Pelvic inflammatory disease (PID)

Definition

Acute PID

  • An acute clinical syndrome comprising a spectrum of inflammatory disorders of the upper female genital tract, including any combination of endometriosis, salpingitis, tubo-ovarian abscess and pelvic peritonitis.
  • The syndrome is 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
  • Polymicrobial
  • Up to 70% of cases have an unidentified cause.
  • STIs such as Neisseria gonorrhoeae, Chlamydia trachomatis and M. genitalium are often implicated, especially in women <25 years.
  • Vaginal facultative bacteria and anaerobic flora present in the vaginal tract have also been implicated.
  • 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. 
Clinical presentation

New onset of pelvic pain among women <25 years is highly predictive of PID, excluding surgical emergencies. Risks include recent partner change, partner with STI or STI symptoms, recent intrauterine instrumentation or pregnancy.

The following symptoms may be present:

  • Lower abdominal pain -  typically bilateral, may worsen with movement or localise to one side or refer to upper right quadrant. Pain may be acute or chronic and may be misdiagnosed as appendicitis.
  • Pain with intercourse
  • Pain with periods
  • Intermenstrual or post-coital bleedingLower genital tract infection – discharge
  • Dysuria (pain on passing urine)
  • Heavy periods
  • Feeling unwell
  • Fever, nausea and vomiting indicate presence of severe infection. Absence of these symptoms does not exclude a diagnosis of PID.

The following signs may be present:

  • Abdominal tenderness – guarding or rigidity, rebound tenderness
  • Tenderness in one or other adnexa – may be unilateral, or a mass may be felt
  • Cervical excitation – pain on rocking the cervix. Speculum examination is recommended to allow for visualisation of the cervix; the presence of mucopurulent discharge in the cervix supports the diagnosis of PID
  • Raised temperature (>38 degrees)
  • 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).
  • Endocervical swab for gonorrhoea and chlamydia and M. genitalium NAAT (no transport medium).
  • Separate endocervical swab for M. genitalium NAAT (no transport medium).
  • First void urine for gonorrhoea, chlamydia and M.genitalium NAAT.
  • Full blood picture – ESR as well as C reactive protein.
  • Pregnancy test and, if positive, urgent pelvic ultrasound to exclude ectopic pregnancy.
  • Pelvic ultrasound may be indicated; transvaginal ultrasound is preferred.
  • Urinalysis for differential diagnosis of UTI.
  • 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
    • Positive gonorrhoea, chlamydia or M. genitalium test.
  • Begin treatment early. Delayed treatment is associated with a significantly increased risk of tubal infertility or ectopic pregnancy.
  • Advise rest and use non-steroidal anti-inflammatory medications for pain relief.
  • Prevent any Candida infection with pessaries during the treatment period.
  • Consider admission if:
    • Diagnosis uncertain.
    • Surgical emergency such as appendicitis or ectopic pregnancy cannot be excluded.
    • Suspicion or diagnosis of pelvic abscess/tuboovarian abscess.
    • Severe illness, nausea or vomiting or high temperature or no response to outpatient medicine
    • The patient cannot take oral therapy.
    • Pregnancy.
  • Advise patient to avoid sexual intercourse until they are non-infectious and symptomatically better.
  • Remove intrauterine device (IUD) if no response to treatment in 48-72 hours.

Immediate treatment

  • Ceftriaxone 500 mg in 2 mL of 1% lignocaine intramuscularly, as a single dose

PLUS

  • Doxycycline 100mg orally, twice daily for 14 days (For patients who may be non-adherent to doxycycline, consider replacing with azithromycin 1g PO, as a further single dose 1 week later)

PLUS

  • Metronidazole 400mg orally, twice daily for 14 days
For mild to moderate infection (outpatient treatment)
  • Ceftriaxone 500mg in 2ml of 1% lignocaine intramuscularly, as a single dose

PLUS

  • Metronidazole 400mg orally, twice daily for 14 days
PLUS
  • Doxycycline 100 mg orally, twice daily for 14 weeks (For patients who may be non-adherent to doxycycline, consider replacing with azithromycin 1g PO, as a further single dose 1 week later)
Advise no alcohol consumption during treatment with either metronidazole or tinidazole, and for 24 hours thereafterFor severe infection (inpatient treatment)
  • Ceftriaxone 2g, administered intravenously, daily

OR

  • Cefotaxime 2g, administered intravenously, three times daily

PLUS

  • Azithromycin 500mg, administered intravenously, daily

PLUS

  • Metronizadole 500mg, administered intravenously, twice daily
Intravenous treatment should continue until there is substantial clinical improvement. Patients with tubovarian abscess need at least 24 hours admission. Following that, the above oral regimen (for mild to moderate infections) can be used to complete two weeks of treatment.

Special Treatment Situations

If M. Genitalium confirmed, 2 weeks of Moxifloxacin 400mg daily for 14 days.

If moxifloxacin is required, seek specialist advice as this requires a private prescription, cannot be used in pregnancy, is expensive and is associated with diarrhoea, occasional tendinopathy and rare neurological and cardiac events.

If pregnant or breastfeeding, substitute for doxycycline

  • Ceftriaxone 500mg in 2ml of 1% lignocaine intramuscularly, or 500mg, administered intravenously as a single dose
PLUS
  • Metronidazole 400mg orally, twice daily for 14 days
PLUS
  • Azithromycin 1g orally, as a single dose
PLUS
  • Azithromycin 1g orally, as a single dose, 1 week later
See Australian categorisation system for prescribing medicine in pregnancy (external site).

Seek specialist advice for complicated infection or where allergy to the principal treatment choice is present.

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. Current sexual partners should be treated to cover chlamydia (and gonorrhoea if likely) immediately, irrespective of test results.

Where the organism is known and isolated, refer to the relevant STI guideline for contact tracing and treatment recommendations:

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.