PID

Question 1

Describe the pathophysiology of PID

Answer 1

Polymicrobial infection, typically caused by sexually transmitted pathogens ascending from the cervix and vagina to the upper genital tract.

The primary organisms implicated are Neisseria gonorrhoeae and Chlamydia trachomatis

Pathophysiology of PID begins with the colonisation of lower genital tract by these pathogens.

During menstruation or following sexual intercourse, cervical barrier function can be compromised, facilitating bacterial ascension into the endometrium.

Question 2

Describe the features of PID

Answer 2

Features
* lower abdominal pain
* fever
* deep dyspareunia
* dysuria and menstrual irregularities may occur
* vaginal or cervical discharge
* cervical excitation
* RUQ tenderness

Examination findings may reveal:
* Pelvic tenderness
* Inflamed cervix (cervicitis)
* Purulent discharge

Question 3

Describe the investigations to perfom for PID [4]

Answer 3

NAAT swabs
- for gonorrhoea, chlamydia and Mycoplasma genitalium

HIV test

Syphilis test

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 4

Describe the management for PID

Answer 4

Give a combination of:

• 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)

NB: due to the difficulty in making an accurate diagnosis, and the potential complications of untreated PID, consensus guidelines recommend having a low threshold for treatment

Question 5

Describe what is meant by Fitz-Hugh-Curtis syndrome [1]

How do you visualise and treat this? [1]

Answer 5

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

Causes RUQ pain

Laparoscopy can be used to visualise and also treat the adhesions by adhesiolysis.

Question 6

Describe the differential diagnoses and how you’d differentiate them from PID [3]

Answer 6

Endometriosis:
- Dyspareunia (pain during or after sexual intercourse); whereas PID pain is constant and not necessarily related to menstrual cycles.
- Pain is more present with dyspareunia deep in the pelvis or even lower back pain radiating down the legs.
- In contrast to PID, physical examination may reveal nodules or tenderness posterior to the uterus in the pouch of Douglas or along the uterosacral ligaments.

Ectopic Pregnancy:
- Sudden pain and more severe
- Key differential: amenorrhoea
- on bimanual examination there might be adnexal tenderness or a palpable mass on one side of the pelvis.

Acute Appendicitis:
- Starts at umbilicus and moves laterally (PID is bilateral pain)
- more acute
- Rebound tenderness

Question 7

Answer 7

A 20-year-old woman presents with a 1 week history of crampy, constant lower abdominal pain, intermenstrual bleeding, dyspareunia and dysuria - pelvic inflammatory disease

Question 8

Answer 8

Pelvic inflammatory disease - oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole