Pelvic Inflammatory Disease

Question 1

Definition

Answer 1

Broad term encompassing multiple types of infection of the upper genital tract. Infection spreads upwards from the endocervix leading to:
- endometritis,
- salpingitis,
- parametritis,
- oophhoritis,
- tubo-ovarian abscess
- and/or pelvic peritonitis.

Question 2

Causative organisms

Answer 2

• Chlamydia trachomatis: MC cause of PID
• Neisseria gonorrhoea
• Mycoplasma genitalium
• Normal vaginal flora organismsL anaerobes, Gardnerella vaginalis, Haemophillus influenzae, and Streptococcus agalactiae

Question 3

Epidemiology and Risk factors

Answer 3

• Current/Previous STI in Px or partner
• Early age of first coitus: highest risk under age of 25
• Multiple sex partners
• Recent new partner
• Insertion of intrauterine devices (IUD): only in the first 4-6 weeks of insertion
• Recent instrumentation of uterus e.g. termination, IVF

Question 4

Signs

Answer 4

• Lower abdominal tenderness: usually bilateral
• Adnexal tenderness or cervical motion tenderness on bimanual examination
• Mucopurulent vaginal or cervical discharge
• Fever > 38°C (often no fever)

Question 5

Symptoms

Answer 5

• Lower abdominal pain: typically bilateral
• Deep dyspareunia
• Abnormal vaginal discharge: may be purulent
• Abnormal vaginal bleeding: including intermentrual and postcoital bleeding and menorrhagia
• Secondary dysmenorrhoea

Question 6

Diagnosis

Answer 6

Should be make on clinical grounds - do not delay treatment waiting for labs
PRIMARY:
- Test chlamydia + gonorrhoea
= chlamydia: vulvogaginal swab, endocervical swab on first catch urine
= gonorrhoea: vulvo-vaginal swab
- Test for syphilis + HIV = bloods
- Pregnancy test = exclude ectopic pregnancy

Question 7

Threshold

Answer 7

Low threshold for treatment: Empirical Abx without waiting for swabs considered in all:
- sexually active women + - lower abdo pain +
- tenderness on bimanual examination
- pregnancy excluded

Question 8

Outpatient treatment

Answer 8

FIRST LINE Abx : IM ceftriaxone (single-dose) followed by oral doxycycline plus metronidazole for 14 days

Second-line options:
- Oral ofloxacin plus metronidazole for 14 days
- Oral moxifloxacin for 14 days
- IM ceftriaxone (single-dose) followed by oral azithromycin

Question 9

When should Ofloxacin and moxifloxacin be avoided?

Answer 9

If risk of gonorrhoea is high (e.g. when a partner has known gonorrhoea, in clinically severe disease, or if has sexual contact abroad) due to widespread resistance

Question 10

What to do with IUD

Answer 10

IUD may be left in situ in mild to moderate PID, but review after 48-72 hours and remove if no significant clinical improvement

Question 11

When should Px be admitted

Answer 11

Patients may need to be admitted urgently if:
- The woman is pregnant
- There are severe symptoms and signs (including signs of pelvic peritonitis)
- A tubo-ovarian abscess is suspected
- Outpatient treatment is not tolerated or has been unsuccessful

Question 12

Inpatient treatment

Answer 12

Option 1 :
- IV ceftriaxone + IV doxycycline,
- followed by oral doxycycline + metronidazole for 14 days

Option 2:
- IV clindamycin + IV gentamicin,
- followed by oral clindamycin/doxycycline plus metronidazole for 14 days

• Surgical management: may be required in severe cases, e.g. laparoscopy to divide adhesions or drain pelvic abscesses, or laparotomy

Question 13

Complication

Answer 13

Tubal infertility
Ectopic pregnancy
Chronic pelvic pain
Tubo-ovarian abscess
Fitz-Hugh-Curtis syndrome