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Editors

LeenaLaitinen

Pelvic Inflammatory Disease (PID)

Essentials

  • Early diagnosis and treatment reduce the late sequelae of PID:
    • infertility
    • ectopic pregnancy
    • chronic abdominal pain.

Epidemiology

Aetiology

Acute PID

  • The most important causative pathogens are the sexually transmitted microbes Chlamydia trachomatis Chlamydial Urethritis and Cervicitis and Neisseria gonorrhoeae Gonorrhoea (significantly rarer) http://www.dynamed.com/condition/pelvic-inflammatory-disease-pid#CAUSES.
  • Mycoplasma genitaliumMycoplasma Genitalium Infection
  • Other causative pathogens: Peptostreptococcus, Bacteroides, Atopobium, Leptotrichia and Clostridium species, Mycoplasma hominis, Ureaplasma urealyticum
  • In addition, approx. 15% of the pathogens involved are of respiratory or intestinal origin: Haemophilus influenzae, Streptococcus pneumoniae, group A Streptococcus, Staphylococcus aureus and Campylobacter species.
  • PID is usually caused by several microbes at the same time.

Chronic PID

  • Mycobacterium tuberculosis (countries with risk of tuberculosis)
  • Actinomyces (patients often have an IUD; the infection is often found in a Pap smear test)

Clinical picture

  • Course of disease in acute PID
    • Typically begins after menstruation or after a procedure, such as the insertion of an IUD (risk increased for up to 3 weeks).
    • The infection ascends via the cervical canal to the uterus where it causes inflammation of the uterine mucosa, or endometritis, and to the fallopian tubes where it causes inflammation of the fallopian tubes, or salpingitis, inflammation of the fallopian tubes and ovaries, or salpingo-oophoritis, or accumulation of pus in the fallopian tubes, or pyosalpinx.
    • Perihepatitis, or superficial inflammation of the fibrous capsule of the liver (tunica fibrosa hepatis), and periappendicitis may also occur in association with PID. A tubo-ovarian abscess and peritonitis may develop in severe cases.
  • Symptoms
    • Lower abdominal pain worsened by movement
    • Abnormal vaginal discharge (intermenstrual bleeding, postcoital bleeding)
    • Pain on intercourse, pain on urination
    • (Mild) fever
    • The severity of symptoms varies: the disease may have very mild symptoms or be nearly asymptomatic (particularly chlamydia) or present as a septic disease with impairment of the patient's general condition.
  • Findings
    • Tenderness of the lower abdomen on palpation
    • Uterine and adnexal tenderness in pelvic examination
    • Mucopurulent or bloody cervical discharge visible in the speculum examination

Workup

Special investigations in hospital

Differential diagnosis

Treatment

  • Outpatient management if:
    • the patient's general condition is good
    • oral antimicrobial treatment can be used
    • inflammatory markers are only slightly increased.
  • Antimicrobial treatment in outpatient care
    • Treatment primarily against chlamydia: 100 mg doxycycline twice daily for 14 days and 400 mg or 500 mg metronidazole three or two times daily, respectively, for 14 days.
    • A non-optimal alternative for patients with allergy, for example, is 500 mg ciprofloxacin three times daily and 400 mg metronidazole three times daily.
    • When gonorrhoea is diagnosed (obvious purulent discharge from the cervix, urine gonococcal nucleic acid detection positive), a gonococcal culture sample should be taken for antimicrobial susceptibility testing. Without waiting for the result, the treatment may be started with a single dose of 250 mg ceftriaxone i.m. and, additionally, 100 mg oral doxycycline twice daily for 14 days.
    • If chlamydial and gonococcal infections can be excluded and the infection occurs after the insertion of an IUD, for example, it is usually a mixed infection caused by normal vaginal flora and can be treated with a combination of cephalexin (500 mg three, or 750 mg two times daily) and metronidazole (500 mg two, or 400 mg three times daily).
  • Indications for hospital treatment http://www.dynamed.com/condition/pelvic-inflammatory-disease-pid#TREATMENT_SETTING
    • Poor general condition or impaired immunity
    • Pregnancy
    • Unclear diagnosis (e.g. differential diagnosis appendicitis or ectopic pregnancy)
    • High fever (N.B.! CRP rises more slowly than leucocyte levels)
    • Suspected abscess in the lesser pelvis
    • Unsuccessful outpatient treatment or follow-up difficult to arrange
  • Antimicrobial treatment in hospital
  • Removal of IUD if the patient has fever and/or her inflammatory markers are clearly increased or the response to pharmacotherapy is poor http://www.dynamed.com/condition/pelvic-inflammatory-disease-pid#INTRAUTERINE_DEVICE_IUD_REMOVAL
  • NSAIDs for symptom alleviation
  • Rest, with a sufficiently long period of sick leave (for the duration of antimicrobial treatment, as necessary, particularly if the patient has fever)
  • Examination and treatment of sexual partner (samples for chlamydia and gonorrhoea) http://www.dynamed.com/condition/pelvic-inflammatory-disease-pid#MALE_SEXUAL_PARTNERS
  • Remember follow-up visit!
  • Depending on the local legislation, the treatment of chlamydia and gonorrhoea may be free of charge for the patient. Find out about local policy.

Prognosis

References

  • Zimmerman HL, Potterat JJ, Dukes RL, Muth JB, Zimmerman HP, Fogle JS, Pratts CI. Epidemiologic differences between chlamydia and gonorrhea. Am J Public Health 1990 Nov;80(11):1338-42. [PubMed]
  • Centers for Disease Control and Prevention, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006 Aug 4;55(RR-11):1-94. [PubMed]
  • Gottlieb SL, Xu F, Brunham RC. Screening and treating Chlamydia trachomatis genital infection to prevent pelvic inflammatory disease: interpretation of findings from randomized controlled trials. Sex Transm Dis 2013;40(2):97-102. [PubMed]
  • Schindlbeck C, Dziura D, Mylonas I. Diagnosis of pelvic inflammatory disease (PID): intra-operative findings and comparison of vaginal and intra-abdominal cultures. Arch Gynecol Obstet 2014;289(6):1263-9. [PubMed]
  • Molander P, Sjöberg J, Paavonen J et al. Transvaginal power Doppler findings in laparoscopically proven acute pelvic inflammatory disease. Ultrasound Obstet Gynecol 2001;17(3):233-8. [PubMed]
  • Brunham RC, Gottlieb SL, Paavonen J. Pelvic inflammatory disease. N Engl J Med 2015;372(21):2039-48. [PubMed]