Pelvic Inflammatory Disease

Question 1

What is pelvic inflammatory disease?

Answer 1

The result of infection ascending from the endocervix, causing endometritis, salpingitis, parmetritis, oophoritis, tubo-ovarian abscess and/or pelvic peritonitis

Question 2

What is endometritis?

Answer 2

Inflammation and infection of the endometrium (lining of the uterus)

Question 3

What is salpingitis?

Answer 3

Inflammation of the fallopian tube.

Question 4

What is the pathophysiology of PID?

Answer 4

Ascending infection from the endocervix and vagina into uterus
Infections cause inflammation
Inflammation causes damage
   - Thus damage to tubal epithelium
   - Thus adhesions form

Question 5

What are the complications of PID?

Answer 5

Ectopic pregnancy
Infertility
Chronis pelvic pain
Fitz-Hugh-Curtis syndrome
   - RUQ pain and peri-hepatitis following chlamydial PID

Question 6

What is PID usually caused by?

Answer 6

Often polymicrobial
Sexually transmitted infections
   - C. trachomatis
   - N. gonorrhoea
Others
   - Gardnerella vaginalis, mycoplasma, anaerobes

Question 7

What are the risk factors for PID?

Answer 7

STIs:
   - Young age
   - Lack of use of barrier contraception
   - Multiple sexual partners
   - Low socioeconomic class
IUCD

Question 8

How would a person with PID present? (History)

Answer 8

Pyrexia
Pain
   - Lower abdominal pain
   - Deep dyspareunia (pain after or during sex)
Abnormal vaginal/cervical discharge
Abnormal vaginal bleeding
Sexual history & prior STI
Contraceptive history

Question 9

How would a patient with PID present on examination?

Answer 9

Fever
Lower abdominal tenderness which is usually bilateral
Bimanual examination:
   - Adnexal tenderness (structures close to uterus)
   - Cervical motion tenderness
Speculum examination:
   - Purulent cervical discharge
   - Cervicitis

Question 10

What investigations would you order if you suspected PID?

Answer 10

Urinary and/or serum pregnancy test
Endocervical and high vaginal swabs:
   - Presence of NG/CT supports diagnosis
   - Absence of NG/CT does not exclude
Blood tests
  - WBC and CRP
Screening for other STIs including HIV

Question 11

How do you manage PID?

Answer 11

Low threshold for empirical treatment
- Delayed treatment increases risk of long term
sequelae

Severe disease requires IV antibiotics and admission for observation and possible surgical intervention
- Pyrexia >38, signs of tubo-ovarian abscess, signs of
pelvic peritonitis
- Increased risk of long term sequelae

Question 12

What is the antibiotic treatment for an outpatient with PID?

Answer 12

IM Ceftriaxone 500 mg STAT
\+
PO Doxycycline 100mg BD
\+
PO Metronidazole 400mg BD

Question 13

What is the antibiotic treatment for inpatient treatment with PID?

Answer 13

IV Ceftriaxone 500mg STAT
\+
IV/PO Doxycycline 100mg BD
\+
IV Metronidazole 400mg BD

then

PO Doxycycline 100mg BD
+
PO Metronidazole 400mg BD

Question 14

What is the surgical management for PID?

Answer 14

Laparoscopy/laparotomy maybe considered if

• No response to therapy
• Clinically severe disease
• Presence of a tubo-ovarian abscess

Ultrasound guided aspiration of pelvic collections is less invasive

Question 15

What do you tell patient when they have PID?

Answer 15

What the diagnosis is
What treatments they are having (side effects, importance of completing course)
What complications they are at risk of
How to reduce the risk of further episodes
Contact tracing
- Empirical treatment of partners
- Abstinence until antibiotic course complete