pelvic inflammatory disease an update for mbbs,mcps,fcps,ms,dgo,mrcog candidates and general practitioner

1. PELVIC INFLAMMATORY DISEASE
PROF SHABNAM NAZ
DEPT OF OBGYN
SMBB MEDICAL UNIVERSITY
LARKANA

2. OVERVIEW
PID is a sexually transmitted infection of the
upper genital tract, typically involving .
• fallopian tubes (salpingitis)
• uterus (endometritis)
• ovaries (oophoritis )
• and pelvic cavity. (Peritonitis )
The infection ascends to the upper
reproductive tract from the vagina and/or
the cervix.
INCIDENCE --- one in ten women suffer
from PID ,may be symptomatic or

3. - The most common organism is
• Chlamydia
• Neisseria gonorrhoeae .
• Gardnerella vaginalis,
• anaerobes (including Prevotella,
Atopobium and Leptotrichia) .
• Mycoplasma genitalium
list the organisms have a
role in the aetiology of PID?
• Chlamydia trachomatis
• Neisseria gonorrhoeae
• Gardnerella vaginalis
• Mycoplasma hominis
• Mycoplasma genitalium
• Anaerobes.
• Ureaplasma urealyticum
• Trichomonas vaginalis
• Haemophilius influenza
• Streptococcus agalactiae
• Enteric Gram-negative rods
• Enterococcus
• Peptococcus species
• Herpes simplex virus 2
• Cytomegalovirus

4. • Risk factors
• Young women <25 years of age
• Multiple sexual partners
• Unprotected sexual intercourse
• History of previous PID
• Intrauterine device----the insertion of an intrauterine device (IUD) increases the risk of
developing PID but only for 4-6 weeks after insertion. This risk is probably highest in women
with pre-existing gonorrhea or C. trachomatis.
• Douching – douching is a potential risk factor for PID as it can result in a
change of the vaginal flora and introduce bacteria from the vagina into the
upper reproductive organs.
• Lower socioeconomic status
• Husband/sexual partner with urethritis or STI.

5. • PID can occur after termination of
pregnancy, pelvic operations (such
as hysteroscopy) and childbirth.
• Hematogenous infection is a rare
cause of PID, except in cases of
tuberculous PID.
• Direct extension of infection from
adjacent viscera (appendicitis or
diverticulitis) and uterine
instrumentation are more important
risk factors in postmenopausal PID.
• Tubo-ovarian abscess in
postmenopausal women can be
associated with gynaecological
malignancy.

6. What are the Clinical Features suggestive of a
diagnosis of PID?
Symptoms
1. Lower abdominal pain which is typically bilateral
2. deep dyspareunia
3. abnormal vaginal bleeding, including post coital, inter-
menstrual and menorrhagia
4. abnormal vaginal or cervical discharge which is often
purulent
Signs
1. Fever (>38°C) ,tachycardia dehydaration. (Signs of
sepsis )
2. Lower abdominal tenderness which is usually
bilateral , guarding +,-
3. on bimanual vaginal examination Adnexal tenderness
4. Cervical motion tenderness
Women with HIV may have more severe symptoms
associated with PID but respond well to standard
antibiotic therapy . No change in treatment
recommendations compared to HIV uninfected patients
History. To be asked from pt
• Age ,marital status. Ist marriage or
second or husband marriages (multiple
sexual partners )
• h/o Pain
• Vaginal discharge Blood stained purulent
• Fever ,nausea vomiting ( acute pid )
• Menorrhagia/ IMB /dysmenorrhoea
• Dysparunia/pcb
• Any urinary or bowel problem
• Contraception. Iucd ,(condomes
protective)
• Pap smear --
• Obs : History of induced abortion or top
• Any postpartum pyrexia
• Past surgical history--- Any gynae
surgery
• Past medical ---- TB,pid,hiv ,d.m
• Partner history of std. ( Discharge pain
warts )
• SHE---- low SE status
• Medication ---- any history of previous tt of
pid,std ,tb,immune suppressive agents
• Allergy --- help ful in selction of drug

