Pelvic Inflammatory Disease (PID)

Last updated 20.09.12

 

Index

 

Definition

-  Inflammatory disorder of the uterus, fallopian tubes & adjacent pelvic structures

-  Includes: endometritis, chorioamnionitis, salpingitis, tubo-ovarian abscess, pelvic cellulitis & pelvic peritonitis

 

Features

-  Caused by ascending infection from organisms from vagina or cervix

-  Usually polymicrobial

-  11% of reproductive age women

-  Non-sexually acquired

-  Mixed vagina flora: anaerobes, gram negatives, Mycoplasma hominis

-  Common as post partum infection: endometritis..

-  Sexually acquired

-  Chlamydia trichomatis

-  Nisseria gonorrhoea

-  Mycoplasma genitalium

-  Pelvic actinomycosis

-  Very rare

-  Chronic polymicrobial inflammatory mass, may mimic malignancy

-  Usually after prolonged IUCD use

 

Causes

-  Most Common

-  Chlamydia trichomatis 40-60%

-  Nisseria gonorrhoea 20%

-  No organism detected in 1/3 pts

-  Others

-  CMV

-  Gardnerella

-  Haemophilus Influenza

-  E. Coli

-  Peptococcus

-  Streptococcus agalactiae

-  Bacteroides fragilis

-  Mycoplasma hominis

-  Mycoplasma genitalium

-  Actinomyces

 

Risk Factors

-  Young age at first intercourse

-  Multiple sexual partners

-  IUCD

-  Risk in first 2-3 weeks post insertion

-  Smoking

-  OCP is protective: increased mucus thickness

 

Associated S/S

-  Lower abdominal pain 90%

-  < 7 days

-  Constant dull ache

-  Worse w exercise

-  Gonorrhoea & Chlamydia more likey to cause pain at end of menses + next 10 days

-  Peritonitis

-  Dysuria

-  Dyspareunia

-  Vaginal discharge 75%

-  Mucopurulent cervical discharge

-  Vaginal bleeding 45%

-  Fever

-  Nausea & vomiting

-  Vaginal Examination

-  Uterine/adnexal tenderness

-  Cervical motion tenderness

 

Complications

-  Tubal infertility 12-50% per episode

-  Ectopic Pregnancy 12-15% increase

-  Chronic pelvic pain 18%+

-  Tubo-ovarian abscess

-  Other STIs: HIV, HBV, Syphilus

 

DDx

-  Appendicitis

-  Adnexal Tumours

-  Ectopic Pregnancy

-  Endometriosis

-  UTI: Cystitis, Pyelonephritis

  

Ix

-  Beta hCG: DDx pregnancy (N or Ectopic)

-  ESR, CRP

-  FBE: WBC

-  High Vaginal & Endocervical Swab: Cultures: Gonorrhoea, Chlamydia

-  Urinalysis

-  Dipstick + MSU for MCS: UTI

-  Urinary (first void of day) PCR/NAT for Gonorrhoea, Chlamydia

-  TV Ultrasound

-  Hydro/haemosalpinx, adnexal mass

-  81% sens, 78% spec

 

Mx

-  Consider removal of IUCD

-  Can reinsert once infection resolved

-  Alternative contraception

-  Hospitlisation if

-  Pregnant

-  Pelvic abscess

-  Immunodeficiency

-  Analgesia

-  Non-sexually acquired

-  Mild to moderate

-  Augmentin DF PO BD 14 days

-  PLUS Azithromycin 1g PO single dose

-  PLUS

-   Azithromycin 1g PO single dose 1 week later

-   OR Doxycycline 100mg PO BD for 14 days

-  Penicillin hypersensitivity

-  Metronidazole 400mg PO BD for 14 days instead of Augmentin DF

-  Severe

-  Amoxycillin/Ampicillin 2g IV QID

-  PLUS Gentamicin 4-6mg/kg IV Daily

-   Max 2-3 doses total

-  PLUS Metronidazole 500mg IV BD

-  Change to PO once clinically stable

-  Sexually acquired

-  Ix & Rx partner

-  +/- reportable disease

-  Mild to moderate

-  Single dose Ceftriaxone 500mg IV OR IM w 2ml 1% Lidocaine (Gonorrhoea)

-  PLUS Metronidazole 400mg PO BD for 14 days

-  PLUS Azithromycin 1g PO single dose

-  PLUS

-   Azithromycin 1g PO single dose 1 week later

-   OR Doxycycline 100mg PO BD for 14 days

-  Severe

-  Ceftriaxone 1g IV Daily

-  PLUS Azithromycin 500mg IV Daily

-  PLUS Metronidazole 500mg IV BD

-  Change to PO once clinically stable

-  Penicillin hypersensitivity

-  Gentamicin 4-6mg/kg IV Daily

-  PLUS

-   Clindamycin 600mg IV TDS

-   OR Lincomycin 600mg IV TDS

-  If suspecting M genitalium

-  May be resistant to Azithromycin + Doxycycline

-  Test of cure by repeat culture 1 month

-  If persistent Moxifloxacin 400mg PO Daily for 10 days

-  Pelvic actinomycosis

-  Expert advice

-  6 month Abx+

-  Removal of IUCD

-  +/- Laparoscopy

 

 

 

References

 

eTG: Pelvic Inflammatory Disease, June 2010