Pelvic Inflammatory Disease (PID)

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Pelvic Inflammatory Disease (PID) comprises a spectrum of inflammatory disorders of the upper female genital tract, including any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis. PID can lead to infertility, chronic pelvic pain and ectopic pregnancy. Repeated episodes of PID are associated increased risk of permanent tubal damage. 

Sexually transmitted pathogens are more likely to be found in women with PID among younger sexually active women. Treatment for PID should cover Chlamydia trachomatis and as well as anaerobic organisms which are often associated with PID. Treatment for gonorrhoea should be added where the prevalence of gonorrhoea is higher – such as among women with overseas contact or in remote Aboriginal and Torres Strait Islander communities. Bacterial Vaginosis is commonly associated with PID. Mycoplasma genitalium can also cause PID and is less responsive to the recommended treatment for PID. 

DIAGNOSIS

Empiric treatment for PID should be initiated in sexually active young women and other women at risk for STIs if they are experiencing pelvic or lower abdominal pain, if no cause for the illness other than PID can be identified, and if one or more of the following minimum criteria are present on pelvic examination:

  • cervical motion tenderness 

or

  • uterine tenderness 

or

  • adnexal tenderness.

The presence of signs of lower-genital tract inflammation (predominance of leukocytes in vaginal secretions and signs of cervicitis), in addition to one of the three minimum criteria, increases the specificity of the diagnosis. The absence of WBCs on cervical and vaginal smears may help exclude the diagnosis. 

While laparoscopy is the best single diagnostic test for PID it is invasive and not used routinely in clinical practice especially in mild to moderate PID. Ultrasound can be useful in excluding other causes of pelvic pain.

TREATMENT
  • Clinicians should have a high index of suspicion for PID, which is underdiagnosed. 
  • Treat early - treatment should not be delayed while waiting for swab results as swabs are commonly negative despite a clinical diagnosis of PID. Delayed treatment increases the chance of complications.
  • Exclude pregnancy as ectopic pregnancy can present in a similar way.
  • Consider pelvic ultrasound.

Mild to moderate severity PID can be managed in an outpatient setting. Women with severe PID should be referred to hospital for intravenous treatment. 

Recommended treatment

  • Azithromycin 1 gram as a single dose plus 
  • Doxycycline 100mg twice daily for 14 days plus 
  • Metronidazole 400mg twice daily for 14 days.

If there has been a partner from overseas or any other reason to suspect gonorrhoea add:

  • Ceftriaxone 500mg in 2 ml of 1% lignocaine by intramuscular injection as a single dose.

If Mycoplasma genitalium is confirmed cease doxycycline and metronidazole and commence moxifloxacin 400mg once a day for 14 days.

Pregnant women with PID
There is a high risk of maternal morbidity and premature delivery associated with PID in pregnancy so pregnant women with PID may require treatment as an inpatient with intravenous antibiotics. 

Women with IUCDs
Consider removing the IUCD in women with mild to moderate PID if there is no clinical improvement at 72 hours. There are limited data on whether an IUCD should be removed or left in place with a diagnosis of mild to moderate PID although there is a suggestion that short term clinical outcomes may be better if it is removed. Ideally at least 36 hours of antibiotics should be given prior to removal of the IUCD. Women with severe PID with an IUCD in situ should be referred to A+E.

REVIEW

Women with PID should be reviewed closely. Review patient in 72 hours. If there is no response consider an alternative diagnosis and/or referral for further investigation and inpatient treatment.

If a specific pathogen such as chlamydia, gonorrhoea or M. genitalium is isolated women please see the relevant MSHC treatment guideline for recommendations on retesting and management of sexual contacts.

CONTACTS

Sexual partners of women with PID should be tested for STI and offered treatment at the first visit with azithromycin 1 gram as a single dose. 

Disclaimer
The content of these treatment guidelines is for information purposes only. The treatment guidelines are generic in character and should be applied to individuals only as deemed appropriate by the treating practitioner on a case by case basis. Alfred Health, through MSHC, does not accept liability to any person for the information or advice (or the use of such information or advice) which is provided through these treatment guidelines. The information contained within these treatment guidelines is provided on the basis that all persons accessing the treatment guidelines undertake responsibility for assessing the relevance and accuracy of the content and its suitability for a particular patient. Responsible use of these guidelines requires that the prescriber is familiar with contraindications and precautions relevant to the various pharmaceutical agents recommended herein. 

Last Updated June 2016