8. Why is it Important to Treat PID ? /. CONSEQUES.
immediate
Pelvic peritonitis or even generalized peritonitis
Septicemia—producing arthritis or myocarditis.
Late
• Dyspareunia
• Infertility
after one episode --2%,
after two episodes increases to 25%
after three raises to 50%. It is due to tubal damage or tubo-ovarian
mass
• Chronic pelvic inflammation is due to recurrent or associated pyogenic
infection
• Formation of adhesions or hydrosalpinx or pyosalpinx and tubo-ovarian
abscess
• Chronic pelvic pain .
• ectopic pregnancy (6-10 fold). --- The interval between PID and tubal damage can
be as little as 1 week, so it is important to treat the initial episode promptly.
• The Fitz-Hugh-Curtis syndrome comprises right upper quadrant pain
associated with perihepatitis (occurs in some women with PID). =>
Although laparoscopic division of hepatic adhesions has been

10. Investigations.
pregnancy test to exclude early pregnancy complications that mimic PID
Cbc.
o Raised wbc
o elevated ESR or C reactive protein also supports the diagnosis but is non-specific
• urine dipstick and if positive then midstream urine specimen for microbiology culture and sensitivity.
• vaginal and endocervical swabs
specific tests for Chlamydia ------(PCR/NAAT),
N. gonorrhoea (culture or NAAT) – may require referral to the genitourinary medicine (GUM)
Serology for syphilis
HBS AG ,HCV AB,HIV AB --- common with std
If suspect TB in history --- than x ray chest ,m .test, laryngeal swabs for afb
If s/s suggestive of uti than urine d/r and c/s .

11. Sonography: It is of limited value for uncomplicated PID but is helpful if an
abscess or hydrosalpix is suspected .Dilated and fluid- filled tubes, fluid in the
pouch of Douglas or adnexal mass are suggestive of PID. It may be
employed where clinical examination is difficult or is not informative because
of acute tenderness or obesity.
. Doppler ultrasound can detect increased blood flow associated with pelvic
infection and may be useful, but it cannot differentiate between PID and other
causes of increased vascularity such as endometriosis
o MRI or CT scanning of the pelvis may be helpful in differentiating PID
from alternative diagnoses25-27 but are not indicated routinely. MRI, when
available, is preferable since it provides high resolution images and avoids
ionising radiation in women of reproductive age.
Lapaorscopy – gold standard reserved only in those cases in which
differential diagnosis includes salpingitis, appendicitis or ectopic pregnancy.
Nonresponding pelvic mass also needs laparoscopic clarification.

12. Laparoscopic Findings and Severity of PID
• Mild: Tubes: Edema, erythema, no purulent exudates and are
mobile
• Moderate: Purulent exudates from the fimbrial ends, tubes–
not freely movable
• Severe: Pyosalpinx, inflammatory complex, abscess
‘Violin string’ like adhesions in the pelvis and around the
• liver suggests chlamydial infection

13. The differential diagnosis ?
1- Ectopic pregnancy=> pregnancy should be excluded in all women suspected of
having PID
2. Acute appendicitis => nausea and vomiting occurs in most patients with
appendicitis but only 50% of those with PID. Cervical movement pain will occur in
about a quarter of women with appendicitis
3. Endometriosis=> the relationship between symptoms and the menstrual cycle may
be helpful in establishing a diagnosis
4. Complications of an ovarian cyst (torsion or rupture)=> often of sudden onset
5. Urinary tract infection=> often associated with dysuria and/or urinary frequency
6. Functional pain => may be associated with longstanding symptoms
7.Diverticulitis

18. PREVENTION
The incidence of PID may have reduced with
screening programmes and public education
campaigns, however, no reduction in the longer-
term complications of PID have been
demonstrated
Protective Factors
􏰃 Contraceptive practice condom, diaphragm
with spermicides
 Oral contraceptives pills.----Produce thick
mucus plug preventing ascent of sperm and
bacterial penetration
 . Vaccines. (hepatitisB,HPV. )
prevent reinfection:
Educating the patient to avoid
reinfection and the potential hazards of
it
􏰃 The patient should be warned
against multiple sexual partners
􏰃 To use condom
􏰃 The sexual partner or partners
are to be traced and properly
investigated to find out the
organism and treated effectively.
If they have got nongonococcal
urethritis, they should be treated
with tetracycline 500 mg 6 hourly or
doxycycline 100 mg twice daily for
7 days.

