Pelvic inflammatory disease (PID) guideline (G121)

• PID is an ascending infection from the endocervix which can cause endometritis, salpingitis, parametritis, oophoritis, tubo-ovarian abscess and/or pelvic peritonitis.
• Can be caused by chlamydia and gonorrhea (25% of cases in the UK), but other organisms such as Gardnerella Vaginalis, Prevotella , Atopobium, Leptotrichia, and Mycoplasma Genitalium have been implicated. 

Image reproduced from RCOG Acute pelvic inflammatory disease (PID): tests and treatment patient information leaflet, November 2016.

Symptoms

• lower abdominal pain (typically bilateral)
• deep dyspareunia
• intermenstrual bleeding, post coital bleeding, menorrhagia
• purulent vaginal or cervical discharge.

Signs

• lower abdominal tenderness
• adnexal tenderness
• cervical excitation on bimanual examination
• temp of 38^∘C or above.

Have you considered the differentials?

• ectopic pregnancy
• acute appendicitis
• endometritis
• ovarian cyst accident
• urinary tract infection
• functional pain
• irritable bowel syndrome (IBS).

 Is there an intrauterine contraceptive device (IUCD) in situ?

Evidence is limited but removal should be considered as may result in better short-term outcomes. Balance this against risk of pregnancy if patient had unprotected sexual intercourse in the previous 7 days. Emergency contraception may be used.

• full blood count /CRP/ liver and renal function tests
• urine analysis
• high/low vaginal swab and endocervical swab
• vulvovaginal nucleic acid amplification test (NAAT) for chlamydia/gonococcus
• pregnancy test
• consider pelvic ultrasound (preferably transvaginal)
• screen for sexually transmitted infections including HIV and syphilis serology
• CT scan only if tubo-ovarian abscess is suspected or to rule out other causes.

• advise patient to avoid intercourse until they and their partner have completed treatment and follow up
• screen all sexual contracts within a 6 month period
• advise condom use
• offer broad-spectrum antibiotic to male partners
• refer to NES Antimicrobial Companion

Analgesia and antibiotics.

Refer to NES Antimicrobial Companion

Consider if:

1. surgical emergency cannot be excluded
2. lack of response to oral therapy
3. clinically severe disease (e.g. pyrexia =/> to 38^∘ C)
4. presence of tubo-ovarian abscess
5. intolerance to oral therapy
6. pregnancy

Refer to NES Antimicrobial Companion

• It is associated with an increase in both maternal and fetal morbidity, therefore parenteral therapy is advised.
• Note: discuss safety profile of drugs with patient.

• Laparoscopy may help by dividing adhesions or draining pelvic abscesses. This may improve antibiotic penetration to infective tissues.
• One may also consider ultrasound-guided drainage of pelvic fluid collections.
• Adhesiolysis in peri-hepatitis is possible – but there is no evidence if this is superior to only antibiotic therapy.

• If no improvement in signs and symptoms within 48 hours:

Consider further investigations, intravenous therapy (if already on iv, discuss with microbiology if change in antibiotics regimen required) and/or surgical management.

• Do a further review under named gynaecology consultant, if attended gynaecology acute admission. This is to:
  • assess response to treatment
  • check compliance
  • ensure partner notification has been undertaken, and take/arrange further syphilis and HIV tests if presentation was during the window periods
  • ensure patients aware of PID sequelae like chronic pain, infertility, ectopic pregnancy
  • to do a pregnancy test if required
  • repeat tests for chlamydia and gonorrhea if baseline tests were negative and symptoms persist
  • discuss, if necessary, to refer on to sexual health.