Pelvic Inflammatory Disease (PID)

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This denotes a spectrum of conditions resulting from infection (usually ascending from the vagina) occurring in the uterus, ovary, and fallopian tubes leading to salpingitis, endometritis, pelvic peritonitis or the formation of tubal ovarian abscess.

Risk factors

  • Age: peak incidence between 15-25 years
  • Multiple sex partners
  • Use of intrauterine contraceptives
  • Previous episode of PID
  • History of STIs in the patient or her partner
  • History of abortion
  • Postpartum endometritis
  • Presence of bacterial vaginosis
  • Unprotected sex

Causes

Often due to multiple pathogens:

  • Neisseria gonorrhoea
  • Chlamydia trachomatis
  • Mycoplasma
  • Gardnerella
  • Bacteroides
  • Gram-negative bacilli, e.g. Escherichia coli

Signs and symptoms

  • Pain in lower abdomen (usually <2 weeks) with dysuria and fever
  • Vaginal discharge: could be offensive and mixed with pus
  • Painful sexual intercourse (dyspareunia)
  • Cervical motion tenderness: vaginal examination will produce tenderness when the cervix is moved and abnormal uterine bleeding
  • Vaginal itching

If severe

  • Swellings may be palpable if there is pus in the tubes or pelvic abscess
  • Signs of peritonitis (rebound tenderness)

Differential diagnosis

  • Ectopic pregnancy threatened abortion
  • Ovulation pain
  • Acute appendicitis
  • Complicated or twisted ovarian cyst
  • Cancer of the cervix
  • Endometriosis
  • Urinary tract infections
  • Renal disorders (e.g. nephrolithiasis)
  • Pelvic adhesions
  • Lower lobe pneumonia

Complications

  • Infertility
  • Ectopic pregnancy
  • Chronic pelvic pain
  • Pelvic abscess
  • Septicaemia
  • Recurrence (about 25%)

Investigations

  • Speculum examination
  • Pregnancy test
  • Cervical and high vaginal swabs: for microscopy, culture and sensitivity
  • Ultrasound (if available) for detection of tubo-ovarian masses, free fluid, peritonitis
  • Full blood count
  • Electrolytes and Urea
  • Blood culture, if complicated with sepsis
  • Urinalysis

Treatment objectives

  • Eradicate the infecting organism(s)
  • Achieve adequate hydration
  • Prevent complications

Pharmacological treatment

Outpatient treatment

Ceftriaxone 500 mg IM STAT

PLUS

Clotrimazole 500mg pessaries OR Nystatin pessaries 500mg

Doxycycline oral

100 mg, every 12 hours for 14 days

PLUS

Metronidazole oral

400 mg, 2 times daily for 14 days

In pregnancy, use

Erythromycin oral

500 mg, every 6 hours for 14 days instead of doxycycline

Treat sexual partner/s for urethral discharge syndrome to avoid re-infection

If severe or not improving after 7 days

Ceftriaxone IV

1 g daily

PLUS

Metronidazole IV

500 mg, every 8 hours until clinical improvement, then continue oral regimen as above

PLUS

Gentamicin IV

6 mg/kg daily.

Note Subsequently, the patient should continue therapy with:

Doxycycline oral

100mg every 12 hours for 14 days

PLUS

Metronidazole oral

400mg every 8 hours for 10-14 days

Prevention

  • Encourage the use of barrier contraceptives with/without spermicides
  • Avoid multiple sex partners
  • Contact tracing to break the chain of infection and prevent recurrence
  • Prompt diagnosis and treatment to prevent long-term complications

Referral

  • Refer all cases with generalized peritonitis, reputed/well-formed tubo-ovarian complex, cervical motion tenderness and septicaemia to gynaecologist