20. What is the Management of PID?
-delaying treatment increases the risk
of long term sequelae such as
ectopic pregnancy, infertility and pelvic
pain so that a low threshold for
empiric treatment of PID is
recommended.
Once diagnosis of PID, empirical
antibiotic treatment, should be
considered and usually offered in any
young (under 25) sexually active
woman who has recent onset, of
bilateral lower abdominal pain
associated with local tenderness on
bimanual vaginal examination, in
whom pregnancy has been excluded.
-Broad spectrum antibiotic therapy is
required to cover N. gonorrhoeae, C.
trachomatis and a variety of aerobic
and anaerobic bacteria commonly
General Advice
• Rest is advised for those with severe
disease.
• Appropriate analgesia should be provided.
• Intravenous therapy is recommended for
patients with more severe clinical disease
e.g. (pyrexia > 38 C, clinical signs of tubo-
ovarian abscess, signs of pelvic peritonitis)
• To avoid reinfection, patients should be
advised to avoid oral or genital intercourse
until they, and their partner(s), have
completed their treatment
• A detailed explanation of their condition with
particular emphasis on the long term
implications for the health of themselves
and their partner(s) should be provided,
reinforced with clear and accurate written

21. When giving information to patients, the clinician should consider the
following:
• an explanation of what treatment is being given and its possible adverse
effects
• that following treatment fertility is usually maintained but there remains a risk
of future infertility, chronic pelvic pain or ectopic pregnancy
• clinically more severe disease is associated with a greater risk of sequelae
• repeat episodes of PID are associated with an exponential increase in the
risk of infertility
• the earlier treatment is given the lower the risk of future fertility problems
• future use of barrier contraception will significantly reduce the risk of PID
• the need to screen sexual contacts for infection to prevent re-infection

22. Outpatient therapy is as effective for patients
with clinically mild to moderate PID
In patient therapy .(Admission ) for
parenteral therapy, observation, further
investigation and/or possible surgical
intervention should be considered in the
following situations
• a surgical emergency cannot be excluded
• lack of response to oral therapy
• clinically severe disease
• presence of a tubo-ovarian abscess
• intolerance to oral therapy
• pregnancy
Outpatient Regimens
First Line Therapy
i.m. ceftriaxone* 1g single dose
followed by oral doxycycline 100mg
twice daily
plus metronidazole 400mg twice
daily for 14 days
• Second Line Therapy
oral ofloxacin 400mg twice daily
• plus oral metronidazole 400mg
twice daily for 14 days
Or
• oral moxifloxacin 400mg once
daily for 14 days
• Levofloxacin is the L isomer of
ofloxacin and has the advantage of
once daily dosing (500mg OD for 14
days). It may be used as a more
convenient alternative to ofloxacin
TREATMENT :
All the recommended regimens are of similar
efficacy.

23. when the above treatments are not appropriate e.g.
allergy, intolerance What to do?
 intramuscular ceftriaxone 1g immediately, followed by azithromycin 1
g/week for 2 weeks
 single doses of azithromycin have the potential to induce macrolide
resistance in M. genitalium and, if possible, use should be restricted to
women who are known to be M. genitalium negative.
 Note. If initial test is positive for M. genitalium start treatment with moxifloxacin. This
agent currently has good microbiological activity against.M. genitalum Treatment failure
following the use of any of the recommended regimens has been reported but is least
likely following treatment with moxifloxacin.

