PELVIC INFLAMMATORY DISEASE

Infection (usually ascending from the vagina) occurring in the uterus, ovary, or uterine tubes and leading to salpingitis, endometritis, pelvic peritonitis or formation of tubal ovarian abscess.

Risk factors

  • Previous pelvic inflammatory disease infections
  • Presence of bacterial vaginosis
  • Multiple or new sexual partners
  • History of STIs in the patient or her partner
  • History of abortion
  • Young age of less than 25 years
  • Postpartum endometritis

Causes

  • Often due to multiple pathogens: Neisseria gonorrhoea, Chlamydia trachomatis, Mycoplasma, Gardnerella,
    Bacteroids, Gram-negative bacilli, e.g. Escherichia coli

Clinical features

  • Pain in lower abdomen (usually <2 weeks) PLUS
  • Dysuria, fever
  • Vaginal discharge: could be smelly and mixed with pus
  • Painful sexual intercourse (dysperunia)
  • Cervical motion tenderness: vaginal examination will produce tenderness when the cervix is moved
  • Abnormal uterine bleeding

If severe

  • Swellings may be felt if there is pus in the tubes or pelvic abscess
  • Signs of peritonitis (rebound tenderness)

Complications of PID

  • Infertility
  • Ectopic pregnancy
  • Chronic pelvic pain

DO NOT TREAT CHRONIC PELVIC PAIN WITH ANTIBIOTICS

Differential diagnosis

  • Ectopic pregnancy, threated abortion
  • Ovulation pain
  • Acute appendicitis
  • Complicated or twisted ovarian cyst
  • Cancer of the cervix

Investigations

  • Speculum examination
  • Pregnancy test
  • Pus swab: For C&S
  • Ultrasound (if available) for detection of tubo ovarian
    masses , free fluid, peritonitis

Management

Treatment is based on a combination of medicines that cover the multiple microorganisms involved.

Outpatient treatment

  • Ceftriaxone 250 mg IM (or cefixime 400 mg stat if ceftriaxone is not available)
  • Plus doxycycline 100 mg orally every 12 hours for 14 days
  • Plus metronidazole 400 mg twice daily orally for 14 days
  • Treat sexual partners as for urethral discharge syndrome to avoid re-infection
  • In pregnancy, use erythromycin 500 mg every 6 hours for 14 days instead of doxycycline

If severe or not improving after 7 days

Refer for ultrasound scan and parenteral treatment

  • Ceftriaxone 1 g IV daily plus metronidazole 500 mg IV every 8 hours until clinical improvement,
    then continue oral regimen as above

Notes

  • All women with PID should be tested for HIV
  • Abstain from sex or use barrier methods during the course of treatment
  • Do not take alcohol when taking metronidazole
  • Avoid sex during menstrual period and for 6 weeks after an abortion
  • In IUD users with PID, the IUD need not be removed. However, if there is no clinical improvement within
    48–72 hours of initiating treatment, providers should consider removing the IUD and help patient choose an
    alternative contraceptive method.