ACEM Fellowship
Pelvic inflammatory disease

Pelvic inflammatory disease

Definition

• Collection of upper genital tract infections in women

• Comprises salpingitis, endometritis, myometritis, parametritis,

oophoritis, tubo-ovarian abscess, peritonitis and perihepatitis

• Most common serious infection in women aged 16-25

• Most common gynaecological cause of ED presentations

• Often present with non-specific complaints

Organisms

• C. trachomatis and N. gonorrhoea instrumental in initial infectious process with

polymicrobial infections arising as inflammation increases and abscesses form

• Mixed infection in 30-40% of cases

• STI: Chlamydia, Gonorrhoea, Trichomoniasis, HSV

• Other:

• Endogenous mycoplasma: M. genitalium, Ureaplasma urealyticum, M. hominis

• Anaerobes: Bacteroides, Peptostreptococcus

• Aerobes: Gardnerella vaginalis, H. influenzae, S. agalactiae, E. coli

• 10-20% of untreated gonorrhoea or chlamydia will progress to PID

• Bilateral tubal ligation does NOT provide protection but patients have less

severe or delayed disease in most cases

Risk factors

• Multiple sexual partners

• Hx of STI or PID

• Hx of sexual abuse

• Frequent vaginal douching

• IUD within previous month

• Overall 10/1000 insertions, with greatest risk in first 20 days

• Adolescence, young adults

Complications

• Tubo-ovarian abscess in 1/3 of women hospitalised for PID

• Rate of ectopic pregnancy 12-15% higher if previous PID

• Tubal factor infertility rises with each episode

• 12-50% incidence

• 50% of women with tubal factor infertility have no hx of PID but have

scarring consistent with this (silent PID)

• Chronic pelvic pain 18%

• Menstrual disturbances

• Dyspareunia

History

• Lower abdominal pain (>90% of cases)

• Abnormal vaginal discharge (75% of cases)

• Vaginal and postcoital bleeding (30% of cases)

• Irritative voiding symptoms

• Fever, malaise, nausea, vomiting

• Need full obs/gyn history in all cases

Examination

• Lower abdominal tenderness, cervical motion tenderness, adnexal or uterine

tenderness

• May have associated peritonitis

• Adnexal tenderness is the most sensitive finding (95%)

• Mucopurulent cervicitis is common and absence should raise suspicion of an

alternative diagnosis

• Fever, adnexal tenderness and elevated ESR are all independent predictors of

endometritis

• RUQ tenderness, esp. with jaundice, may indicate Fitz-Hugh-Curtis syndrome

• Seen in 4% of mild-moderate PID

• May not have any PID symptoms/signs

• Normal LFT

• USS useless and needs CT or laparoscopy for diagnosis

Differential

• Adnexal torsion

• Ectopic pregnancy

• Cervicitis

• Endometriosis

• Ovarian cyst +- rupture

• Spontaneous abortion

• Septic abortion

• Cholecystitis

• Appendicitis

• Diverticulitis

• Pyelonephritis

• Renal colic

Investigations

• CT with contrast if appendicitis cannot be ruled out

• Pregnancy test

• Endocervical and high vaginal swabs

• Raised WCC, ESR or CRP support diagnosis

• Urinalysis to exclude UTI

• Blood cultures are NOT helpful unless septic

• Urine PCR for STI

• 95% sensitive for C. trachomatis (vs. 80% for swabs)

• 92% sensitivity for Gonorrhoea (vs. 97% for swabs)

• Endocervical swab for STI

• Adds diagnostic utility only if purulent discharge for Gonorrhoea

Transvaginal USS

• Findings

• May demonstrate thickened (>5mm), fluid-filled fallopian tubes

• Free pelvic fluid

• Not specific enough for definitive diagnosis

• Tubo-ovarian abscess may appear as a complex adnexal masses with

multiple internal echoes

• May also help rule out ovarian torsion, haemorrhagic ovarian cyst,

appendicitis and endometriosis

Abdominopelvic CT/MRI

• May show

• Obscuration of pelvic fascial planes

• Cervicitis

• Oophoritis

• Salpingitis

• Thickening of uterosacral ligaments

• Simple or complex pelvic fluid or abscess collections

• Can help rule out adnexal torsion if USS has shown normal ovarian

anatomy

Laparoscopy

• Gold standard for diagnosis

• Most sensitive and specific than clinical criteria

• Can obtain material for definitive culture without vaginal contamination

• Fails to identify PID in 20% still as can only see surface of organs and as

such may not appreciate full extent of disease/miss diagnosis

Diagnosis (CDC)

