Management of Acute Pelvic Inflammatory Disease

MANAGEMENT OF ACUTE PELVIC INFLAMMATORY DISEASE

Dr Judith Kundodyiwa MRCOG

Table of content

1. Definition

2. Complications

3. Diagnosis

4. Treatment

5. General advice

6. Reference

Definition

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.

While sexually transmitted infections (STIs) such as Chlamydia trachomatis

and Neisseria gonorrhoeae have been identified as causative agents,

additional STIs including Mycoplasma genitalium, anaerobes and other

organisms may also be implicated.

COMPLICATIONS

Infertility, ectopic pregnancy and chronic pelvic pain.

DIAGNOSIS

The following clinical features are suggestive of a diagnosis of PID:

• Bilateral lower abdominal tenderness (sometimes radiating to the legs)
• Abnormal vaginal or cervical discharge
• Fever (greater than 38°C)
• Abnormal vaginal bleeding (intermenstrual, postcoital or ‘breakthrough’)
• Deep dyspareunia
• Cervical excitation tenderness on bimanual vaginal examination
• Adnexal tenderness on bimanual vaginal examination (with or without a

palpable mass).

• Consider alternative diagnosis e.g ectopic pregnancy, appendicitis, endometriosis, irritable bowel syndrome, ovarian cyst accident, UTI, functional pain.
• Perform speculum examination and take triple swabs.
• Check FBC and CRP.
• If the diagnosis is clear-cut, there is no need for USS or laparoscopy.
• May need USS if suspicion of pelvic abscess or laparoscopy if severe and not improving after 48 hours of antibiotics.

TREATMENT

A low threshold for empiric treatment of PID is recommended because of the lack of definitive clinical diagnostic criteria and because the potential consequences of not treating of PID are significant.

OUTPATIENT TREATMENT

• Ceftriaxone 500mg IM stat plus
• Doxycycline oral 100mg BD plus Metronidazole oral 400mg BD for 14 days

(If pregnant or breastfeeding– substitute Doxycycline with Erythromycin oral 500mg BD)

Admission criteria

• Other surgical emergency cannot be excluded
• Clinically severe disease
• Tubo-ovarian abscess
• PID in pregnancy
• Lack of response to oral therapy
• Intolerance to oral therapy

INPATIENT TREATMENT

• Give IV therapy until apyrexia for >24hours.
• Administer Gentamicin IV (5mg/kg daily) ( Check your hospital microbiology guideline) gentamycin prescription chart plus intravenous clindamycin 900 mg three times daily and then switch to (once clinical improvement observed)
• doxycycline oral 100mg BD plus Metronidazole oral 400mg BD for 14 days total treatment
• Surgical treatment, by laparoscopy or open laparotomy, should be considered in non-resolving cases or where there is clear evidence of a pelvic abscess. Ultrasound-guided aspiration may be equally effective.
• Consideration should be given to removing an intrauterine contraceptive device (IUD) in women presenting with PID, especially if symptoms have not resolved within 72 hours. The decision to remove it needs to be balanced against the risk of pregnancy in those who have had otherwise unprotected intercourse in the preceding 7 days.
• HIV positive women diagnosed with PID should be treated with the same antibiotic regimens as above. They should be managed in conjunction with their HIV physician.

GENERAL ADVICE

• Analgesia
• Severe infections may require bed rest
• Explain risks of complications (e.g. infertility, ectopic pregnancy, chronic pain) and reinforce with clear accurate written information. (Patient info leaflet available)
• Refer woman and her partner to GUM clinic. (Fast track referral form to sexual health should be used for all women with PID)
• Advise to avoid intercourse until she and her partner have completed any treatment.

Reference