Pelvic Inflammatory Disease

• PID can be caused by genital mycoplasmas, endogenous vaginal flora (anaerobic and aerobic bacteria), aerobic streptococci, Mycobacterium tuberculosis, and sexually transmitted infections such as Chlamydia trachomatis or Neisseria gonorrhoeae.² Genital chlamydial infection is currently the most common sexually transmitted infection diagnosed in genito-urinary medicine (GUM) clinics in the United Kingdom.^3,4 Pelvic infections are often polymicrobial.
• The incidence of gonorrhoea is increasing and therefore becoming a more common cause of PID.⁵
• Other organisms implicated in PID include those commonly associated with bacterial vaginosis (e.g. Gardnerella vaginalis, Mycoplasma hominis, Mobiluncus spp. and other anaerobes).⁶ Actinomycetes are part of the normal vaginal flora and a rare cause of PID.⁷

Risk factors

• Risk factors for acquiring sexually transmitted infections, e.g. young age, new sexual partner, multiple sexual partners, lack of barrier contraception, lower socio-economic group.²
• Insertion of intrauterine device (IUD) - for the first 3 weeks after insertion⁸
• Termination of pregnancy⁹

The positive predictive value of a clinical diagnosis of acute PID is 65-90% compared with laparoscopic diagnosis.¹ Many episodes of PID go unrecognised, as women often have absent, mild, or atypical symptoms.

Symptoms

• Many women with PID will have no symptoms. The following features are suggestive of PID:¹
• Lower abdominal pain
• Dyspareunia
• Abnormal vaginal bleeding
• Vaginal discharge

Signs

• Lower abdominal tenderness (usually bilateral)
• Mucopurulent cervical discharge and cervicitis seen on speculum examination
• Cervical motion tenderness and adnexal tenderness on bimanual vaginal examination
• Fever above 38° (but may be apyrexial)

Differential diagnosis

• Other causes of abdominal pain, e.g. appendicitis, ectopic pregnancy
• Other causes of abnormal vaginal bleeding
• Other causes of vaginal discharge, e.g. foreign body
• Other causes of dyspareunia, e.g. endometriosis

• Pregnancy test (pregnant women with PID should be admitted; ectopic pregnancy may be confused with PID)
• Cervical swabs for chlamydia and gonorrhoea: a positive result supports the diagnosis of PID, but a negative result does not exclude PID.
• An elevated ESR or CRP also supports a diagnosis of PID.
• Endometrial biopsy and ultrasound scanning may also be helpful.
• Laparoscopy with direct visualisation of the Fallopian tubes is the best single diagnostic test, but is an invasive procedure and therefore not appropriate in routine clinical practice.⁶
• Urinalysis and urine culture: to exclude urinary tract infection.

• Provide adequate pain relief.
• The evidence for whether an intrauterine contraceptive device (IUCD) should be left in situ or removed is limited. Removal of the IUD may be associated with better short term clinical outcomes. The decision to remove the IUD needs to be balanced against the risk of pregnancy in those who have had otherwise unprotected intercourse in the preceding 7 days.¹
• Consider referral to a GUM clinic, for a full sexually transmitted infection screen (HIV etc.), contact tracing and treatment of sexual partners.

Antibiotic treatment

• Do not delay antibiotic treatment while waiting for the results of tests if PID is clinically suspected. It is likely that delayed treatment increases the risk of long-term complications, such as ectopic pregnancy, infertility and pelvic pain. Negative swabs do not exclude PID and therefore should not influence the decision to treat.¹ Emphasise the importance of completing the course of antibiotics to reduce the risk of long-term complications.
• Broad-spectrum antibiotic treatment to cover C. trachomatis, N. gonorrhoeae and anaerobic infection is recommended.
• The current outpatient treatment recommendation is ceftriaxone 250 mg as a single intramuscular dose, followed by doxycycline 100 mg orally twice-daily and metronidazole 400 mg twice-daily, for 14 days.⁶
• Other recommended regimes include:¹
  • Outpatient regimens:
    • Intramuscular ceftriaxone or cefoxitin with oral probenecid 1 g; followed by oral doxycycline plus metronidazole for 14 days.
    • Ofloxacin 400 mg orally twice-daily plus oral metronidazole 400 mg twice-daily, for 14 days.¹⁰ This is not recommended if the woman is at high risk of gonococcal PID because of increasing quinolone resistance of gonorrhoea.
  • Severely ill patients:
    • Intravenous therapy is recommended for patients with more severe clinical disease, e.g. pyrexia above 38°, clinical signs of tubo-ovarian abscess, signs of pelvic peritonitis.¹
    • Initial treatment with doxycycline, single dose intravenous ceftriaxone and intravenous metronidazole, then change to oral doxycycline and metronidazole to complete 14 days of treatment.

