Pelvic Inflammatory Disease

Question 1

Pelvic inflammatory disease

Answer 1

• Usually an ascending infection from endocervix resulting in adhesions
• Usually from a STI (especially Chlamydia) or vaginal infection
• Can result in:
  a. Endometritis
  b. Salpingitis
  c. Oophoritis
  d. Tubo-ovarian abscess (TOA)
  e. Cervicitis
  f. Abdominal: Peri-hepatitis (Fitz-Hugh-Curtis Syndrome)/ Peritonitis/ Periappendicitis

Question 2

Risk factors for PID

Answer 2

Multiple sex partners
Unprotected sex (no barrier contraception)
Intrauterine device
Immunocompromised states (DM, HIV)

Question 3

Symptoms of PID

Answer 3

1. Classic triad:
   a. Lower abdominal pain +/- radiate to legs
   b. Low grade fever
   c. Foul smelling vaginal discharge
2. Abnormal vaginal bleed
   - Prolonged menses
   - IMB
   - PCB
3. Dyspareunia

Question 4

Signs of PID

Answer 4

Lower abdominal tenderness
Cervical excitation**
Adnexal tenderness**
+/- adnexal mass
+/- septic shock

Question 5

Differentials for PID

Answer 5

Ectopic pregnancy
- hx of missed menses, UPT positive
Ruptured ovarian cyst
- acute onset severe pain
Acute appendicitis
UTI
Endometriosis
- cyclical, chronic pain
Diverticulitis
- bowel sx

Question 6

Investigations for PID

Answer 6

POCT
- UPT TRO ectopic pregnancy
- Urinalysis, urine c/s, urine dipstick TRO UTI

Bloods
- FBC
- ESR, CRP

Swabs
- Endocervical swab test for Gonorrhea and Chlamydia (+ve supports Dx but -ve doesn’t exclude PID)
- High vaginal swab to test for trichomonas, bacterial vaginosis and candidiasis (VP3)

Imaging
- U/S pelvis to look for tubo-ovarian abscess (TOA) and pus in pelvis

Question 7

Indications for admission

Answer 7

• Sepsis
• Lack of response to oral therapy -> need for IV abx (immunocompromised)
• Intolerance to oral therapy
• Development of tubo-ovarian abscess
• Pregnancy
• Signs of pelvic peritonitis (Rebound tenderness, rigidity, guarding)

Question 8

Acute management of PID

Answer 8

1. Antibiotics (outpatient or inpatient) - Broad spectrum antibiotics
   - Ceftriaxone
   - Doxycycline
   - Metronidazole
2. Analgesia
   - Paracetamol, NSAIDs (pain ladder)
3. Surgical
   - If acute infection fails to respond to IV antibiotics
   - Laparoscopic adhesiolysis and drainage of abscesses
   - Ultrasound-guided aspiration of pelvic fluid collection
4. STI counselling
   - Partners: Screen for STI + HIV + Contact tracing and Tx
   - Avoid unprotected intercourse until they + partner have completed Tx and F/U

Question 9

Complications of PID

Answer 9

1. Infertility 2° to tubal damage
2. Ectopic pregnancy
3. Chronic pelvic pain
4. Fitz Hugh Curtis syndrome
   - inflammation of the liver capsule and peritoneum
   - RUQ pain
5. Recurrent PID
6. Hydrosalpinx 2° to tubal damage