Pelvic Inflammatory Disease

Question 1

What is PID?

Answer 1

A term used to describe infection and inflammation of the female pelvic organs including the uterus, Fallopian tubes, ovaries and surrounding peritoneum.

Question 2

What causes PID?

Answer 2

Ascending infection from the endocervix causing:
Endometritis
Salpingitis
Parametritis 
Oophoritis 
Tubo-ovarian abscess 
And/ or peritonitis

Question 3

The ascending infection causes…

Answer 3

Inflammation, which causes damage
Adhesions form
Damage to tubal epithelium

Question 4

What is salpingitis?

Answer 4

Inflammation of Fallopian tubes

Question 5

What are the causative organisms?

Answer 5

Sexually transmitted:
Chlamydia trachomatis
Neisseria gonorrhoeae

Enterobacteriaceae:
E. Coli

Anaerobes:
Bacteroides
Peptostreptoccocus
Peptococcus

Usually associated with intrauterine device:
Actinomyces

Gardnerella vaginalis
Streptococcus agalactiae
Mycoplasma genitalium
Mycoplasma hominis 
Haemophilius influenzae
Streptococcus pyogenes 

Rare: pelvic tuberculosis

Question 6

What risk factors are there?

Answer 6

Young age (<25)
New sexual partner 
Multiple sexual partners
Early age of first sexual intercourse 
Non use of barrier contraception 
Previous PID, chlamydia or gonorrhoea infection 
Immunocompromised 
Co existing endometriosis 
IUD/ coil insertion 
Termination of pregnancy/miscarriage 
Instrumentation of uterus 
Appendicitis

Question 7

Has it been reported in non sexually active women?

Answer 7

Yes

Question 8

Is PID often polymicrobial?

Answer 8

Yes in 30-40%

Question 9

Is it common in the UK and amongst what age group?

Answer 9

Yes - underestimated

Sexually active women: peak 20-30 years

Question 10

How does it present?

Answer 10

Pain - lower abdominal, deep dyspareunia
Pyrexia
Discharge abnormal 
IMB and PCB 
Dysuria
Can be asymptomatic

Question 11

What examination findings are often seen?

Answer 11

Fever
Lower abdominal tenderness - usually bilateral
Bimanual examination - adnexal tenderness +/-mass , cervical motion tenderness
Speculum examination - lower genital tract infection, purulent cervical discharge, cervicitis

Question 12

What investigations should be done?

Answer 12

Pregnancy test (urinary+/or serum) - exclude ectopic
FBC, CRP, U and E
Urinalysis - exclude concomitant UTI
Triple swabs - high vaginal and endocervical sent for culture and microscopy
Screening for other STIs including HIV
USS pelvis/abdo - hydrosalpinx, tubo-ovarian abscess
X ray if questing if bowel involvement
Diagnostic = laparoscopy - can also treat at same time e.g adhesiolysis and drain abscess

Question 13

What does a high vaginal swab test for?

Answer 13

Posterior fornix for:
TV
BV 
Candida 
GBS

Question 14

What gynaecological differentials are there?

Answer 14

Ectopic pregnancy
Endometriosis
Ovarian cyst complications

Question 15

What GI differentials are there?

Answer 15

Appendicitis

IBS

Question 16

What urinary differentials are there?

Answer 16

UTI

Question 17

If the triple swab is negative, does this exclude PID?

Answer 17

No - there are other causative organisms

Question 18

Why should there be a low threshold for treatment?

Answer 18

Delay in treatment increases long term sequelae

Question 19

What is the outpatient treatment?

Answer 19

IM ceftriaxone 500mg single dose
Plus PO doxycycline 100mg BD 
Plus PO metronidazole 400mg BD 
For 14 days
Also give pain relief and antiemetics

Question 20

In severe disease there is a risk of…

Answer 20

Sepsis

Question 21

Severe disease requires..

Answer 21

IV antibiotics and admission for observations and possible surgical intervention - laparoscopy/ laparotomy for drainage

Question 22

What antibiotic inpatient treatment is required?

Answer 22

IV ceftriaxone 2g daily
PLUS IV doxycycline 100mb BD (oral if tolerated)
Followed by oral doxycycline 100mg BD plus oral metronidazole 400mg BD for 14 days

Question 23

What counselling is required?

Answer 23

Future ectopic risk

Subfertility

Question 24

Should partners be notified and treated if necessary?

Answer 24

Yes

Question 25

Can appendicitis, pyelonephritis and diverticulitis cause PID?

Answer 25

Yes - haematogenous spread or direct spread

Question 26

What complications are there?

Answer 26

I FACE PID 
Infertility
Fitz Hugh Curtis syndrome
Abscess
Chronic pelvic pain 
Ectopic pregnancy 
Peritonitis 
Intestinal obstruction - adhesions 
Disseminated infection - sepsis, endocarditis, arthritis, meningitis

Question 27

What is Fitz Hugh Curtis syndrome?

Answer 27

Complication of PID - liver capsule inflammation leading to adhesions

Question 28

Describe a common patient presentation

Answer 28

Young, nulliparous female complaining of lower abdominal/pelvic pain and vaginal discharge, possible change to periods. Associated fever, nausea and vomiting, along with deep dyspareunia

Question 29

Is USS of value in confirming diagnosis?

Answer 29

No, but can be useful if suspecting complications or if patient not improving
Useful in detecting abscesses, hydrosalpinx or any free fluid

Question 30

What is the admission criteria?

Answer 30

Severe clinical illness - high fever, nausea, vomiting, severe abdo pain
Complicated PID with pelvic abscess
Possible need for invasive diagnostic evaluation or surgical intervention e.g suspected ruptured tubo-ovarian abscess
Inability to take oral medications
Pregnancy
Lack of response or tolerance to oral medications
Concern for non adherence to therapy

Question 31

Before discharging and treating as outpatient, what should be done?

Answer 31

Inform patient that partner notification and treatment for STI required
Follow up - in 48-72 hours to check for clinical improvement
Advised to refrain from any sexual intercourse until both her and partner successfully treated
Safety netting - awareness of possible complications and signs/symptoms to look out for e.g high fever and rigours, severe abdo pain, uncontrollable vomiting