24. INPATIENT REGIMENS
1,i.v. ceftriaxone 2g daily plus i.v. doxycycline 100mg
twice daily followed by oral doxycycline 100mg twice
daily plus oral metronidazole 400mg twice daily for a
total of 14 days
2,i.v. clindamycin 900mg 3 times daily plus i.v.
gentamicin (2mg/kg loading dose)
followed by 1.5mg/kg 3 times daily [a single daily
dose of 7mg/kg may be substituted]) followed by either
oral clindamycin 450mg 4 times daily or oral
doxycycline 100mg twice daily plus oral
metronidazole 400mg twice daily to complete 14 days
Gentamicin levels should be monitored if this regimen is
used.
intravenous therapy should be continued until 24 hours
after clinical improvement and then switched
Alternative Regimens if allergy
,intolerance
i.v. ofloxacin 400mg BD plus i.v.
metronidazole 500mg TID for 14
days.
i.v. ciprofloxacin 200mg BD plus i.v.
(or oral) doxycycline 100mg BD plus
i.v. metronidazole 500mg TID for 14
days

25. Pregnancy and Breastfeeding
• PID in pregnancy is uncommon but associated with an increase in both
maternal and fetal morbidity, therefore parenteral therapy is advised (e.g. i.v.
ceftriaxone, i.v. erythromycin and i.v. metronidazole switching to oral therapy
following clinical response and completing 2 weeks of treatment)

26. Surgical Management
• laparoscopy may help early
resolution of severe disease by
dividing adhesions and draining
pelvic abscesses
• but ultrasound guided aspiration of
pelvic fluid collections is less
invasive and may be equally
effective
• laparotomy may be required to
assess and treat clinically severe
pelvic infection
• it is possible to perform adhesiolysis
in cases of perihepatitis but there is
no evidence on whether this is
superior to only using antibiotic
Indications of Surgery
The indications of surgery are
comparatively less. The
unequivocal indications are:
􏰃 Generalized peritonitis
􏰃 Pelvic abscess
􏰃 Tubo-ovarian abscess
which does not respond (48–
72 hours) to antimicrobial
therapy.

27. Sexual Partners :/ contact tracing
 -Current male partners of women with PID should be contacted and offered health
advice and screening for gonorrhoea and chlamydia.
 Other recent sexual partners may also be offered screening
 - tracing of contacts within a 6 month period of onset of symptoms is recommended but
this time period may be influenced by the sexual history .
 - Gonorrhoea or chlamydia diagnosed in the male partner should be treated appropriately
and concurrently with the index patient.
 - Because many cases of PID are not associated with gonorrhoea or chlamydia, broad
spectrum empirical therapy should also be offered to male partners e.g. azithromycin 1g
single dose
 - If screening for gonorrhoea is not available additional specific antibiotics effective
against Neisseria gonorrhoeae should be offered e.g. i.m. ceftriaxone 1gm single dose
 - Partners should be advised to avoid intercourse until they and the index patient have
completed the treatment course .

28. Follow Up
Review at 72 hours is recommended for those with moderate or severe symptoms or signs
Failure to improve suggests the need for further investigation, parenteral therapy and/or surgical
intervention.
if symptoms improve Further review, either in clinic or by phone, 2-4 weeks after therapy is
recommended to ensure:
•adequate clinical response to treatment
•compliance with oral antibiotics
•screening and treatment of sexual contacts
•awareness of the significance of PID and its sequelae
•repeat pregnancy test, if clinically indicated
•If initial testing for gonorrhoea was positive, repeat testing should be routinely performed after 2 to 4
weeks.
• If initial testing for C. trachomatis was positive, repeat testing after 3 to 5 weeks
•if the initial test for M. genitalium is positive: ---The optimal time for repeat testing is not known but 4
weeks is recommended based on expert opinion.
•

29. Key points
• PID is caused by polymicrobial􏰃
infection. Chlamydia and gonorrhoea
are implicated most frequently􏰃
in PID.
• These initially cause cervicitis and if untreated then spread to the upper
genital tract in 10–30% of women.
• If PID is inadequately treated, it can result in complications, such as
tubo-ovarian abscess, adhesions, pelvic pain and subfertility.
• Risk factors for tubo-ovarian abscess are a history of PID, multiple
sexual partners, an intrauterine device and immunosuppression.
• Tubo-ovarian abscess are more common in the third and fourth
decades of a woman's life.
• First-line treatment in acute PID is as follows:
• inpatient - intravenous ceftriaxone 2 g daily until clinical improvement
(to cover gonorrhoea) + doxycycline and metronidazole for 14 days
• outpatient - intramuscular ceftriaxone 500 mg single dose + doxycycline
and metronidazole for 14 days

30. key points.
• C. trachomatis is the commonest identified cause accounting for 14-
35% of cases
• N. gonorrhoeae and C. trachomatis are detected less commonly in
older women with PID
• Clinical trial data support the use of cefoxitin for the treatment of
PID but it is not easily available in the UK so used ceftriaxone
with similar efficecy.
• Metronidazole is included in some regimens to improve coverage
for anaerobic bacteria.
•
• -Ofloxacin and moxifloxacin should be avoided in patients who
are at high risk of gonococcal PID because of increasing
quinolone resistance in the UK (e.g. when the patient’s partner
has gonorrhoea, in clinically severe disease, following sexual
contact abroad).

