4.6 Pelvic Inflammatory Disease

Question 1

What is pelvic inflammatory disease?

Answer 1

Pelvic inflammatory disease (PID) is inflammation and infection of the organs of the pelvis, caused by infection spreading up through the cervix. It is a significant cause of tubular infertility and chronic pelvic pain.

It is worth remembering the technical terms for the affected organs:

• Endometritis is inflammation of the endometrium
• Salpingitis is inflammation of the fallopian tubes
• Oophoritis is inflammation of the ovaries
• Parametritis is inflammation of the parametrium, which is the connective tissue around the uterus
• Peritonitis is inflammation of the peritoneal membrane

Question 2

Causes of PID?

Answer 2

Most cases of pelvic inflammatory disease are caused by one of the sexually transmitted pelvic infections:

• Neisseria gonorrhoeae tends to produce more severe PID
• Chlamydia trachomatis
• Mycoplasma genitalium

Pelvic inflammatory disease can less commonly be caused by non-sexually transmitted infections, such as:

• Gardnerella vaginalis (associated with bacterial vaginosis)
• Haemophilus influenzae (a bacteria often associated with respiratory infections)
• Escherichia coli (an enteric bacteria commonly associated with urinary tract infections)

Question 3

Risk factors for PID?

Answer 3

There risk factors for pelvic inflammatory disease are the same as any other sexually transmitted infection:

• Not using barrier contraception
• Multiple sexual partners
• Younger age
• Existing sexually transmitted infections
• Previous pelvic inflammatory disease
• Intrauterine device (e.g. copper coil)

Question 4

Presentation of PID?

Examination findings?

Answer 4

Women may present with symptoms of:

• Pelvic or lower abdominal pain
• Abnormal vaginal discharge
• Abnormal bleeding (intermenstrual or postcoital)
• Pain during sex (dyspareunia)
• Fever
• Dysuria

Examination findings may reveal:

• Pelvic tenderness
• Cervical motion tenderness (cervical excitation)
• Inflamed cervix (cervicitis)
• Purulent discharge

Patients may have a fever and other signs of sepsis.

Question 5

Investigations in PID?

Answer 5

Patients with pelvic inflammatory disease should have testing for causative organisms and other sexually transmitted infections:

• NAAT swabs for gonorrhoea and chlamydia
• NAAT swabs for Mycoplasma genitalium if available
• HIV test
• Syphilis test
• A high vaginal swab can be used to look for bacterial vaginosis, candidiasis and trichomoniasis.
• A microscope can be used to look for pus cells on swabs from the vagina or endocervix. The absence of pus cells is useful for excluding PID.
• A pregnancy test should be performed on sexually active women presenting with lower abdominal pain to exclude an ectopic pregnancy.
• Inflammatory markers (CRP and ESR) are raised in PID and can help support the diagnosis.

Question 6

Management of PID?

Answer 6

Where appropriate patients should be referred to a genitourinary medicine (GUM) specialist service for management and contact tracing. Antibiotics are started empirically, before swab results are obtained, to avoid a delay and complications.

A suggested outpatient regime is:

• A single dose of intramuscular ceftriaxone 1g (to cover gonorrhoea)
• Doxycycline 100mg twice daily for 14 days (to cover chlamydia and Mycoplasma genitalium)
• Metronidazole 400mg twice daily for 14 days (to cover anaerobes such as Gardnerella vaginalis)
• Ceftriaxone and doxycycline will cover many other bacteria, including H. influenzae and E. coli.

More severe cases, particularly where there are signs of sepsis or the patient is pregnant, require admission to hospital for IV antibiotics. Where a pelvic abscess develops, this may need drainage by interventional radiology or surgery.

Question 7

Complications of PID?

Answer 7

• Sepsis
• Abscess
• Infertility
• Chronic pelvic pain
• Ectopic pregnancy
• Fitz-Hugh-Curtis syndrome

Question 8

What is Fitz-Hugh-Curtis syndrome?

Answer 8

Fitz-Hugh-Curtis syndrome is a complication of pelvic inflammatory disease. It is caused by inflammation and infection of the liver capsule (Glisson’s capsule), leading to adhesions between the liver and peritoneum. Bacteria may spread from the pelvis via the peritoneal cavity, lymphatic system or blood.

Fitz-Hugh-Curtis syndrome results in right upper quadrant pain that can be referred to the right shoulder tip if there is diaphragmatic irritation. Laparoscopy can be used to visualise and also treat the adhesions by adhesiolysis.