Pelvic inflammatory disease

• A syndrome comprising a spectrum of inflammatory disorders of the upper female genital tract, including any combination of endometritis, salpingitis, tubo-ovarian abscess and pelvic peritonitis
• Clinical presentation varies widely in both severity and symptomatology, estimated up to 60% subclinical
• In addition to sexual transmission, pelvic inflammatory disease (PID) may follow intrauterine device (IUD) insertion, termination of pregnancy, child birth and upper genital tract instrumentation
• True incidence is unknown due to non-specificity of diagnostic signs
• Risk factors:
  • Age under 30 years
  • Partner with a sexually transmitted infection (STI)
  • Recent change in sexual partner
  • Recent STI
  • Recent pregnancy
  • Upper genital tract instrumentation
  • IUD insertion
• Prompt treatment is essential to prevent long term sequelae

• Chlamydia trachomatis, Neisseria gonorrhoeae, mycoplasmas and mixed anaerobes
• Polymicrobial
• Up to 70% of cases do not have an identifiable cause

• Lower abdominal or pelvic pain in woman, especially those with risk factors
• Risk factors:
  • Age under 30 years
  • Partner with an STI
  • Recent change in sexual partner
  • Recent STI
  • Recent pregnancy
  • Upper genital tract instrumentation
  • IUD insertion

• Diagnosis is clinical, taking into account the history, clinical findings and supplemental tests
• No single laboratory test is diagnostic, and STI tests are often negative
• A low threshold for treatment is appropriate in view of important sequelae and diagnostic uncertainty

Investigations

• All women of reproductive age with new onset abdominal pain should have the following investigations:
  • Urine pregnancy test and, if positive, urgent pelvic ultrasound (exclude ectopic pregnancy)
  • STI screening as per sexual health check guideline
  • Urinalysis – the presence of nitrites or leucocytes plus prominent symptoms of dysuria and frequency makes urinary tract infection a possible differential diagnosis

• Initiate PID treatment for the following criteria
  • Lower abdominal pain AND one or more of the following:

Uterine tenderness

OR

Adnexal tenderness

OR

Cervical motion tenderness

Bimanual examination is necessary to elicit cervical motion tenderness and adnexal or uterine tenderness. The inability to perform a bimanual examination should not alter making a provisional diagnosis and commencing treatment

Additional supportive features:

• Abnormal cervical or vaginal mucopurulent discharge
• Fever > 38 degrees
• Elevated white cell count or CRP
• Confirmed infection with an STI or bacterial vaginosis

PID is severe if:

• Acute abdomen
• Pregnancy
• Fever, vomiting or systemically unwell
• Intolerant of oral therapy
• Clinical failure at review

Main differential diagnoses to consider:

• Pregnancy complications, including ectopic
• Appendicitis
• Urinary tract infection
• Ruptured ovarian cyst

Initiate PID treatment for the following criteria

• Lower abdominal pain AND one or more of the following:

Uterine tenderness

OR

Adnexal tenderness

OR

Cervical motion tenderness

Treatment options

Special Situations

• Advise to abstain from sex or use condoms for 2 weeks from the start of treatment, and until partner(s) tested and treated
• Rest and simple analgesia where required (non-steroidal anti-inflammatory medications, paracetamol)
• Consider removal of IUD if no response to treatment in 48-72 hours
• Consider admission if:

• • diagnosis uncertain
  • a surgical emergency cannot be excluded
  • suspicion or definitive diagnosis of a pelvic abscess
  • severe illness or poor response to outpatient therapy
  • intolerance to oral therapy

• Contact tracing is important to prevent re-infection and reduce transmission
• All sexual contacts in the last 3 months should be notified
• Most patients choose to tell contacts themselves; giving written information can be helpful
• Notifying all contacts may not be possible e.g. if there is insufficient information or a threat of violence

Management of sexual contacts

• Contacts should have a sexual health check, and empirical treatment with doxycycline 100 mg orally twice daily for 7 days, assuming no allergies or contraindications
• Advise contacts to abstain from sex or use condoms until results are available, and treatment completed
• If index case or contacts test positive for an STI, see appropriate STI guideline for management
• Patient-delivered partner therapy is not legal in Aotearoa New Zealand

Referral to a specialist is recommended for:

• Allergy or contraindication to standard treatment options
• Suspected PID in pregnancy
• Severe PID (consider inpatient management)
• Complicated clinical situations for further management

• 100% of people diagnosed with PID have had investigations for gonorrhoea and chlamydia

Just the facts