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Pelvic inflammatory disease (PID) diagnosis and management

Last updated: June 2013

Diagnosis

Background

  • Pelvic inflammatory disease (PID) is usually the result of infection ascending from the endocervix causing endometritis, salpingitis, parametritis, oophoritis, tubo-ovarian abscess and/or pelvic peritonitis.
  • There is no single historical, physical or lab finding that is both sensitive and specific for the diagnosis of PID.
  • Clinical diagnosis based on history and examination alone is difficult.
  • Delaying treatment may increase the risk of long term sequelae such as ectopic pregnancy, infertility and pelvic pain.
  • A low threshold for empiric treatment for PID is recommended.
  • A combination of clinical and laboratory information is required for definitive diagnosis.
  • Pregnancy test should be done to exclude complications of pregnancy and guide antibiotic choice.

Presumptive diagnosis

Clinical examination and laboratory findings

Minimum criteria for diagnosis includes:

  • cervical motion tenderness and/or
  • uterine tenderness and/or
  • adnexal tenderness:

Plus any of the following criteria:

  • temperature greater than 38° C
  • abnormal cervical discharge
  • pelvic abscess or inflammatory complex on bimanual examination
  • gram stain of the endocervix showing gram negative intracellular diplococci
  • positive chlamydia test
  • positive mycoplasma genitalium test
  • leucocytosis >10 x 109 WBC/L
  • elevated ESR or elevated C-reactive protein

Note:

  • These findings may be sufficient for a suspected diagnosis of PID.
  • Commencement of empirical treatment in a woman with a mild presentation, at risk of sexually transmitted infections (STIs) and in the absence of strong evidence for a competing diagnosis is recommended.
  • When symptoms are severe other diagnoses should be considered.

Definitive criteria

  • Histopathologic evidence of endometritis on endometrial biopsy
  • transvaginal sonography or other imaging techniques showing thickened fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex
  • laparoscopic abnormalities consistent with PID.

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Treatment

Indications for in patient management

  • Severe clinical disease such as fever, tubo-ovarian abscess or peritonitis
  • when surgical emergencies such as appendicitis and ectopic pregnancy cannot be excluded
  • pregnancy
  • failure to respond to outpatient oral therapy
  • the woman is unable to follow or tolerate an outpatient oral regimen.

Note:

  • Objectives of antimicrobial therapy
    • short term - elimination of symptoms and signs of infection and eradication of pathogens
    • long term - reduction of tubal damage (impossible to evaluate using current data)
  • treatment is usually initiated empirically before a microbial cause is established
  • PID is polymicrobial. Neisseria gonorrhoeae and Chlamydia trachomatis are implicated most often but there are a variety of endogenous anaerobic and
  • aerobic bacteria that may also cause PID, particularly following upper reproductive tract surgery, instrumentation, or post-delivery.

Standard therapy for outpatient management

Ceftriaxone 500 mg IMI as one dose (B1)

plus

Doxycycline 100 mg orally twice a day for 14 days (D)

plus

Metronidazole 400 mg orally 12 hourly for 14 days (B2).

Metronidazole may be discontinued after 5 days in mild to moderate PID where the woman fails to tolerate it.

Alternate therapy (limited evidence)

Ceftriaxone 500 mg IMI as one dose (B1)

plus

Azithromycin 1 g weekly for 2 weeks (B1)

plus

Metronidazole 400 mg orally 12 hourly for 14 days (B2).

Removal of an Intra Uterine Contraceptive Device (IUCD)

  • There is no need for removal of the IUCD if the patient wishes to continue using it.
  • If it is to be removed, it should be done so after the commencement of antibiotic treatment.
  • Emergency contraceptive medication can be used to prevent pregnancy.
  • If the infection worsens generally the course would be to remove the IUCD.

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Patient education

The following points should be discussed:

  • the nature of the infection
  • the condition may not be sexually acquired
  • partners should be tested and treated for sexually transmitted infections
  • clinical review is required at 72 hours or before if symptoms are failing to settle and at 2 weeks.
  • long term sequelae of PID
  • the presence of PID indicates the need for a complete STI/Human immunodeficiency virus (HIV) screen
  • poor specificity of diagnostic criteria.

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Contact tracing

Sexual partners should be offered screening for STIs and contact tracing is required if a notifiable sexually transmitted infection is identified.

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Follow up

Close follow up is required at 72 hours or earlier if symptoms are failing to settle.

Review at 2 weeks to assess for response to treatment and the development of any complications which may occur in spite of adequate treatment and include:

  • infertility
  • chronic persistent pain
  • increased incidence of ectopic pregnancy
  • increased risk of further episodes of PID
  • tubo-ovarian abscess.

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Further information

For more information on the diagnosis and management of PID contact Clinic 275.

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Disclaimer

These guidelines are based on review of current literature, current recommendations of the United States Centers for Disease Control and Prevention, World Health Organization, the British Association for Sexual Health and HIV and local expert opinion.

They are written primarily for use by Clinic 275 staff and some flexibility is required in applying them to certain private practice situations.

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