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