Pelvic Inflammatory Disease (PID)

Pelvic inflammatory disease is a general term for infection of the upper genital tract, including the uterus, fallopian tubes, and ovaries. PID usually results from ascending infection from the cervix.¹ Pelvic inflammatory disease is a common and serious complication of some sexually transmitted diseases, especially chlamydia and gonorrhoea. PID can damage the fallopian tubes and tissues in and near the uterus and ovaries. Untreated PID can lead to serious complications, including infertility, ectopic pregnancy, abscess formation and chronic pelvic pain.

• 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 GUM clinics in the United Kingdom.³ Pelvic infections are often polymicrobial.
• The incidence of gonorrhoea is increasing and therefore becoming a more common cause of PID.⁴
• Other organisms implicated in PID include those commonly associated with bacterial vaginosis (e.g. Gardnerella vaginosis, Mycoplasma hominis, Mobiluncus spp., and other anaerobes).⁵ Actinomycetes are part of the normal vaginal flora and is a rare cause of PID.⁶

Risk factors

• Risk factors for acquiring sexually transmitted infections, e.g. young age, new sexual partner, multiple sexual partners, lack of barrier contraception, lower socioeconomic group.²
• Insertion of intrauterine device (for the first 3 weeks after insertion)⁷
• Termination of pregnancy⁸

The positive predictive value of a clinical diagnosis of acute PID is 65-90% compared with laparoscopic diagnosis.¹ Many episodes of PID go unrecognized, 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 degrees (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.⁵
• Urinalysis and urine culture: to exclude urinary tract infection.

• Provide adequate pain relief.
• The evidence for whether an intrauterine contraceptive device 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 genitourinary medicine (GUM) clinic, for a full sexually transmitted infection screen 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.⁵
• Other recommended regimes include:¹
  • Outpatient regimens
    • Intramuscular ceftriaxone or cefoxitin with oral probenecid 1g; 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. 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 degrees, 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.⁹
• 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 genito-urinary medicine (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:⁵

• 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-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 preterm 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.⁵
• 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.⁵
• Routine prophylactic antibiotics prior to IUD insertion are not recommended.⁵