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Pelvic inflammatory disease

Specialties > General practice

Background knowledge 🧠

Definition

  • Pelvic inflammatory disease (PID) refers to the inflammation of the upper female genital tract, including the uterus, fallopian tubes, and ovaries.
  • Primarily caused by sexually transmitted infections (STIs), most commonly Chlamydia trachomatis and Neisseria gonorrhoeae.
  • Can lead to chronic pelvic pain, infertility, and ectopic pregnancy if untreated.

Epidemiology

  • Common among sexually active women, particularly those aged 15-24.
  • Annual incidence in the UK estimated at around 1 in 50 women.
  • Higher risk in women with multiple sexual partners or a history of STIs.
  • Asymptomatic cases are common, complicating diagnosis.

Aetiology and Pathophysiology

  • Primarily caused by ascending bacterial infection from the lower genital tract.
  • Common pathogens: Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, and anaerobic bacteria.
  • Risk factors: multiple sexual partners, prior PID, recent IUD insertion, and douching.
  • Infection leads to inflammation, scarring, and adhesions, particularly in the fallopian tubes.
  • Complications include tubal factor infertility and increased risk of ectopic pregnancy.

Types

  • Acute PID: presents with severe symptoms such as pelvic pain, fever, and purulent discharge.
  • Chronic PID: low-grade infection that may lead to long-term complications like chronic pelvic pain and infertility.
  • Subclinical PID: asymptomatic or mild symptoms, often undiagnosed, but can still cause significant reproductive damage.
  • Recurrent PID: repeated episodes, often due to incomplete treatment or reinfection.

Clinical Features 🌡️

Symptoms

  • Lower abdominal or pelvic pain, often bilateral.
  • Abnormal vaginal discharge, usually purulent.
  • Intermenstrual or post-coital bleeding.
  • Dyspareunia (pain during sexual intercourse).
  • Dysuria (painful urination).
  • Systemic symptoms: fever, malaise, and nausea in severe cases.

Signs

  • Lower abdominal tenderness, often bilateral.
  • Cervical motion tenderness (positive chandelier sign).
  • Adnexal tenderness, indicating possible tubo-ovarian abscess.
  • Fever (temperature > 38°C) in severe cases.
  • Purulent cervical or vaginal discharge.
  • Rebound tenderness and guarding may indicate peritonitis.

Investigations 🧪

Tests

  • Pregnancy test to exclude ectopic pregnancy.
  • Endocervical swabs for Chlamydia trachomatis and Neisseria gonorrhoeae.
  • High vaginal swab for microscopy, culture, and sensitivity.
  • Blood tests: FBC, CRP, and ESR to assess infection and inflammation.
  • Pelvic ultrasound to check for tubo-ovarian abscess or other pelvic masses.
  • Consider laparoscopy for definitive diagnosis in uncertain cases.

Management 🥼

Management

  • Empirical antibiotic therapy: Ceftriaxone 1g IM single dose + Doxycycline 100 mg PO twice daily + Metronidazole 400 mg PO twice daily for 14 days.
  • Admit to hospital if severe disease, pregnancy, or lack of response to outpatient therapy.
  • Consider surgical intervention for abscess drainage if indicated.
  • Partner notification and treatment to prevent reinfection.
  • Advise abstinence from sexual intercourse until treatment is completed.
  • Follow-up in 72 hours to assess clinical response.

Complications

  • Tubo-ovarian abscess, which may require surgical drainage.
  • Chronic pelvic pain affecting quality of life.
  • Infertility due to tubal scarring and occlusion.
  • Increased risk of ectopic pregnancy.
  • Fitz-Hugh-Curtis syndrome: perihepatitis associated with PID.
  • Recurrence of PID due to incomplete treatment or reinfection.

Prognosis

  • With prompt treatment, most women recover without significant complications.
  • Delay in treatment increases the risk of long-term complications, including infertility and chronic pain.
  • Recurrence is common, highlighting the need for effective partner treatment and sexual health education.
  • Prognosis worsens with each episode of PID.

Key Points

  • PID is a common and potentially serious condition in sexually active women.
  • Early diagnosis and treatment are crucial to prevent long-term complications.
  • Management includes broad-spectrum antibiotics, partner treatment, and follow-up.
  • Awareness of risk factors and preventive measures is essential for reducing incidence.
  • Recurrent PID poses a significant risk for fertility and quality of life.

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General practice