• Group 1: Minimum criteria

• Uterine or adnexal tenderness

• Cervical motion tenderness

• Group 2: Additional criteria to improve diagnostic accuracy

• Oral temp >38.3

• Abnormal cervical mucopurulent secretions

• Elevated ESR or CRP

• Lab evidence of N. gonorrhoea or C. trachomatis

• Group 3: Specific criteria for PID based on procedures that may be suitable for

patients

• Laparoscopic confirmation

• TVUSS (or MRI) showing thickened, fluid-filled tubes with/without pelvic free fluid or tuboovarian

abscess

• Endometrial biopsy showing endometritis

Treatment

• Recommended to maintain low threshold for aggressive therapy as crucial to treat

early in maintaining fertility, preventing transmission and improving symptoms

• Long-term outcomes are improved by early empirical treatment

• Large trial showed no difference between oral and parenteral treatment regimes

• CDC guidelines

• Empiric treatment recommended for women at risk who exhibit lower abdominal pain,

adnexal tenderness and cervical motion tenderness (as per groups above)

• Antibiotics (See next) + Analgesia, antipyretics, antiemetics

• Remain abstinent or adhere strictly to condom use, until symptoms have abated and

entire antibiotic regime complete

• Contact tracing for positive results

Treatment (Dunn)

Sexually acquired

• Mild/moderate – Azithromycin 1g PO stat + Metronidazole 400mg BD for 14 days + Ceftriaxone 250mg IM/IV stat + repeat Azithromycin in one week or give doxycycline course 100mg BD for 14 days (poor compliance)

• Severe – Ceftriaxone 2g IV daily + Metronidazole 500mg IV BD + Azithromycin 500mg IV daily with ultimate 2 week course

Non-sexually acquired

• Mild/moderate – Augmentin 875/125 BD + Doxycycline 100mg BD for 14 days

• Severe – Amp/Gent/Metronidazole

Treatment

• Mild-moderate sexually acquired PID – Azithromycin 1g PO stat then repeat in 7 days, Metronidazole 400mg PO q12h for 14 days, Ceftriaxone 500mg IM or IV as single dose if gonorrhoea suspected

• Mild-moderate non-sexually acquired PID – Augmentin q12h for 14 days, Azithromycin 1g PO stat and repeat in 7 days

• Severe sexually acquired PID – Ceftriaxone 2g daily IV + Azithromycin 500mg IV daily + Metronidazole 500mg IV q12h

• Admit and treat as severe if HIV + irrespective of CD4+ count

• Studies have shown poor compliance with doxycycline therapy (alternative regimes to above), 20-25% of patients never fill their

script

• Can change to oral therapy after 24 hours if improvement and total course of 14 days

• Re-evaluate at 72 hours for clinical improvement if discharged home

• Single dose azithromycin effective for lower tract STI but NOT upper tract

Tubo-ovarian abscess

• Disproportionate unilateral adnexal tenderness or adnexal mass/

fullness may indicate tubo-ovarian abscess

• 60-80% resolve with antibiotics alone

• If this fails, laparoscopy may be useful for identifying potentially

drainable abscess or demonstrate alternative pathology

Who gets admitted?

• Parenteral regimes if severe and HITH not available

• Severe symptoms

• Low likelihood of adherence to outpatient regime

• High likelihood of major anaerobic infection (IUD, suspected abscess or recent

instrumentation)

• Uncertainty of diagnosis

• Coexisting illness

• Immunosuppressed

• Pregnant

• Major fertility issues

Contact tracing

• All sexual partners of the last 60 days require treatment empirically for

both Chlamydia and Gonorrhoea

Last Updated on September 27, 2021 by Andrew Crofton