Introduction Aetiology and Epidemiology: • Pelvic Inflammatory Disease • • • • • • Pelvic Inflammatory Disease (PID) is the term used to describe upper genital tract infection in women Infection may involve the endometrium with or without involvement of the fallopian tubes and peritoneal space PID is usually initiated by a sexually transmitted organism. The organisms most commonly implicated are Neisseria gonorrhoeae and Chlamydia trachomatis. Regardless of the initiating event, the microbiology of PID usually includes a mixture of bacteria from vaginal flora e.g. anaerobes, streptococci, Haemophilus and enteric gram-negative bacteria. True incidence unknown. Pelvic infections may also occur after IUCD insertion, TOP, spontaneous abortion, instrumentation of upper genital tract, during pregnancy or postpartum. Symptoms and signs: • Estimated up to 60% are sub-clinical - no or minimal symptoms • Pelvic pain, deep dyspareunia, abnormal vaginal bleeding, fever • On examination may have cervical motion tenderness, uterine and adnexal tenderness, cervicitis, fever Complications: • Perihepatitis (Fitz-Hugh-Curtis syndrome) occurs in ~10-20% • Tubo-ovarian abscess • Chronic pelvic pain • Ectopic pregnancy and tubal factor infertility Tests • • Pelvic examination Sexual health screen, including testing for Neisseria gonorrhoeae, Chlamydia trachomatis, high vaginal swab for yeasts, bacterial vaginosis and Trichomonas vaginalis. Screening for HIV, syphilis and HBV infection and immunity. CMDHB Primary Care Sexual Health Workstream February 2007 • • Urine pregnancy test Consider urine dipstick, FBC, ESR and CRP Diagnosis • • Pelvic Inflammatory Disease No single laboratory test is diagnostic of PID Diagnosis is clinical, taking into account the history, clinical findings and results of sexual health screen and supplementary tests A low threshold for treatment is appropriate in view of important sequelae and unreliability of diagnostic features • Minimum criteria are: • Pelvic pain AND • Bilateral adnexal tenderness OR uterine tenderness OR cervical motion tenderness Additional suggestive features: • Abnormal cervical or vaginal mucopurulent discharge • Fever >38ºC • Elevated ESR, FBC or CRP • Confirmed infection with Neisseria gonorrhoeae or Chlamydia trachomatis Differential diagnosis The main differential diagnoses to consider are: • Appendicitis • Pregnancy complications e.g. ectopic, spontaneous abortion • Torsion of an ovarian cyst • UTI Management • • • Treatment should cover infection with Neisseria gonorrhoeae, Chlamydia trachomatis and anaerobes (particularly in moderate to severe infection) Patients with severe infection requiring hospitalisation should be referred to Gynaecology for initial inpatient management. Assessment by the local O&G service is also recommended if the patient is pregnant. Outpatient regimens for PID of mild to moderate severity: Preferred: • • Ceftriaxone 500mg im stat. AND Doxycycline 100mg bd po 14 days • +Metronidazole 400mg bd for 14 days IF moderately severe PID and extra anaerobic cover required Alternative regimen e.g. for patients with a history of penicillin or cephalosporin anaphylaxis: CMDHB Primary Care Sexual Health Workstream February 2007 • Substitute the stat dose of ceftriaxone for Ciprofloxacin 500mg po stat. Pelvic Inflammatory Disease IUCD Users: • There is recent evidence suggesting that treatment of PID is not hindered by the presence of an IUCD • The decision as to whether or not an IUCD should be left in situ should be made on a case by case basis in consultation with the patient • If the IUCD is removed, recommend delaying this until approx 24 hours into antibiotic therapy and consider ECP • If there is inadequate clinical response within 24-48 hours, removal of the IUCD should be considered Pregnancy: • PID in pregnancy is very uncommon, especially after the 12th week as the gestational sac occludes the uterine cavity. However, chorioamnionitis may also result from haematogenously spread infection • Pregnant woman who have suspected PID should be assessed by the local O&G service and treated with parenteral antibiotics Partner notification and management of sexual partners Partner notification: • Patient should be encouraged to notify all sexual partners from the preceding 2 months (or most recent partner if over 2 months since last contact) and advise them to attend for testing and treatment Management of sexual partners: • Perform a sexual health screen and treat empirically with a regimen suitable for Chlamydia. • If the index case is diagnosed with N. gonorrhoeae and/or Trichomonas vaginalis infection, treat partner empirically for these also. • If the sexual partner is positive for Chlamydia trachomatis or Neisseria gonorrhoeae – further partner notification as above Follow-up • • • In mild infection patients should be reviewed in 1 week and pelvic examination repeated to confirm resolution of signs In moderate infection patients should be reviewed in 48 hrs and if not improving consider Gynaecology referral. Repeat a sexual health screen approx 3 months after treatment. Referral guidelines Referral to a Specialist Sexual Health Service is recommended for: • Management of sexual partners if clinician wishes CMDHB Primary Care Sexual Health Workstream February 2007