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 and associated structures, ovaries, and peritoneum of the pelvis. The majority of severe acute symptomatic PID (STI in origin) is caused by gonorrhoea. PID caused by chlamydia may be associated with low-grade symptoms.
  • 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.
  • Ascending spread of normal commensals, which become pathogenic, often following trauma, pregnancy, intra-uterine device (IUD), in long-standing PID or recurrences, or abscess formation.

Causative organisms include Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma hominis/Ureaplasma urealyticum, Mycoplasma genitalium and other bacterial vaginosis organisms; Coliforms: E. coli and KlebsiellaBacteroides species;ActinomycesM. tuberculosis (rare in Australia).

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.

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.
Investigations
  • high vaginal swab for MC&S and endocervical swab for MC&S
  • endocervical swab for NAAT
  • 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
  • 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
    • severe illness or no response to outpatient medicine
    • no clinical follow-up
    • cannot take 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

        or

  • a second dose of azithromycin 1 g 7 days later (where compliance is thought to be an issue).

        plus either

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

        or

  • tinidazole 500 mg orally, daily for 2 weeks.

If pregnant or breastfeeding, substitute for doxycycline

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

  • doxycycline 100 mg orally, 12-hourly

        plus either

  • cefotaxime 1 g intravenously, eight-hourly

        or

  • ceftriaxone 1 g intravenously, daily.

Intravenous treatment should continue until there is substantial clinical improvement. 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. PID is known to be associated with the sequelae of infertility and ectopic pregnancy. 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.

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 (IUDs) should be used with caution in those at high-risk of further STIs.

Barrier contraception is protective.

Public health issues

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