Pelvic inflammatory disease (PID)

Definition

Acute PID

  • An acute clinical syndrome due to ascending spread of micro-organisms from the vagina and endocervix to the endometrium, fallopian tubes, ovaries, and peritoneum of the pelvis. The majority of severe acute symptomatic PID (STI in origin) is caused by gonorrhoea, though PID caused by chlamydia may be also present with acute pelvic symptoms, it is more often associated with low-grade symptoms. A role for Mycoplasma Genitalium in pelvic inflammatory disease is emerging. 
  • Similar terms: Acute salpingitis, adnexitis, pelvic peritonitis.
Organism
  • Community acquired. In women aged under 25 years, 60–80 per cent is caused by gonorrhoea or chlamydia, mixed with facultative and anaerobic flora present in the vaginal tract.
  • Some data also suggest a role for Mycoplasma genitalium 
  • Ascending spread of normal commensals, which become pathogenic, may follow surgical or other trauma, pregnancy, or intra-uterine device (IUD) insertion, although this is only a risk in the first 3 weeks post insertion. PID may result in tuboovarian abscess formation. 
  • M. tuberculosis rarely causes PID in Australia
  • Less than 15% are not STI related and are associated with enteric (eg E.Coli) or respiratory (Haemophilus influenza, Strep. pneumonia, Staph. aureus) that have colonized the lower genital tract.
Clinical presentation

The following symptoms may be present:

  • lower genital tract infection – discharge
  • lower abdominal pain that worsens with movement
  • pain with intercourse
  • fever
  • dysuria (pain on passing urine)
  • pain with periods
  • intermenstrual bleeding
  • heavy periods
  • feeling unwell
  • nausea, vomiting
  • chronic pelvic pain. 

The following signs may be present:

  • abdominal tenderness – guarding or rigidity, rebound
  • tenderness in one or other adnexa – may be unilateral, or a mass may be felt
  • cervical excitation – pain on rocking the cervix
  • temperature may be raised
  • perihepatitis and peritonitis are possible and present with abdominal pain, tenderness, guarding/rigidity and right upper quadrant pain.

STI Atlas (external site)

Investigations
  • high vaginal swab for MC&S and endocervical swab for MC&S (charcoal or non-charcoal agar gel)
  • first void urine and endocervical swab for gonorrhoea and chlamydia NAAT (no transport medium)
  • first void urine for NAAT
  • full blood picture – ESR as well as C reactive protein
  • pregnancy test to exclude ectopic pregnancy
  • pelvic ultrasound may be indicated
  • consider referral for laparoscopy.
Treatment
  • Because of the difficulty of diagnosis and the potential for damage to the reproductive tract, health care providers should have a low threshold for diagnosis and treatment of PID.
  • Empirical treatment for PID should be given to sexually active women with pelvic and lower abdominal pain that do not have another cause for their illness and that have one or more of the following minimum criteria:
    • cervical motion, uterine or adnexal tenderness
    • temperature > 38C
    • abnormal cervical discharge or friability
    • increased ESR/CRP or positive C.trachomatis/N.gonorrhoea test
  • Begin treatment early. Delayed treatment is associated with a significantly increased risk of tubal infertility or ectopic pregnancy.
  • Rest.
  • Use non-steroidal anti-inflammatory for pain relief.
  • Prevent any Candida infection with pessaries during the treatment period.
  • Admit if:
    • diagnosis uncertain
    • surgical emergency – appendicitis or ectopic pregnancy
    • pelvic abscess/tuboovarian abscess 
    • severe illness, nausea or vomiting or high temperature or no response to outpatient medicine
    • no clinical follow-up
    • cannot take oral therapy.
  • Patient to avoid sexual intercourse until they are non-infectious and symptomatically better.

Sexually acquired

Immediate treatment

  • Azithromycin 1 g orally, as a single dose

        plus

  • ceftriaxone 500 mg in 2 mL 1% lignocaine intramuscularly, as a single dose.

For mild to moderate infection (outpatient treatment)

After the immediate treatment above, continue with:

  • doxycycline 100 mg orally, 12-hourly for 2 weeks

        AND

  • metronidazole 400 mg orally, 12-hourly for 2 weeks

  • A second dose of azithromycin 1 g 7 days later can be used instead of doxycycline (where compliance is thought to be an issue).
  • tinidazole 500 mg orally, daily for 2 weeks can be used instead of metron

If pregnant or breastfeeding, substitute for doxycycline

  • roxithromycin 300 mg orally, daily for 2 weeks (category B1).
  • A second dose of azithromycin 1g 7 days later can be used instead of roxithromycin where compliance is thought to be an issue. 
  • Medicines in Pregnancy.

Advise avoidance of consuming alcohol during treatment with either metronidazole or tinidazole, and for 24 hours thereafter.

For severe infection (inpatient treatment)

  • Metronidazole 500 mg intravenously, 12-hourly

        plus

  • Azithromycin 500mg intravenously daily (as below for sites recomending this therapy)

        plus either

  • cefotaxime 2 g intravenously, eight-hourly

        or

  • ceftriaxone 2 g intravenously, daily.

Intravenous treatment should continue until there is substantial clinical improvement. Patients with tubovarian abscess need at least 24 hours admission. 

After that the above oral regimen (for mild to moderate infections) can be used to complete two weeks of treatment.

If pregnant or breastfeeding, substitute for doxycycline

  • azithromycin 1 g at day 7 (category B1)

        or

Related links

Education, counselling and prevention

Women who have had an episode of PID are at increased risk of further episodes: 25% will experience a recurrence. PID is known to be associated with the sequelae of infertility and ectopic pregnancy, especially with repeated infections. Counselling should be undertaken to encourage risk reduction and early presentation if symptoms of STIs and ectopic pregnancy occur.

See also general considerations in STI/HIV counselling.

Management of partners

It is essential to investigate and treat the partners, who are mostly asymptomatic in cases of PID.

It is important to treat partners, as reinfection increases the risk of tubal infertility and ectopic pregnancy 

Follow up

Follow up in three days, then weekly until the condition has improved or resolved. It is important to monitor patients closely to ensure compliance with medication and resolution of signs and symptoms. Perform a test of cure at four weeks if a gonococcal or chlamydial infection was found.

Intrauterine devices cause little if any increased risk of infection. The risk of PID is primarily limited to the first 3 weeks after insertion and is uncommon thereafter. If an IUD user receives a diagnosis of PID the IUD does not need removal unless there is no clinical improvement after 48-72 hours of treatment.

Barrier contraception is protective.

Public health issues

This is not a notifiable disease, unless a notifiable organism is detected.