Pelvic inflammatory disease (PID) is usually the result of infection ascending from the endocervix causing endometritis, salpingitis, parametritis, oophoritis, tubo-ovarian abcess and/or pelvic peritonitis.
Neisseria gonorrhoeae and Chlamydia trachomatis account for a quarter of UK cases.
Gardnerella vaginalis, anaerobes (Prevotella, Atopobium and Leptotrichia) and other organisms commonly found in the vagina likely play a role.
Mycoplasma genitalium has been associated with upper genital tract infection in women and is a very likely cause of PID.
The insertion of an intrauterine device (IUD) increases the risk of developing PID but only for 4-6 weeks after insertion. This risk is probably highest in women with pre-existing gonorrhoea or trachomatis.
Diagnosis of PID and empirical antibiotic treatment should be considered and usually offered in any woman under 25 who has recent onset, bilateral lower abdominal pain associated with local tenderness on bimanual examination, in whom pregnancy has been excluded.
Fitz-Hugh-Curtis syndrome comprises right upper quadrant pain associated with perihepatitis
Randomised controlled trial evidence for whether an intrauterine contraceptive device should be left in situ or removed in PID is limited. The decision to remove the IUD needs to be balanced against the risk of pregnancy. Hormonal emergency contraception may be appropriate for some women in this situation.
Women with HIV may have more severe symptoms but respond well to standard treatment (Grade 1B).
PID may be symptomatic or asymptomatic.
Symptoms and signs lack sensitivity and specificity (positive predictive value of a clinical diagnosis is 65-90% compared to laparoscopic diagnosis).
A positive test for gonorrhoea, chlamydia or M. gen supports the diagnosis but the absence of infection does not exclude PID. Testing for all three organisms is recommended. Local availability of M. gentesting currently varies but implementation of testing is strongly recommended to guide the choice of appropriate therapy.
Elevated ESR or C-reactive protein also supports the diagnosis but is non-specific.
The absence of endocervical or vaginal pus cells has a good negative predictive value (95%) for a diagnosis of PID but their presence is non-specific (poor positive predictive value – 17%).
Differential diagnosis of lower abdominal pain in a young woman includes:
Delaying treatment is likely to increase the risk of long-term sequelae such as ectopic pregnancy, infertility and pelvic pain. Because of this, and the lack of definitive diagnostic criteria, a low threshold for empiric treatment of PID is recommended. Broad spectrum antibiotic therapy is required to cover a wide variety of aerobic and anaerobic bacteria.
Rest if severe disease (Grade 1D).
Analgesia (Grade 1D).
Intravenous therapy is recommended in more severe clinical disease (Grade 1D) e.g. pyrexia > 38⁰C, signs of tubo-ovarian abscess or pelvic peritonitis.
Avoid unprotected intercourse until patient and partner(s) have completed treatment and follow-up (Grade 1D).
Give a detailed explanation with clear and accurate written information (Grade 1D). A patient information leaflet is here
Admission for parenteral therapy, observation and possible surgical intervention should be considered in clinically severe disease, if a surgical emergency cannot be excluded, if no response to oral therapy and in those with a tubo-ovarian abscess or who are pregnant.
All the recommended regimens are of similar efficacy.
(1) Outpatient Regimens:
*Ofloxacin and moxifloxacin should be avoided in patients who are at high risk of gonococcal PID because of increasing quinolone resistance in the UK. Quinolones are not licensed in under 18s
**Of the three recommended PID treatment regimens, moxifloxacin provides the highest microbiological activity against M. genitalium.
*** Ofloxacin, levofloxacin and moxifloxacin are effective for the treatment of C. trachomatis. Quinolones (ofloxacin, levofloxacin and moxifloxacin) can cause disabling and potentially permanent side-effects involving tendons, muscles, joints and the nervous system, and are therefore only recommended as second line therapy, except for the treatment of M. genitalium associated PID where no alternative therapy is available.
Alternative Outpatient Regimens:
(2) Inpatient Regimens:
Intravenous therapy should be continued until 24 hours after clinical improvement and then switched to oral.
*Gentamicin levels need to be monitored if this regimen is used.
Alternative Inpatient Regimens:
Pregnancy and Breastfeeding
Laparoscopy may help early resolution by dividing adhesions and draining pelvic abscesses but ultrasound guided aspiration of pelvic fluid collections is less invasive.
Review at 72 hours is recommended, particularly if moderate or severe signs (Grade 2D).
Failure to improve suggests the need for further investigation, parenteral therapy and/or surgical intervention.
Further review 2-4 weeks (Grade 1D) after therapy may be useful to ensure:
The following are recommended if the initial test for M. genitalium is positive:
Current male partners should be contacted and offered screening for gonorrhoea and chlamydia.
Other recent sexual partners may also be offered screening - tracing of contacts within 6 months of symptom onset is recommended but this may be influenced by sexual history (Grade 2D)
In women with confirmed M. genitalium infection, their male partner(s) should be offered testing for M. genitalium and, if positive, treated appropriately and concurrently with the index case
Because many cases of PID are not associated with gonorrhoea, C. trachomatis or M. genitalium, broad spectrum empirical therapy should also be offered to male partners e.g. doxycycline 100mg twice daily for 1 week (Grade 2D)
Partners should be advised to avoid intercourse until they and the index patient have completed the treatment course (Grade 2D)