Definition

PID is an inflammation of the pelvic organs. It is usually caused by an infection spreading from the vagina and cervix to the uterus (womb), fallopian tubes, ovaries and pelvic area.

If severe, it can cause an abscess (collection of pus) inside the pelvis.

Acute PID is the inflammation of the uterus, fallopian tubes, ovaries and pelvic area caused by an infection. If left untreated, it can cause abdominal pain and fertility problems in the future.

Sometimes the inflammation can persist for a long time and this is known as chronic PID (see the section ‘Are there any long-term effects.

Aetiology

Untreated sexually transmitted infections (STIs) such as chlamydia or gonorrhoea are the most likely causes of PID and account for one-quarter of the cases in the UK.

Mycoplasma genitalium (MGen) is emerging as a significant sexually transmitted pathogen.

Acute PID is more common in young sexually active women. PID may also be caused by a number of less common infections that may, or may not, be sexually transmitted.

Occasionally, PID can develop after events such as a miscarriage or termination of pregnancy, after having a baby or after a procedure such as the insertion of an intrauterine device (IUD) or coil.

Risk factors

Index case	Partner	Recent instrumentation of uterus
Age<25 years Early age of first coitus Past hx of STI BV	MultipleRecent new partner (within 3 months)Past hx of STI	TerminationIVF IUI IUCD insertion in previous 6 weeks HSG Postpartum endometritis

DD

Surgical	Gyn	Other
Acute appendicitisUTIIBS	Ectopic OvaryEndometriosis Cyst accidents	Functional pain

Diagnosis

Lower abdominal pain , fever, tender uterus, discharge in reproductive age

Complications

Fitz-hugh-curtis syndrome- perihepatitis
CPP
Infertility
Ectopic pregnancy

Hx,

Ill, Pain B/L, fever,discharge, dysperunia, HMB,IMB,PCB

Ex

Fever .38,B/L tender,Cervical excitation, uterine tenderness

Investigations

Confirm microbiology	DD exclusion	Complications
HVS for BV:bacterial vaginosis and candidiasis Test for chlamydia (VV swab)and Gonorrhoea ( HVS) CRPFBCESR	Preg/Ectopic-Urine hCGUTI-UFR and culture USS- ovarian cyst, cyst accidents, acute appendicitis	TVS and power Doppler-inflammed and dilated fallopian tubes, Tubo-ovarian abscess Laparoscopy -not justified on routine basis, intratubal inflammation and endometritis -lacks sensitivity

Management

General

MDT -local GenitoUrinary medicine clinics
Rest for ill
Appropriate analgesia
Avoid sexual intercourse (barrier contraception)till settle
STI screening and HIV testing
Contact tracing 6 months and treatment
Admit SOS

Criteria for admission

Suspected ectopic pregnancy/acute appendicitis
Clinically severe disease Fever >38C
Tubo-ovarian abscess
PID in pregnancy
Signs of pelvis peritonitis
Lack of response or intolerance to oral therapy

Specific

Medical–

antibiotics (Outpatient and inpatient)
keep low threshold for empirical antibiotics because lack of definitive diagnosis criteria and potential consequences ( SF,CPP,Ectopic )of not treating PID are significant (PEACH study)

Different regimes

Outpatient

Outpatient antibiotic treatment should be based on one of the following regimens:
● oral ofloxacin 400 mg twice daily plus oral metronidazole 400 mg twice daily for 14 days
● intramuscular ceftriaxone 250 mg single dose,* followed by oral doxycycline 100 mg twice daily plus
metronidazole 400 mg twice daily for 14 days.

Cefoxitin has a better evidence base for the treatment of PID than ceftriaxone but is not easily available in the UK.
Ceftriaxone is therefore recommended.

Inpatient

Inpatient antibiotic treatment should be based on intravenous therapy which should be continued until
24 hours after clinical improvement and followed by oral therapy.
Recommended regimens are:
● ceftriaxone 2 g by intravenous infusion daily plus intravenous doxycycline 100 mg twice daily,* followed by oral
doxycycline 100 mg twice daily plus oral metronidazole 400 mg twice daily for a total of 14 days

Oral doxycycline may be used if tolerated.
● intravenous clindamycin 900 mg three times daily plus intravenous gentamicin,* followed by either
● oral clindamycin 450 mg four times daily to complete 14 days
OR
● oral doxycycline 100 mg twice daily plus oral metronidazole 400 mg twice daily to complete 14 days.
Gentamicin should be given as a 2 mg/kg loading dose followed by 1.5 mg/kg three times daily [or a single
daily dose of 7 mg/kg may be substituted].
● intravenous ofloxacin 400 mg twice daily plus intravenous metronidazole 500 mg three times daily for 14 days.

A combination of cefotaxime, azithromycin and metronidazole for 14 days may be used.

The risks associated with metronidazole are uncertain but no confirmed associations with adverse outcomes have been reported.
Ofloxacin should be avoided,

Surgical

Read tubo-ovarian abscess note

Adhesiolysis in cases of peri-hepatitis -no evidence that it is superior to antibiotic therapy

Follow up

Review in 72 hours (moderate and severe presentation)
Assess compliance
Contraception-barrier and hormonal

Special situations

Pregnancy	IUD	HIV
Rare (septic abortion) High maternal and fetal morbidity Need IV antibiotics Safety- significant drug toxicity results in failed implantation Avoid tetracycline Refine once isolation of organism	Start antibiotics Assess response in 72 hours If poor, remove IUD (associated with better short term clinical outcome) : Use emergency hormonal contraception (if sex in previous 7 days)	More severe disease Respond well to standard antibiotics