Pelvic Inflammatory Disease (PID)

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Cause

  • Spectrum of inflammatory disorders of the upper female genital tract, including endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis.
  • Can lead to infertility, chronic pelvic pain and ectopic pregnancy.
    • Repeated episodes of PID are associated with an increased risk of permanent tubal damage. 
  • Sexually transmitted pathogens are more likely to be found in younger sexually active women with PID.
    • 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 if suspected and where the prevalence of gonorrhoea is higher.  
    • Mycoplasma genitalium can also cause PID and is less responsive to the recommended treatment for PID. 

Clinical presentation

  • While PID may be asymptomatic, symptoms include
    • Pelvic pain
    • Vaginal discharge
    • Abnormal vaginal bleeding, including post coital bleeding
    • Dyspareunia

Diagnosis

  • The diagnosis of PID is often subtle and clinicians need to have a high index of suspicion.
  • A combination of the presence of the above listed symptoms and the following examination findings are used
    • Cervical motion tenderness
    • Uterine tenderness
    • Adnexal tenderness
  • The additional presence of signs of lower-genital tract inflammation (predominance of leukocytes in vaginal secretions and signs of cervicitis), increases the specificity of the diagnosis.
  • While laparoscopy is the best single diagnostic test for PID, it is invasive and not used routinely in clinical practice.
  • Women suspected of having PID should have:
    • swabs for microscopy and STI testing (chlamydia, gonorrhoea, and MG) 
    • bHCG to exclude pregnancy
  • Consider pelvic ultrasound to exclude other causes of pelvic pain

Management

Index patient

Condition

Recommended

Extra comments

Mild to moderate PID

Doxycycline 100mg twice daily for 14 days

PLUS

Metronidazole 400mg twice daily for 14 days

If gonorrhoea is suspected add

Ceftriaxone 500mg in 2 ml of 1% lignocaine IM as a single dose.

Empiric treatment for PID should be initiated early, before swab results.

If Mycoplasma genitalium is confirmed please refer to the MG Management guidelines.

Women should ideally be reviewed at 72 hours. If there is no clinical improvement, consider an alternative diagnosis and/or referral for further investigation and inpatient treatment.

If an STI is isolated, see relevant MSHC Management guidelines for retesting and contact tracing

Severe PID

Refer to hospital for intravenous antibiotics

 

Pregnant woman with PID

As there is a high risk of maternal morbidity and premature delivery associated with PID in pregnancy, consider inpatient admission for intravenous antibiotics. 

 

Woman with intrauterine contraceptive device (IUD)

Consider removing the IUCD in women with mild to moderate PID if there is no clinical improvement at 72 hours.

Women with severe PID with an IUCD in situ should be referred to hospital.

 


Sexual Contacts
  • Current sexual partners should be tested for STIs and offered treatment at the first visit with doxycycline 100mg bd for 7 days.

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 Feb 2021