Pelvic inflammatory disease (PID)

• Chlamydia trachomatis and Neisseria gonorrhoea can both be a cause of PID (Chlamydia is the commonest cause, estimated to be involved in 14 – 35% of cases).
• Gardnerella vaginalis, anaerobes (Prevotella, Atopobium and Leptotrichia) and other vaginal organisms (E Coli, Haemophilus influenza, streptococci, staphylococci) can be implicated in upper genital tract infections.
• Mycoplasma genitalium has been implicated as a cause of PID. Its full significance, particularly in relation to tubal factor infertility, is uncertain.
• Pathogen negative PID is common.
• The insertion of an IUD increases the risk of developing PID in the first 4-6 weeks after insertion.

Clinical symptoms and signs lack sensitivity for diagnosing PID (the PPV of clinical diagnosis is 65 – 90% compared to laparoscopy). The following symptoms are suggestive of PID:

• Low abdominal pain, usually bilateral.
• Abnormal vaginal or cervical discharge, often purulent.
• Deep dyspareunia.
• Abnormal vaginal bleeding, including post-coital bleeding (PCB), intermenstrual bleeding and menorrhagia.
• Dysmenorrhoea.

Examination (signs)

• Low abdominal tenderness, usually bilateral.
• Adnexal tenderness on bimanual vagina examination.
• Cervical motion tenderness on bimanual vaginal examination.
• Fever (> 38 C) in moderate to severe disease.

Differential diagnosis

• Ectopic pregnancy – pregnancy should be excluded in all women.
• Acute appendicitis – nausea and vomiting are more common in patients with appendicitis.
• Endometriosis – the frequency of symptoms often coincides with menstrual cycles.
• Ovarian cyst, rupture, or torsion – the symptoms are often of sudden onset.
• Urinary tract infection – often associated with urinary frequency and/or dysuria.
• Irritable bowel syndrome - disturbances in the bowel habit and often a long term history.
• Functional pain (of unknown aetiology) may be associated with longstanding symptoms.

Complications

• Tubo-ovarian abscess: to be considered in women who are systemically unwell, have a palpable pelvic or adnexal mass or have severe pelvic pain.
• Right upper quadrant pain (Fitz Hugh Curtis syndrome) is associated with perihepatitis (more common with C. trachomatis infections).
• PID is uncommon in pregnancy, but it is associated with maternal and foetal morbidity.
• Women with HIV may have more severe symptoms but respond well to standard treatments.
• PID is associated with long term complications such as ectopic pregnancy, infertility/subfertility, and chronic pelvic pain.

Diagnosis

• See investigations of pelvic pain.
• In addition, women with suspected PID should be offered a full STI screening, including serology for Syphilis and HIV.

Treatment should aim to cover the most common pathogens (Chlamydia and anaerobes) and the duration should be 14 days.

The use of Ceftriaxone IM should be considered in all women with moderate or severe presentations and those in whom the possibility of gonococcal PID is higher (ie, contacts of GC and/or microscopy is suggestive of GC).

An outpatient follow-up appointment 48 to 72 hours after starting treatment should be considered in those with moderate disease and admission considered if symptoms are not improving. In severe cases, the patient should be referred to Gynaecology at the Borders General for admission.

Patients should be advised to abstain from sexual intercourse until the treatment has been completed.

In women presenting with PID and an IUD in situ, the removal of the IUD should be considered but balanced against the risk of pregnancy (if sex < 7 days), the severity of disease and the alternative choices of contraception. In cases of moderate and severe disease, it is reasonable to re-assess the response to antibiotic therapy in 48-72hours and consider removal of IUD* if necessary.

*^{Consider sending the device for culture if removed.}

1. Outpatient therapy

For mild to moderate PID (no fever, systemically well)

• Doxycycline 100mg twice daily + metronidazole 400mg twice daily for 14 days

If doxycycline contraindicated:

• Ofloxacin 400mg twice daily
• Metronidazole 400mg twice daily 14 days

For moderate to severe PID or where there is a high risk of gonococcal infection

• Ceftriaxone 1g IM single dose followed by:
  
  • Doxycycline 100mg twice daily +
  • Metronidazole 400mg twice daily for 14 days

If doxycline contraindicated:

• Ceftriaxone 1g IM single dose followed by:
  
  • Ofloxacin 400mg twice daily +
  • Metronidazole 400mg twice daily 14 days

If severe beta-lactam reaction:

• Azithromycin 2g* orally followed by:
  
  • Doxycycline 100mg twice daily +
  • Metronidazole 400mg twice daily 14 days

*^{recommended with food to minimise nausea and vomiting}

Alternative treatment

• Ceftriaxone 1g IM + Azithromycin 1g orally/week x 2 weeks (Grade 2B)
• If M. Genitalium positive, moxifloxacin 400mg once daily for 14 days

2. Inpatient treatment for moderate to severe PID

In severe cases, when hospital admission is required, IV therapy is recommended. This should be continued until 24 hours after clinical improvement and then switched to oral treatment.

First line if able to tolerate oral medication

TOTAL DURATION: 14 days (total duration = IV + oral therapy)

• IV ceftriaxone 2g daily + oral doxycycline 100mg 12 hourly + oral metronidazole 400mg 12 hourly

Review ceftriaxone daily and STOP 24 hours after clinical improvement - single dose treatment acceptable

Second line treatment (severe penicillin allergy or oral route not available)

TOTAL DURATION: 14 days (total duration = IV + oral therapy)

• IV ofloxacin 400mg 12 hourly + IV metronidazole 500mg 8 hourly
  
  • IV to oral switch: oral ofloxacin 400 mg 12 hourly + Metronidazole 400mg 12 hourly

Allergy

Patients with known allergy should be treated with an alternative. There is no clear evidence of a clear superiority between one regimen and the other.

Follow up

• In 48-72 hours in moderate/ severe cases managed in BSH – reassess and consider admission if no improvement
• In 2-4 weeks’ time to assess clinical response, compliance with antibiotics, awareness of the significance of PID and its sequelae and to repeat the pregnancy test if indicated.
• If no improvement, test for Mycoplasma genitalium (see M gen protocol).
• Follow up by phone consultation is reasonable in mild to moderate disease.
• Patients managed at Gynaecology:
  
  • Contact the team at Borders Sexual Health for those discharged from hospital with no follow up arranged:
    
    • sexualhealth2@borders.scot.nhs.uk
      or
    • Phoning: 01896 663700/3703
  • OPD review is routinely arranged for patients with Tubo-ovarian abscesses or needing a surgical procedure.

Partner notification

• Current male partners should be offer testing for STI, including Chlamydia and Gonorrhoea, and treated empirically with Doxycycline 100mg twice daily for 7 days.
• In women with confirmed M. Genitalium infection, their partner should be offered testing and if positive, treated appropriately.

Guidance

United Kingdom National Guideline for the Management of Pelvic
Inflammatory Disease (2019 Interim Update)

2017 European guideline for the management of pelvic inflammatory disease

CDC basic patient fact sheet