Pelvic Inflammatory Disease

Question 1

Define pelvic inflammatory disease

Answer 1

Infection of the upper genital tract
Infection spreads upwards from the endocervix to cause endometritis, salpingitis, parametritis, oophoritis, tubo-ovarian abscess or pelvic peritonitis

Question 2

Define chronic pelvic inflammatory disease

Answer 2

> 6 months (due to scarring -> constant pain, worsening when moving in certain directions, not linked with periods)

Question 3

What are the causes of pelvic inflammatory disease

Answer 3

The infection usually begins in the cervix and if untreated, it may ascend to the upper genital tract.

Chlamydia trachomatis (14-35%)
Neisseria gonorrhoea (2-3%)
Mycoplasma genitalium
Organisms of the normal vaginal flora: Gardnerella vaginalis, haemophilus influenzae, streptococcus agalactiae)
Pathogen-negative PID

Question 4

What are the risk factors of pelvic inflammatory disease

Answer 4

Age <25
Early age of first coitus
Multiple sexual partners
Recent new partner
History of STI in the woman or her partner
Termination of pregnancy
Insertion of IUD (especially in women with pre-existing infection)
Hysterosalpingography
Dilation and curettage
IVF

Question 5

What are the symptoms of pelvic inflammatory disease

Answer 5

Lower abdominal pain
- Usually bilateral but may be unilateral
- Gradual onset
- Cramping
- Can radiate to the back and vagina
Deep dyspareunia
Abnormal vaginal bleeding (Intermenstrual, postcoital, breakthrough) or discharge
Fever
RUQ pain (Fitz-Hugh-Curtis syndrome)
Secondary dysmenorrhoea
Nausea and vomiting

Question 6

What are the differentials for pelvic inflammatory disease

Answer 6

Ectopic pregnancy
Threatened abortion
Rupture corpus luteal cyst
Acute appendicits
Endometriosis
Irritable bowel syndrome
Diverticular disease
Rupture/torsion/haemorrhage of ovarian cyst
UTI

Question 7

What are the signs of pelvic inflammatory disease on examination

Answer 7

General obs: temp >38

Abdominal exam
- Lower abdominal tenderness, usually bilateral

Pelvic exam
- Adnexal tenderness
- Cervical motion tenderness
- Uterine tenderness
- Abnormal cervical or vaginal mucopurulent discharge on speculum

Question 8

What investigations should be done for pelvic inflammatory disease

Answer 8

Do NOT delay treatment waiting for results

bedside:
- Endocervical swab for NAAT (Chlamydia, gonorrhoea)
- Pregnancy test
- High vaginal swab (BV, TV, cand.)
- Wet-mount vaginal smear: pus cells (if absent, PID unlikely)

Bloods
CRP/ESR: raised
FBC: leucocytes raised
LFTs, HIV serology, syphilis serology

Other
USS: abscess of hydrosalpinx identification
MRI/CT

Question 9

What is the management for pelvic inflammatory disease

Answer 9

Refer to GUM clinic

1. Analgesia e.g. ibuprofen, paracetamol
2. Empirical antibiotics
   - Ceftriaxone IM single dose
   - Oral doxycycline 2x daily + oral metronidazole 2x daily for 14 days
3. Partner tracing (6 months)
4. Sexual abstinence/barrier methods until both woman and her partner(s) have complete the treatment
5. Screen for other STIs

+ follow up within 72 hours of treatment completion
+ follow up in 2-4 weeks to check compliance and partner notification
± removal of IUD if symptoms have not resolved within 72 hours

Question 10

What features necessitate admission for pelvic inflammatory disease

Answer 10

Ectopic pregnancy cannot be ruled out or confirmed
Symptoms and signs are severe e.g. N&V, fever >38
Surgical emergency cannot be ruled out
Signs of pelvic peritonitis
Tubo-ovarian abscess is suspected
Woman is unable to tolerate outpatient treatment

Question 11

What is the management for pelvic inflammatory disease in secondary care

Answer 11

IV ceftriaxone (2g) + IV doxycycline (100mg BD)
Followed by:
PO doxycycline (100mg BD) + metronidazole(400mg BD) for 14 days (PO is given 24 hours after clinical improvement with IV)

± laparoscopy (abscess drainage, separation of adhesions, adhesiolysis for perihepatitis)

Question 12

What are the complications of pelvic inflammatory disease

Answer 12

Early: peritonitis, intestinal obstruction (Adhesions), sepsis, tubal blockage, hydrosalpinx, tubo-ovarian abscess
Tubal infertility (may be as high as 10-20%)
Ectopic pregnancy
Chronic pelvic pain
Tubo-ovarian abscess
Fitz-Hugh-Curtis syndrome (RUQ pain with per-hepatitis) - occurs in around 10% of cases

Note: fertility NOT impaired if compliant with medication

Question 13

What is the prognosis for pelvic inflammatory disease

Answer 13

Good in patients treated within 3 days of symptom onset and who are able to complete the full course of therapy
Cure rates of 88-100% have been reported after abx treatment
Risk of tubal occlusion and infertility depend on severity of infection before treatment
Clinical improvement may not translate into improved fertility