PID - 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.
- Prompt treatment is essential to prevent long term sequelae.
- Up to 70% of cases have an unidentified cause
- STIs (e.g. Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium implicated)
- Vaginal facultative bacteria are a possible cause and other vaginal bacteria have also been implicated
- Disruption of the cervical epitheliumand facilitates change in cervicovaginal environment allowing vaginal bacteria to ascend to the upper genital tract.
|Lower pelvic pain||
Typically bilateral, may worsen with movement and may localise to one side. Pain described like period pain in character and distribution.
Pain may refer to upper right quadrant.
|Vaginal/cervical discharge||Intermenstrual, post-coital bleeding or Menorrhagia may occur|
|Vaginal bleeding||Intermenstrual, postcoital and menorrhagia|
|Fever, nausea, vomiting||Indicates severe infection. Absence of these symptoms does not exclude a diagnosis of PID.|
Diagnosis is clinical, and as severity can vary (from asymptomatic to severe), a low threshold of suspicion is necessary.
- Examination is important to make an accurate diagnosis.
- New onset of pelvic pain among women <25 years is highly predictive of PID (with exclusion of surgical emergencies).
- Rapid response to appropriate antibiotic treatment is highly predictive of PID.
- Risks include: recent partner change, partner with STI or symptoms of an STI, recent uterine instrumentation or pregnancy
- Exclude ectopic pregnancy and surgical emergencies e.g. appendicitis
- The presence of STI supports the diagnosis, but no organism is identified in 70% of cases.
|NAAT plus culture|
|M. genitalium||Endocervical swab||NAAT|
NAAT – Nucleic Acid Amplification Test
Clinician collected specimens is recommended. However self collection can be used if patient declines speculum and bimanual.
- All women of reproductive age with new onset abdominal pain should have the following investigations
- Urine pregnancy test and, if positive, urgent pelvic ultrasound
- Testing for STIs as indicated in diagnosis
- Urinalysis – the presence of nitrites or leucocytes plus prominent symptoms of dysuria and frequency makes UTI a possible differential diagnosis
- Bimanual examination is necessary to elicit cervical motion tenderness and adnexal or uterine tenderness. However, although a bimanual is ideal, the inability to perform a bimanual should not alter making a provisional diagnosis and commencing treatment. Positive predictive value of pain on bimanual is non-specific whereas the absence of pain has a high negative predictive value.
- Speculum examination allows for visualisation of the cervix. The presence of mucopurulent discharge supports the diagnosis of PID.
- Pelvic ultrasound is useful to detect alternative causes of pain, if the diagnosis is uncertain. In PID, the pelvic ultrasound may be normal or may show indicators of pelvic inflammation. Transvaginal ultrasound is preferred.
|Principal Treatment Options|
Mild to moderate:
Ceftriaxone 500mg in 2mL of 1% lignocaine IMI, or 500 mg IV, stat
|Ceftriaxone 2g IV, daily
Cefotaxime 2g IV, TDS
Azithromycin 500mg IV, daily
Metronidazole 500mg IV, BD
* If M.genitalium confirmed 2 weeks of Moxifloxacin 400mg daily for 14 days
- Begin treatment immediately with provisional diagnosis, without waiting for test results.
- For patients who may be non-adherent to doxycycline, consider replacing with azithromycin 1g PO, as a further single dose 1 week later.
- Remove intrauterine device (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 no response to outpatient medicine
- intolerance to oral therapy
Other immediate management
- Patient to avoid sexual intercourse for a week following treatment or until symptomatically better
- Rest and simple analgesia where required (non-steroidal anti-inflammatory medications, paracetamol)
- Prophylactic Candida infection treatment may be commenced
- Contact tracing
- Provide patient with factsheet.
Special treatment situations
- Current sexual partners should be treated to cover chlamydia (and gonorrhoea if likely) immediately, irrespective of test results.
- Where organism is isolated, refer to relevant STI guideline for contact tracing recommendations:
See Australasian Contact Tracing Manual - PID for more information
Follow up provides an opportunity to:
- Review at day 3 to assess response to treatment
- Further review at 1-2 weeks to ensure adequate clinical response to treatment, compliance testing and treatment of sexual contacts, repeat pregnancy test, if clinically indicated
For test of cure (TOC) and retesting advice see:
100% of people diagnosed with PID have had investigations for gonorrhoea and chlamydia.