PID

• Pelvic inflammatory disease (PID) is the inflammation of the upper female genital tract that usually arises from an ascending infection from the endocervix. PID can affect the uterus, fallopian tubes, and ovaries.
• PID is usually caused by STIs:

  • Chlamydia trachomatis (most common)
  • Neisseria gonorrhoeae - tends to cause more severe PID
  • Mycoplasma genitalium
• Pelvic inflammatory disease can less commonly be caused by non-sexually transmitted infections, such as:

  • Gardnerella vaginalis (associated with bacterial vaginosis)
  • Haemophilus influenzae (a bacteria often associated with respiratory infections)
  • Escherichia coli (an enteric bacteria commonly associated with urinary tract infections)
• Risk factors for PID include:

  • Young age, especially <25
  • Multiple or new partners
  • Previous history of a sexually transmitted infection or PID
  • Not using condoms during sex
  • Instrumentation of the uterus (e.g. abortions, gynaecological procedures such as endometrial biopsies, intrauterine device fitting)
• Symptoms:

  • Lower abdominal pain - can be bilateral or unilateral
  • Deep dyspareunia
  • Menstrual changes - post-coital bleeding, inter-menstrual bleeding, and heavy menstrual bleeding
  • Abnormal vaginal discharge
  • Fever
  • Dysuria
• Clinical exam:

  • Abdominal - tenderness, guarding, peritonism in cases of severe PID
  • Speculum - mucopurulent cervicitis
  • Bimanual - cervical motion tenderness, adnexal tenderness, palpable mass if tubo-ovarian abscess has formed
• Relevant bedside investigations include:

  • Pregnancy testing: to rule out an ectopic pregnancy
  • Urinalysis: to exclude urinary tract infection
• Relevant laboratory investigations include:

  • Vaginal swabs: chlamydia, gonorrhoea and mycoplasma genitalium nucleic acid amplification technique (NAAT)
  • MC&S swab of cervical discharge (for gonorrhoea culture, but will also detect other bacteria)
  • Routine HIV and syphilis testing
  • Patients admitted to hospital will have FBC (neutrophilia) and CRP (raised)
• Imaging:

  • Transvaginal ultrasound scan can be performed to exclude ovarian pathology, free fluid in the pelvis or if there is suspicion of an abscess
• Diagnosis:

  • There is no single test to diagnose PID
  • Based on clinical judgement according to clinical features, risk factors and consideration of other differentials
  • A negative STI screen does not rule out PID
  • Low threshold for diagnosis
• Management overview:

  • Managed with antibiotics
  • Type of antibiotics and the route depends on the severity of the illness
  • Regimen designed to cover chlamydia, gonorrhoea and anaerobic bacteria
  • First line treatment does not cover mycoplasma genitalium
  • Abstain from sexual contact until patient and their partner has completed antibiotic course
• First line outpatient antibiotic treatment:

  • 1g intramuscular ceftriaxone single dose
  • 100mg oral doxycycline BD for 14 days
  • 400mg oral metronidazole BD for 14 days
• Inpatient management:

  • For patients with systemic illness, no response to outpatient management, intolerance to outpatient management or evidence of tubo-ovarian abscess
  • Same antibiotics as outpatient but given IV
  • IV therapy should be continued for 24 hours after clinical improvement, the patient can then switch for oral therapy
• Current male partners should be treated as a contact of PID with 100mg oral doxycycline twice daily for seven days

  All partners over the last six months should be contacted and tested for chlamydia and gonorrhoea.
• A test of cure is required:

  • Chlamydia - repeat test 3-5 weeks after treatment finished
  • Gonorrhoea - 2 weeks after treatment finished
  • Mycoplasma genitalium - 5 weeks after treatment finished
• Clinical symptoms should improve within 72 hours of treatment. If symptoms have not improved, consider arranging further investigations, switching to inpatient treatment or making an alternative diagnosis
• If left untreated, PID can have several long-term complications including:

  • Chronic pelvic pain (even after treatment)
  • Increased risks of future ectopic pregnancies
  • Subfertility (due to scarring caused by infections)
  • Abscesses in the ovaries and fallopian tubes (tubo-ovarian abscess) and pus (pyosalpinx) or fluid (hydrosalpinx) in the fallopian tubes
• Fitz-Hugh-Curtis syndrome:

  • Inflammation of the liver caused by the infection spreading across the peritoneum
  • Typically associated with chlamydia
  • Can present with right upper quadrant pain
• There will be pus cells seen on microscopy of the swabs