Pelvic inflammatory disease

Question 1

Define PID.

Answer 1

Pelvic inflammatory disease (PID) is a term used to describe infection and inflammation of the female pelvic organs, including any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis.

Question 2

How common is PID?

Answer 2

~30% of women in the UK have experienced an episode of PID

Peaks in those aged 20-24yrs

Question 3

What is the aetiology of PID?

Answer 3

It is usually the result of ascending infection from the endocervix.

Chlamydia trichomatis is the most commo cause of PID (causing around a third of all infections)

Question 4

What are the most common causative organisms of PID?

Answer 4

• Chlamydia trachomatis
• Neisseria gonorrhoeae
• Mycoplasma genitalium
• Mycoplasma hominis

STIs especially N. gonorrhoeae and C. trachomatis, are common; however, micro-organisms of the vaginal flora (e.g., anaerobes, Gardnerella vaginalis, Haemophilus influenzae, enteric gram-negative rods, and Streptococcus agalactiae) have also been associated with PID.

Question 5

What is the pathophysiology of PID?

Answer 5

• Infection, if untreated in the cervix, ascends to upper genital tract
• Epithelial damage by initial organisms may allow opportunistic entry of other micro-organisms
• Spread may also be caused by iatrogenic dilation and curettage, TOP or IUD insertion.
• Infection is caused by disruption of the protective cervical barrier and direction introduction of bacteria into the endometrial cavity from vagina or cervix

Question 6

What are the risk factors for PID?

Answer 6

• Prior chlamydia or gonorrhoea infection - most significant RF for PID
• Young age at onset of sexual activity
• Unprotected sexual intercourse with multiple partners
• PID history
• IUD use - first 3 weeks after insertion
• Vaginal douching - disrupts mucus barrier
• Smoking

Question 7

What are the symptoms of PID?

Answer 7

• lower abdominal pain - bilateral
• fever
• deep dyspareunia
• dysuria and menstrual irregularities (PCB, IMB, HMB) may occur
• vaginal or cervical discharge
• cervical excitation

Question 8

What are the findings on examination in PID?

Answer 8

• Fever
• Abdominal tenderness on light and deep palpation
• Vaginal discharge
• Speculum examination - mucopurulent or purulent exudate
• Bimanual examination - cervical motion tenderness, uterine tenderness, adnexal tenderness

Question 9

What investigations should be done for PID?

Answer 9

• Pregnancy test should be done to exclude an ectopic pregnancy
• High vaginal swab - often negative, PMNC on wet mount vaginal secretions confirm vaginal infection
• Screen for Chlamydia and Gonorrhoea - but does not exclude presence of other infections
• Bloods - high WCC, raised CRP, raised ESR but only often in mod-severe PID.

Consider:

TVUSS - if diagnosis is uncertain. May see tubal wall thickness >5 mm, incomplete septae within the tube, fluid in the cul-de-sac, and a cog-wheel appearance on the cross-section of the tubal view; may also see tubo-ovarian abscess

CT/MRI - may show subtle changes, thickened uterosacral ligaments, inflammatory changes of the tubes and ovaries, abnormal fluid collection; in progressive disease, reactive inflammation of surrounding pelvic and abdominal structures may be seen

Question 10

What is the management of PID?

Answer 10

Due to the difficulty in making an accurate diagnosis, and the potential complications of untreated PID, consensus guidelines recommend having a low threshold for treatment

• Oral levofloxacin 500mg OD 2 weeks + oral metronidazole 500mg BD 2 weeks
• OR IM ceftriaxone 500mg once + oral doxycycline 100mg BD 2 weeks + oral metronidazole 500mg BD 2 weeks

Consider removal of IUD

Treat contacts

If cultures positive then treat based on sensitivity.

Question 11

Should IUS/IUD be removed in PID?

Answer 11

RCOG guidelines suggest that in mild cases of PID intrauterine contraceptive devices may be left in.

The more recent BASHH guidelines suggest that the evidence is limited but that ‘ Removal of the IUD should be considered and may be associated with better short term clinical outcomes’

Question 12

What are the complications of PID?

Answer 12

• Perihepatitis (Fitz-Hugh Curtis Syndrome) - occurs in around 10% of cases; characterised by RUQ pain and may be confused with cholecystitis
• Infertility - the risk may be as high as 10-20% after a single episode with tubal damage
• Chronic pelvic pain
• Ectopic pregnancy
• Tubo-ovarian abscess

Question 13

What is the prognosis with PID?

Answer 13

Recovery is good for those who present within 3 days of symptom onset and who are able to complete the full course of therapy.