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
- Full STI check
- If pregnant — medical consult about diagnosis, treatment, sending to hospital
- If not pregnant — Flowchart 5.1
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