhoea)
Plus
●
Metronidazole 400 mg orally, 12 hourly for 14 days
Plus
●
Azithromycin 1gram orally, as a single dose
Plus either:
●
Doxycycline 100 mg orally, 12 hourly for 14 days
Or (for women who are pregnant or patients suspected to be non-adherent to
doxycycline):
●
An additional dose of Azithromycin 1gram orally, 1 week later.
For severe infection use:
●
Ceftriaxone 2 grams IV, daily (or cefotaxime 2 grams IV 8 hourly).
Plus
●
Azithromycin 500 mg IV, daily
PLUS
●
Metronidazole 500 mg IV, 12-hourly
For full antibiotic prescribing details, and alternative regimes, see latest
edition of the Antibiotic Therapeutic Guidelines.
Disposition:
Most patients who have PID may be managed as outpatients.
Indications for Admission include:
●
Clinically severe disease:
♥
Intractable pain
♥
Complications such as abscess formation, peritonitis, septicemia.
●
Diagnosis uncertain and when other urgent surgical conditions, such as
appendicitis or
ectopic pregnancy need to be ruled out.
●
Significant co-morbidity such as pregnancy or diabetes.
●
Oral antibiotics not appropriate because of vomiting or unpredictable
compliance. This
is important especially in adolescents where consequences may
be significant.
Follow-up:
●
Any patient discharged on oral medication, should be reviewed within 24 - 48
hours to
assess the response to therapy.
References:
1.
eTG - March 2015.
●
2.
Antibiotic Therapeutic Guidelines, 15th ed 2014.
S. Bryan. Pelvic Inflammatory Disease, in Textbook of Adult Emergency
Medicine: Cameron et al 4th ed 2015.
Dr J Hayes
Reviewed June 2015.