Pelvic inflammatory disease

Adapted from BASHH UK national guideline for the management of PID (June 2011) and current practice in Sexual Health Department, Nithbank, Dumfries.

Features suggestive of PID

Lower abdominal pain, typically bilateral
Deep dyspareunia
Abnormal vaginal bleeding, including post coital, inter-menstrual and menorrhagia
Abnormal vaginal or cervical discharge
Adnexal tenderness/cervical motion tenderness
Fever ≥ 38°C

Consider admission in following:

Consider:

If sexually active, offer and encourage pregnancy test and STI testing including HIV (patients may initially fail to disclose sexual activity)
Consider emergency contraception
Triple swabs
- high vaginal for culture
- endocervical for culture (absence of pus cells has negative predictive value of 95% for PID)
- endocervical for chlamydia/gonorrhoea PCR testing
CRP, WCC, ESR may be elevated
Blood cultures If temperature ≥ 38°C
Laparoscopy (gold standard), although may not identify 15-30% PID

Delay increases risk of sequelae e.g., infertility, ectopic pregnancy and chronic pelvic pain
Outpatient treatment as effective as inpatient therapy for clinically mild-moderate PID
All recommended regimens are of similar efficacy, however, consider need for gonococcal cover and select regimen with cover (see ‘Treatment’ below). Higher risk of gonorrhoea in:
- young adults
- previous gonorrhoea
- known contact with gonorrhoea
- female with male partner who has sex with men
- sexual contact overseas
- severe symptoms
Continue IV antibiotics for 24 hours after clinical improvement then switch to oral
Avoid use of ofloxacin in women <16 years (risk of musculoskeletal damage)
Avoid ofloxacin in women positive for gonorrhoea due to increasing quinolone resistance
Follow up at 72 hours as well as 2-4 weeks to ensure adequate clinical improvement
For management of patients with IUCDs, see below

Complete total of 14 days of treatment for all regimens
The arrows indicate suggested IV to oral therapy 24 hours following clinical improvement – to complete total of 14 days treatment
Two alternative regimens given below as per BASHH guideline if first line unsuitable for any reason or unavailable. For IV to oral switch using these regimens please speak to microbiology

Current male partners of women with PID should be offered STI testing and where appropriate, treatment for chlamydia +/- gonorrhoea
Up to 75% cases PID not associated with chlamydia/gonorrhoea therefore partners who test negative should be offered broad spectrum empirical therapy (eg azithromycin 1g single dose)
Patients with PID and their male partners should be advised to avoid sexual intercourse until the female has completed the treatment course and if 1g single dose azithromycin is used to treat the partner then sexual activity should not resume for 7 days
Patients who test positive for gonorrhoea should all be discussed with Sexual Health who can assist in following up the patient as they will require a test of cure three weeks following treatment commencing

FSRH recommends against IUCD removal in cases of PID except in those with lack of clinical response within 72 hours – in these cases consider removal
Oral emergency contraception may need to be considered where IUC removed
Conception can occur in women having an IUS removed at any time if condom-less sex has occurred in the 7 days prior to removal
Conception can occur in women having an Cu-IUD if condom-less sex has occurred in the current menstrual cycle in the 7 days prior to removal unless the Cu-IUD is removed within the first three days of a cycle.

Last reviewed: 22/09/2022

Next review date: 22/09/2024

Reviewer name(s): Heather Currie.