Pelvic inflammatory disease (PID)
(Note:
Pelvic inflammatory disease (PID) is usually the result of infection ascending from the endocervix causing endometritis, salpingitis, parametritis, oophoritis, tubo-ovarian abscess and/or pelvic peritonitis
C. trachomatis is the commonest identified cause accounting for 14-35% of cases whilst Gardnerella vaginalis, anaerobes and other organisms commonly found in the vagina may also be implicated
Mycoplasma genitalium has been associated with upper genital tract infection in women and is a very likely cause of PID.
Pathogen-negative PID is common
The insertion of an intrauterine device (IUD) increases the risk of developing PID but only for 4-6 weeks after insertion
The risk of PID is highest in women aged under 25 not using barrier contraception and with a history of a new sexual partner)
Questionnaire/history:
Lower abdominal pain (typically bilateral (but can be unilateral)?
Abnormal vaginal or cervical discharge (often purulent)?
Deep dyspareunia?
Abnormal vaginal bleeding (including postcoital bleeding, inter-menstrual bleeding and menorrhagia)?
Secondary dysmenorrhoea?
Past medical history?
Current medication?
Known drug allergies?
Examination:
Lower abdominal tenderness (usually bilateral)?
Adnexal tenderness on bimanual vaginal examination?
Tender mass (sometimes present)?
Cervical motion tenderness on bimanual vaginal examination?
Fever (> 38°C) in moderate to severe disease?
Differential diagnoses:
Ectopic pregnancy: Pregnancy should be excluded in all women suspected of having PID
Acute appendicitis: Nausea and vomiting (in most patients with appendicitis but only 50% of those with PID), cervical movement pain will occur in about a quarter of women with appendicitis)
Endometriosis: If pain cyclical and related to the menstrual cycle
Ovarian cyst complication (eg torsion or rupture): Symptoms often of sudden onset
Urinary tract infection: Often associated with dysuria and/or urinary frequency
Irritable bowel syndrome: Disturbance in bowel habit and persistence of symptoms over a prolonged time period are common
Acute bowel infection or diverticular disease can also cause lower abdominal pain usually in association with other gastrointestinal symptoms
Investigations:
Pregnancy test
Testing for gonorrhoea, C. trachomatis and M. genitalium in the lower genital tract is recommended since a positive result supports the diagnosis of PID and may alter subsequent therapy but the absence of infection at this site does not exclude PID
Local availability of M. genitalium testing currently varies but testing is strongly recommended
Consider bloods (ESR/CRP/WCC) (unspecific and usually only abnormal in moderate or severe PID)
Management:
Admission for IV antibiotics, further investigation and/or possible surgical intervention should be considered in the following situations:
- A surgical emergency cannot be excluded
- Lack of response to oral therapy
- Clinically severe disease
- Presence of a tubo-ovarian abscess - usually systemically unwell and/or have severe pelvic pain; an adnexal mass may be present
- Intolerance to oral therapy
- Pregnancy
Ideally, all women with suspected PID should be referred for same-day GUM assessment (if not being admitted) for full infection screening (including M. Genitalium) and contact tracing
Empirical antibiotics should be started as soon as possible but ideally, full STI screening should have been done before antibiotics started, however starting antibiotics is a priority and should not be delayed whilst awaiting an appointment/swab result
Outpatient therapy is effective for mild to moderate PID; regime options include:
IM ceftriaxone 500 mg stat followed by oral doxycycline 100 mg twice BD plus metronidazole 400mg BD for 14 days
Oral ofloxacin 400 mg BD plus oral metronidazole 400 mg BD for 14 days
Oral moxifloxacin 400 mg OD for 14 days (1st line for M. Genitalium PID)
Evidence for whether an IUD should be left in situ or removed in women presenting with PID is limited. In women with mild to moderate PID the IUD may be left in situ but a review should be performed after 48-72 hours and the IUD removed if significant clinical improvement has not occurred
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