Pelvic Inflammatory Disease

Background

  • PID is due to infection of the upper female genital tract
    • This can encompass a wide range of pathology: mild endometritis to pelvic peritonitis
  • Causative organisms are commonly sexually transmitted e.g. Chlamydia trachomatis; Gonorrhoeae etc; or endogenous vaginal flora e.g. Bacteroides
  • Fairly common- ~280/100,000 (although this may be an underestimate due to asymptomatic patients)
  • Most common in young women (20-29)
  • Increased risk with multiple sexual partners/unprotected sex; also small risk with instrumentation e.g. TOP/insertion of IUD/hysteroscopy etc

Presentation

  • Pelvic or lower abdominal pain (usually bilateral and constant, worse with movement)
    • In 10-20% of women, there is also right upper quadrant pain due to ‘peri-hepatitis’ (Fitz-Hugh-Curtis syndrome)
      • Caused by the development of adhesions between the liver and peritoneum
  • Deep dyspareunia
  • Abnormal vaginal bleeding
  • Abnormal cervical/vaginal discharge (or history of abnormal discharge- as this is often mild and transient, particularly with chlamydial infection)
  • Signs include
    • Lower abdominal tenderness (bilateral)
    • Adnexal tenderness (+/- mass); cervical motion tenderness (cervical excitation); uterine tenderness (on bimanual examination)
    • There may be a fever (though often not)

Investigation

  • Endocervical swabs for gonorrhoea/chlamydia and high vaginal swabs for other vaginal infections (including culture and sensitivity)
  • FBC (WCC); ESR/PV; CRP
  • Urinalysis
  • Occasionally, where other results are negative, USS may be helpful (can diagnose tubo-ovarian abscess – further imaging may be useful if this is suspected e.g. swinging temperature; abdominal/pelvic mass etc)
  • Pregnancy test to exclude ectopic pregnancy

Management

  • Pain relief
    • Ibuprofen or paracetamol +/- codeine
  • Outpatient
    • Oral Ofloxacin 400mg BD + Oral Metronidazole 400mg BD for 14 days ASAP (do not wait for results)
    • OR (if patients at high risk of gonococcal infection)
      • IM Ceftriaxone 500mg then oral Doxycline 100mg BD + oral Metronidazole 400mg BD for 14 days
  • Inpatient (or
    • IV Ciprofloxacin 400mg BD + IV Metronidazole 500mg TDS + IV Ceftriaxone 2g OD
    • THEN (once patient has improved)
      • Oral Ofloxacin 400mg BD + Oral Mitronidazole 400mg BD until 14 days
  • NB Special cases
    • In Pregnancy
      • IV Ceftriaxone and IV Clindamycin should be used
    • If an IUCD is thought to be contributing (i.e. patient not improving after 72 hours of treatment), consider removal
    • Surgery may be required in severe cases or those with a pelvic abscess
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