[CG] Pelvic inflammatory disease, acute management

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Pelvic inflammatory disease (PID) results from ascending spread of infections from the endocervix to the upper genital tract causing infection and inflammation of endometrium, fallopian tubes, ovaries and pelvic peritoneum.

PID is a common cause of morbidity and delay in receiving appropriate treatment greatly increases the risk of sequelae such as infertility, ectopic pregnancy and chronic pelvic pain. PID is most commonly caused by sexually transmitted infections (STIs) such as Chlamydia trachomatis and Neisseria gonorrhoea. However organisms including Mycoplasma genitalium and anaerobes may be causal.

Women who have had recent instrumentation of the genital tract eg hysteroscopy, endometrial ablation, evacuation of uterus, termination of pregnancy, egg retrieval etc are at higher risk of ascending infection caused by organisms such as coliforms.

Clinical features suggestive of PID

  • Bilateral lower abdominal pain and tenderness
  • Abnormal cervical or vaginal discharge
  • Abnormal vaginal bleeding (intermenstrual, postcoital or breakthrough)
  • Deep dyspareunia
  • Nausea and vomiting
  • Fever
  • Lower abdominal tenderness with rebound
  • Cervical excitation
  • Adnexal tenderness (with or without palpable mass)
  • Mild PID: apyrexial, pain controlled by simple analgesia
  • Moderate PID: pyrexia <38ºC
  • Severe PID: pyrexia >38ºC, symptoms of acute abdomen eg tenderness with rebound or severe pain

Investigations

  • Urine pregnancy test – should be carried out in all cases of suspected PID to rule
    out ectopic pregnancy
  • Bimanual vaginal examination
  • Swabs –
    • Vulvovaginal NAAT (nucleic acid amplification test) swab in Chlamydia transport
      medium
    • High vaginal swab from lateral vaginal wall in charcoal medium
  • FBC (full blood count), CRP (C-reactive protein) – useful in monitoring response to treatment in moderate and severe PID
  • USS – helps to diagnose tubo-ovarian abscess and to rule out some of the differential diagnoses

Differential diagnosis

  • Ectopic pregnancy
  • Ovarian cyst accident
  • Endometriosis
  • Acute appendicitis
  • UTI (urinary tract infection)
  • IBS (irritable bowel syndrome)

Treatment

Antibiotic treatment should be commenced as soon as a diagnosis of PID is suspected because of the lack of definitive diagnostic criteria and because of the significant potential consequences of not treating PID.

Broad spectrum antibiotic therapy is required to cover Chlamydia, gonorrhoea and anaerobes. In mild or moderate PID outpatient treatment is as effective as inpatient treatment.

In the presence of symptoms suggestive of severe disease eg pyrexia >38°C, symptoms/ signs of an acute abdomen, presence of a pelvic mass) the patient should be admitted for treatment and monitoring.

Outpatient antibiotic regime:

The usual prescribing restrictions regarding pregnancy and breast feeding apply – consult the appropriate appendix in BNF.

1 gram ceftriaxone IM stat
Then
Oral doxycycline 100mg bd
Plus
Oral metrondizole 400mg bd for 14 days

If risk of pregnancy:
Oral erythromycin 500mg twice daily + oral metronidazole 400mg twice daily for 14 days

Patients treated as outpatients (particularly those with moderate PID) should be reviewed after 72 hours to ensure clinical improvement.

NB1: All patients - if pregnant, discuss with patient’s obstetrician the possibility of admission for parenteral therapy (e.g. iv ceftriaxone plus iv/oral erythromycin)
NB2: Avoid strong sunlight / sunbeds with doxycycline, discontinue if skin erythema. Warn re alcohol and metronidazole.
NB3: The evidence for whether an intrauterine contraceptive device should be left in situ or removed is limited. Removal of the IUD should be considered and may be associated with better short term outcomes. The decision to remove the IUD needs to be balanced against the risk of pregnancy in those who have had otherwise unprotected intercourse in the preceding 7 days.

Indications for hospital admission

  • Surgical emergency cannot be excluded
  • Clinically severe disease
  • Pyrexia
  • Lower abdominal tenderness with rebound
  • Tubo-ovarian abscess
  • PID in pregnancy
  • Lack of response to oral therapy
  • Intolerance to oral therapy
  • Pain not controlled by simple analgesia

Inpatient antibiotic regimen:

The usual prescribing restrictions regarding pregnancy and breastfeeding apply – consult the appropriate appendix in BNF.

2 grams IV ceftriaxone stat
Plus
IV/Oral antibiotic treatment to cover chlamydia as tolerated
(doxycycline 100mg bd + metronidazole 400 mg bd)
to complete 14 days

IV antibiotics should be continued until 24 hours after clinical improvement and followed by oral therapy. Total treatment is 14 days.

Appropriate analgesia should be provided. Consideration should also be given to the need for thromboprophylaxis including TED stockings, remembering that patients may be immobilised by pain.

Surgical treatment
This is a consultant decision. This should be considered in severe cases or where there is clear evidence of pelvic abscess. Pelvic abscess aspiration under ultrasound guidance may be considered as an option. Laparoscopic division of adhesions and drainage of pelvic abscess may help early resolution of disease.

Other aspects

PID with intrauterine contraceptive device (IUCD) in situ
Consider removal of IUCD if symptoms have not resolved with antibiotic treatment in 72 hours.

Women who are infected with HIV
These women should be treated with the same antibiotic regimen as women who are HIV negative.

Partner notification
PN in suspected PID is mandatory. Current sexual partner(s) should be contacted and offered screening and treatment for chlamydia and gonorrhoea. No sexual intercourse until both patient and partner(s) has completed antibiotics.
Please refer to /contact Sandyford Services Health Advisers on 0141 211 8634.

Contraception and PID
Women on hormonal contraception presenting with breakthrough bleeding should be screened for Chlamydia.
If a woman is likely to be at risk of future PID and requires an IUCD for contraception, the Levonorgestrel -IUS (Mirena ®) would be appropriate.

DISCUSS need for post-coital contraception

Appendix 1: How to reconstitute 1 gram ceftriaxone with lidocaine

To reduce the pain experienced by patients receiving intramuscular ceftriaxone the drug is administered with 1% lidocaine (lignocaine).

  1. Take 1G vial of ceftriaxone powder
  2. Draw up 3.5ml lidocaine 1% into a syringe.
  3. Reconstitute the 1G vial of ceftriaxone with 3.5ml of lidocaine 1%.
  4. Draw up the reconstituted ceftriaxone solution from the vial into one syringe. This makes a total of 4.1ml.
  5. Administer the 4.1ml solution of ceftriaxone 1gram by deep intramuscular injection. Well developed muscles eg ventrogluteal, vastus lateralis and dorsogluteal can take up to 5mls volume.

NOTE: Lidocaine must also be prescribed.

Last reviewed: 11 November 2020

Next review: 31 October 2023

Author(s): Dr Kay McAllister

Version: 3

Approved By: Dr R Jamieson, Clinical Director