• Although most infected male partners have no symptoms, infection rates of 53% for C. trachomatis and 41% for N. gonorrhoeae have been reported among partners of women with PID.¹¹
• Patients should be advised to avoid unprotected intercourse until they, and their partner(s) have completed treatment and follow-up.¹
• Screen for other sexually transmitted infections, ideally at a GUM clinic. All sexual partners within the previous 6 months (or the most recent sexual partner if there have been no sexual contacts within the previous 6 months) should be notified and offered screening for sexually transmitted infections.
• Sexual partners should be treated for chlamydial infection even if this is not identified on testing.
• Treatment for gonorrhoea only needs to be offered if N. gonorrhoeae is identified in the woman with pelvic inflammatory disease or her partner.
• Empirical treatment for chlamydial infection and gonorrhoea should be given to partners who are unwilling to be screened.

Admission to secondary care (for intravenous antibiotics and/or further investigation) should be considered in the following situations:⁶

• Diagnostic uncertainty, e.g. where appendicitis or ectopic pregnancy cannot be excluded
• Severe symptoms or signs
• Deteriorating clinical condition
• Clinical failure with oral treatment (i.e. failure to show substantial improvement within 3 days)
• Inability to tolerate oral treatment (e.g. due to nausea and vomiting)
• Presence of a tubo-ovarian abscess
• Pregnancy
• Immunodeficiency, e.g. HIV infection, immunosuppression therapy

• Infertility: the risk of infertility following PID is related to the number of episodes of PID and their severity
• Ectopic pregnancy
• Chronic pelvic pain
• Perihepatitis (Fitz-Hugh and Curtis syndrome): causes right upper quadrant pain. Occurs in up to 10-20% of women with PID.¹
• Tubo-ovarian abscess
• Reiter's syndrome (reactive arthritis)
• In pregnancy: PID is associated with an increase in pre-term delivery, and maternal and fetal morbidity
• Neonatal: perinatal transmission of C. trachomatis or N. gonorrhoeae can cause ophthalmia neonatorum. Chlamydial pneumonitis may also occur.

• Limited evidence suggests that screening for chlamydia and treating identified infection prior to IUD insertion reduces the risk of PID.⁶
• It has been recommended that chlamydia testing be offered to women at increased risk of sexually transmitted infections and all sexually active women aged under 25 years.⁶
• Routine prophylactic antibiotics prior to IUD insertion are not recommended.⁶

1. Management of PID, British Association for Sexual Health & HIV (2005)
2. Simms I, Stephenson JM; Pelvic inflammatory disease epidemiology: what do we know and what do we need to know? Sex Transm Infect. 2000 Apr;76(2):80
3. Health Protection Agency; Chlamydia (Chlamydia trachomatis)
4. Chlamydia - uncomplicated genital, Clinical Knowledge Summaries (May 2009)
5. Health Protection Agency; Gonorrhoea (Neisseria gonorrhoeae).
6. Pelvic inflammatory disease, Clinical Knowledge Summaries (August 2009)
7. Lippes J; Pelvic actinomycosis: a review and preliminary look at prevalence. Am J Obstet Gynecol. 1999 Feb;180(2 Pt 1):265-9. [abstract]
8. Farley TM, Rosenberg MJ, Rowe PJ, et al; Intrauterine devices and pelvic inflammatory disease: an international perspective. Lancet. 1992 Mar 28;339(8796):785-8. [abstract]
9. Sawaya GF, Grady D, Kerlikowske K, et al; Antibiotics at the time of induced abortion: the case for universal prophylaxis based on a meta Obstet Gynecol. 1996 May;87(5 Pt 2):884 [abstract]
10. Management of Infection - Guidance for Primary Care; Management of Infection - Primary Care Guidance, Health Protection Agency (various dates); Guidelines for primary care (including diagnosis - quick reference guides)
11. Lawson MA, Blythe MJ; Pelvic inflammatory disease in adolescents. Pediatr Clin North Am. 1999 Aug;46(4):767 [abstract]

• Chlamydia. Chlamydia is the most common sexually transmitted infection (STI) in the UK. Toni Belfield gives advice on who's at risk, where to get tested and what the treatment involves. A short video from NHS Choices. (October 2007)
• WHO Sexually transmitted and other reproductive tract infections: A guide to essential practice
• www.chlamydiae.com; web resource for both patients and professionals