Introduction

Pelvic inflammatory disease is an inflammatory condition (often secondary to infection), affecting any part of the higher female reproductive system, e.g.; uterus, fallopian tubes, ovaries.

  • Salpingitis – this term is sometimes used interchangeably with PID, but technically only refers to inflammation in the fallopian tubes.
  • Endometritis – inflammation of the endometrium
PID typically results from an ascending infection from the cervix, and most commonly is a result of the sexually transmitted infections chlamydia, or less so, gonorrhoea.
PID can cause irreversible damage to the strict of the female reproductive system, and untreated, can result in infertility, ectopic pregnancy, chronic pain, and pelvic abscess.

Epidemiology

  • Exact incidence is uncertain
    • Often asymptomatic
    • Under-diagnosed
  • Incidence reported as 280 per 100 000 per year
  • Most commonly affects women aged 20-29

Aetiology

STD

  • Young age (16-24)
  • Multiple sexual partners
  • Chlamydia / gonorrhoea
    • 90% of pelvic inflammatory disease cases are sexually acquired
    • Mostly due to chlamydia
    • Chlamydial infection is often less severe clinically than gonorrhoea. Gonorrhoea tends to cause more of an acute infection
    • 60% of chlamydia cases are asymptomatic
    • 10% of cases occur after childbirth, particularly if forceps are used.
  • IUD insertion
  • Previous pelvic inflammatory disease
  • Termination of pregnancy
  • Bacterial vaginosis
Every patient having an IUD should be screened for infection before insertion to reduce the risk of PID – as the IUD can introduce the infection from the lower tract to the upper tract
Other organisms associated with PID include those that commonly cause bacterial vaginosis, such as Gardnerella, mycoplasma and other other anaerobes. In these cases, there are often multiple organisms involved.

Presentation

Abdominal pain

  • Usually lower region
  • Can be bilateral or unilateral
  • If pain is severe, may be associated with nausea and vomiting. If nausea and vomiting are present, this suggests peritonitis.
  • Dyspareunia (pain on sexual intercourse)

Cervical / vaginal discharge

  • Often foul smelling

Irregular vaginal bleeding

  • Heavy blood loss suggests endometritis

Fever (About 1/3 of patients)
Cervicitis

  • The cervix will appear red and will bleed easily

OFTEN ASYMPTOMATIC!

Differential diagnosis

  • Appendicitis
  • Ectopic pregnancy

Investigations

Pregnancy test

Swabs

  • Chlamydia – endocervical swab
  • Gonorrhoea – endocervical swab

Bloods

  • FBC
  • CRP

Ultrasound

  • May be useful to help exclude differentials, but unless there is abscess formation, it is usually not able to recognise PID

Laparoscopy – if suspected complication that can be treated surgically

  • Also consider in patients who do not respond very quickly to antibiotic treatment – abscess may be present that needs draining.

Examination

  • Cervical excitation
  • Tendernes / peritonism
  • Tenderness at the fornices

Diagnosis

  • Should be suspected in any woman with lower abdo pain and unusual cervical / vaginal discharge
  • Should be consider in any woman with unexplained irregular bleeding

Complications

  • Abscess formation – occurs in up to 15% of patients. May cause severe pain and peritonitis. May rupture.
  • Infertility
  • Chronic pelvic pain
  • Ectopic pregnancy
  • Fitz-Hugh-Curtis Syndrome – inflammation of the liver capsule, secondary to PID
  • Chronic salpingitis – chronic infection of the fallopian tubes. Can cause fibrosis and adhesions. May occur if PID not treated prompty.

Treatment

Antibiotics

  • Take swabs first – but don’t delay treatment whilst awaiting results
    • Negative swab does NOT rule out PID
  • Some patients may be suitable for oral antibiotics and outpatient treatment
    • Check local antibiotics guidelines
    • Typical regimen might be single IM dose of ceftriaxone with 14 days doxycyline + metronidazole
  • If very unwell (i.e. abnormal vital signs, fevers, any evidence of peritonitis), may have to admit for IV (usually ceftriaxone), and then also subsequently treated with oral doxycycline and metronidazole for 14 days

Contact tracing – as per STI
Advice

  • Avoid intercourse until patient and partner have been successfully treated
  • Contact tracing should be attempted for all partners within the las 6 months (ideally via sexual health (GUM) clinic)
    • Partners should be treated for chlamydia even if their own testing is negative
    • Treat partner for gonorrhoea on the same basis – but only if the index case has been identified as being caused by gonorrhoea

Prevention

  • Safe sex advice – particularly use of barrier forms of contraception
  • Current UK guidelines recommend all sexually active men and women under the age of 25 be screened annually and on every change of partner for chlamydia

References

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