Pelvic Inflammatory Disease

Background

Pelvic inflammatory disease (PID) is defined as the clinical syndrome associated with ascending spread of micro-organisms from the vagina or cervix to the endometrium, Fallopian tubes, and/or contiguous structures. PID might include endometritis, parametritis, salpingitis, oophoritis, pelvic peritonitis, and pelvic (tubal, tubo-ovarian) abscess.

PID can occur throughout reproductive life. It may be acute or chronic.

Epidemiology

PID is caused by two major groups of organisms:

1. Sexually transmitted infections (Chlamydia trachomatis and Neisseria gonorrhoea)
   and
2. Organisms belonging to the endogenous flora of the lower genital tract

C. trachomatis is the most important identifiable pathogen and is responsible for up to 60% of PID in northern European countries. Prevalence rates of C. trachomatis in the community are between 1-8%. Isolation of C. trachomatis from the lower genital tract is significantly associated with age (under 25), oral contraception and recent change of sexual partner. Approximately 10% of women infected with chlamydia develop PID.

Diagnosis

The diagnosis of PID made on clinical grounds alone is only 65% accurate. However, it is accepted good clinical practice to err on the side of over-diagnosing and over-treating milder cases in view of the long-term complications associated with PID.

Management should be tailored to the individual needs of each patient. When a diagnosis of PID is made, however doubtful the clinician is, he/she should always advise that the sexual partner is also treated even if they are asymptomatic, as 50% of male partners of women with PID have been shown to have a urethritis.

The minimum clinical criteria that are needed for the diagnosis of PID are:

1. Lower abdominal or pelvic pain
2. Cervical excitation, and pain and tenderness on pelvic examination

(Other signs & symptoms that increase the specificity of the diagnosis are: Pyrexia, palpable adnexal mass, irregular bleeding, purulent cervicitis, dyspareunia, pain/discomfort in the right upper abdominal quadrant.)

Complications

Following one episode of PID there is:

• 13% reduction in fertility (this doubles with each episode)
• 7-10 fold increased risk of an ectopic pregnancy
• 25% chance of a recurrence
• 20% chance of chronic pelvic pain/dyspareunia

Management

Counselling

Discussion about the lack of specificity of the diagnosis whilst emphasising that PID is not an indicator of infidelity by their partner.

Investigations

A. Triple swabs should be taken: cervical and urethral samples must be taken for the detection of N. gonorrhoea and C. trachomatis. Different clinics may have different detection methods for chlamydia available to them. (Your local microbiology laboratory or the Department of Public Health at wyz
B. Additional tests to be used at the discretion of the physician to increase specificity:

• FBC & C reactive protein
• TV ultrasound if clinically indicated
• Pregnancy test
• MSU
• Chlamydia antibody titres

C. Routine observations: Pulse / BP / Temperature

Hospitalisation is recommended if:

• Uncertain diagnosis in a sick patient
• Surgical emergencies need to be excluded
• Pelvic abscess suspected
• Severe illness
• Pregnancy
• Patient unable to follow outpatient regime
• Failure to respond to outpatient therapy
• Clinical follow-up can not be guaranteed

Recommended Treatment

If an IUD is in situ, it should be removed after treatment has been established. However, consideration must be given to the contraceptive needs of that patient.

If it is decided to manage the patient as an outpatient, the antibiotic cover should be aimed at a polymicrobial infection; two antibiotics offer a broader cover, one of these should be active against Chlamydia trachomatis.

A single dose therapy for uncomplicated gonorrhoea. Some doctors may choose to omit this treatment until they have the results of the swabs.

1. Ciprofloxacin 500mg stat (OR Amoxicillin 3G stat and Probenecid 1G stat.) PLUS
2. Doxycycline 100mg twice daily for two weeks (OR Ofloxacin 400mg bd for two weeks)
   • Erythromycin 500mg qds for two weeks can be substituted for Doxycycline or Tetracycline where it is inappropriate to prescribe these drugs (pregnancy lactation, allergy, intolerance) PLUS
3. Metronidazole 400mg bd for up to 14 days

Alternative regimens are listed in the US CDC and Prevention Sexually Transmitted Diseases Treatment Guidelines

Follow-up

The patient should be seen at 3 days to ensure satisfactory response to treatment, and then after completion of treatment.

The sexual partners should be advised to attend the Department of Genitourinary Medicine.

Sexual intercourse must be avoided until the partner has been seen and treated.