Pelvic inflammatory disease

Inflammation of part or all of female upper genital tract usually caused by STI

  • Common cause of lower abdominal pain in non-pregnant women at high risk of STIs (15–34 years). Often missed. Can cause serious problems
  • In pregnancy PID can cause miscarriage and increase morbidity
  • Diagnosed through clinical history and examination
  • Decision to manage as PID is based on clinical assessment even if laboratory or POC Test results negative
  • Always suspect if new onset lower abdominal pain and young age

Ask and check file notes

  • Age — higher risk if 15–34 years, highest risk under 25 years
  • History of STIs, PID, ectopic pregnancy, urinary infections
  • Recent operations on genital tract
  • Recent insertion of intrauterine device (IUD)
  • Recent childbirth — see Infections after childbirth
  • Date and results of last STI check and cervical screening

Ask

  • Abdominal pain — where, when, how long, what makes worse or better
    • Can stay as ongoing mild pain or get worse
    • Often starts with period
  • Menstrual periods
    • Last normal period
    • Change — more or less bleeding, bleeding between periods, pain with period, ongoing pain
  • Fever, nausea, vomiting, feeling generally unwell
  • Sexually active
    • Pain deep inside when having sex
    • Bleeding after sex
  • Ask about names of contacts if possible
  • Vaginal discharge — amount, colour, smell, how long
  • Urinary problems — pain, frequency, blood in urine
  • IUD

Check

  • Calculate REWS — AVPU, RR, O2 sats, pulse, BP, Temp
  • Weight, BGL 
  • If urinary symptoms or pregnant — always do midstream urine for dipstick and MC&S
  • See Lower abdominal pain for other causes of pain

 Do

Flowchart 5.1 Suspected PID in non-pregnant woman

Do — if severe PID or diagnosis uncertain

  • Medical consult send to hospital
  • Do not let woman eat or drink anything — may need operation
  • Put in IV cannula — largest possible, insert 2 if time
  • Blood for FBC and blood culture, syphilis and HIV serology — send in with patient
  • Normal saline 1L at 125mL/hour or as directed by doctor
  • Give ceftriaxone IV — adult 2g, single dose. If no IV access give IM — 2 x 1g vials, each mixed with  lidocaine (lignocaine) 1% and injected into separate buttocks, not more than 1g ceftriaxone in each buttock
    • AND azithromycin oral — adult 1g, single dose
    • AND metronidazole IV  — adult 500mg, single dose
  • If allergy — medical consult

Do — if mild–moderate PID

  • If not pregnant  treat and follow-up in community
  • Start treatment straight away. Do not wait for STI results
Day 1
  • Give  ceftriaxone IM — adult 500mg, single dose mixed with lidocaine (lignocaine) 1%
  • AND doxycycline oral  — adult 100mg, twice a day (bd) for 14 days. Do not use if pregnant 
    • OR azithromycin oral — adult 1g, single dose — second dose 1 week later
  • AND metronidazole oral — adult 400mg, twice a day (bd) for 14 days 
  • If allergy — medical consult
  • If pain relief needed — see Pain management 
  • Contact trace and provide partner/s with treatment for gonorrhea and chlamydia — men, women
  • STI and safer sex education
  • Consider discussing contraception
Day 3
  • Examine woman, ask if symptoms improving
  • If improving — PID likely. Explain important to finish treatment, do contact tracing
  • If not improving — medical consult send to hospital
Day 8
  • If using azithromycin — give azithromycin oral — adult 1g, single dose
Day 14
  • Examine woman and ask if symptoms improving
  • If still has symptoms, tenderness on abdominal or bimanual exam (do if skilled) — medical consult

Do also — if IUD

  • Medical consult. Doctor should talk with gynaecologist
    • Mild PID can be managed in community without removing IUD
    • Very careful follow-up — must be seen daily for 3 days
    • If not improving — medical consult
  • If IUD removed
    • Take 2 swabs from IUD for MC&S, NAAT for gonorrhoea, chlamydia, trichomonas
    • Put IUD in yellow-top jar and send for MC&S

Follow-up

  • Check that partner/s have been treated
  • If woman treated in hospital — check if follow-up needed (eg pelvic ultrasound)
  • If positive test result re-test in 3 months — standard STI check

Follow-up if ongoing symptoms

  • Check treatment and compliance (if all medicine taken)
  • Check partner/s have been treated
  • Medical consult about further testing including NAAT for mycoplasma genitalium