31. Key points.
- Quinolones should also be avoided as first line empirical treatment for
PID in areas where >5% of PID is caused by quinolone resistant
Neisseria gonorrhoeae.
- Replacing intramuscular ceftriaxone with an oral cephalosporin (e.g.
cefixime) is not recommended because there is no clinical trial evidence to
support its use, and tissue levels are likely to be lower which might
impact on efficacy
- the use of doxycycline plus metronidazole, in the absence of ceftriaxone, is not
recommended because the evidence base is limited, previous trials have
reported significant rates of treatment failure and the addition of ceftriaxone
improves treatment outcome

32. BRAIN
STORMING

33. IUCD USER DEVELOP PID HOW
WILL YOU TRET HER
n women with mild to moderate PID
the IUD may be left in situ a
review should be performed after 48-
72 hours
IUD removed if significant clinical
improvement has not occurred.
The decision to remove the IUD needs
to be balanced against the risk of
pregnancy in those who have had
otherwise unprotected intercourse in
the preceding 7 days.
Emergency hormonal contraception
following removal of an IUD may be
appropriate for some women in this
situation.
FOR LONG-TERM INTRAUTERINE DEVICE
USERS, IF AN ACTINOMYCES-LIKE ORGANISM
IS IDENTIFIED ON A ROUTINE SMEAR IN:
asymptomatic women:
• the coil does not need to be removed
• no antibiotics are required
• no follow-up is required
• if the coil is due for removal or the woman
wants it to be removed, then the coil should
not be sent for culture.
symptomatic women
with(pain/dyspaereunia/IMB/vaginal
discharge/pelvic inflammatory disease)
• the intrauterine device should be removed
and sent for culture;
• alternative contraception advised
• a course of antibiotics (amoxicillin 250 mg
three times daily for 2 weeks or
erythromycin 500 mg three times daily􏰃
for 2
weeks) should be prescribed with referral to
gynaecologists.

34. WOMEN WITH A TUBO-OVARIAN ABSCESS
commonly present with symptoms and signs similar to those of
sepsis. The initial investigation is inflammatory markers and
transvaginal ultrasound.
If ultrasound is inconclusive, then MRI/CT is required to aid the
diagnosis.
The diagnosis is based on:,history,examination nvestigations
Investigations. ---(full blood count, C-reactive protein, swabs
and cultures)
imaging (ultrasound, MRI and CT)
laparoscopy (this has been the gold standard in diagnosis and
treatment for many years).
However, with the advancement in ultrasound machines, more
evidence is emerging in support of image-guided drainage of
pelvic abscess with concomitant antibiotics

35. • For a suspected abscess, transvaginal ultrasound (TVUS) is the first investigation of choice.
• TVUS-guided aspiration with broad-spectrum antibiotics is equally effective and less invasive for
women.
• If laparoscopy/laparotomy is performed then a conservative approach is undertaken to reduce the
risk of intraoperative complications.
• In postmenopausal women with a diagnosis of tubo-ovarian mass, a further investigation is
required to exclude malignant disease.
• If patients are diagnosed with tubo-ovarian abscess and have a long-term coil then the coil
should be removed, sent for microscopy and long-term antibiotics commenced for 3 months.
• Chronic pelvic pain and sexual dysfunction have long-term implications leading to relationship
difficulties and general ill health.
• Women with recurrent PID can also develop menstrual irregularities, subfertility and have a high
risk of ectopic pregnancy. Referral to a local GUM clinic can be made for a full sexual health
screen for both the woman and her partner(s).

37. • REFRANCES
• rcog guidline on pid 2019