Pelvic inflammatory disease

Pelvic inflammatory disease describes a spectrum of inflammatory disorders of the upper genital tract and surrounding structures caused by ascending infection from the lower genital tract

• bacteria spread directly from the cervix to the endometrium and on to the upper genital tract (1,2,3,4)

Clinical features of PID are not specific and may range from asymptomatic to serious illness (5)

• PID can cause endometritis, parametritis (infection of the structures near the uterus), salpingitis (infection of the fallopian tubes), oophoritis (infection of the ovary), and tubo-ovarian abscess
• peritonitis and perihepatitis can also occur.
  • peritonitis, tubo-ovarian abscess, and severe systemic illness (e.g. fever and malaise) are considered severe forms of PID

PID is an important cause of chronic pelvic pain, infertility and ectopic pregnancy

• among women with PID, 10% to 20% may become infertile, 40% will develop chronic pelvic pain, and 10% of those who conceive will have an ectopic pregnancy (5)

PID is almost always caused by sexually transmitted organisms (2).

PID has a prevalence of between 2% and 12% (5)

PID does not have a diagnostic gold standard.

• the most commonly used diagnostic criteria are based on those from the Centers for Disease Control and Prevention (CDC) (4), namely sexually active young women and
  other women at risk for sexually transmitted disease (STD) who are experiencing recent pelvic or lower abdominal pain where no cause other than PID can be identified, and one or more of the following minimum criteria are present on pelvic examination:
  • cervical motion tenderness,
  • uterine tenderness,
  • or adnexal tenderness
• the requirement for all three minimum criteria to be present increases the specificity of the diagnosis but reduces sensitivity (5)

Key points (6):

• refer women and sexual contacts to GUM
  
  
• raised CRP supports diagnosis, absent pus cells in HVS smear good negative predictive value
  
  
• exclude:
  • ectopic pregnancy, appendicitis, endometriosis, UTI, irritable bowel, complicated ovarian cyst, functional pain
    
    
• moxifloxacin has greater activity against likely pathogens, but always test for gonorrhoea, chlamydia, and M. genitalium
  
  
• If M. genitalium tests positive use moxifloxacin

Reference:

1. Ross J et al. 2017 European guideline for the management of pelvic inflammatory disease. Int J STD AIDS. 2018 Feb;29(2):108-114.
2. Center for disease control 2006. Morbidity and mortalty weekly report - Sexually Transmitted Diseases Treatment Guidelines
3. 2019 United Kingdom National Guideline for the Management of Pelvic Inflammatory Disease; British Association for Sexual Health and HIV (BASHH - 2018, last updated 2019)
4. Workowski KA, Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR. Recommendations and Reports : Morbidity and Mortality Weekly Report
   2015;64(RR-03):1-137.
5. Savaris RF et al. Antibiotic therapy for pelvic inflammatory disease. Cochrane Database of Systematic Reviews 2020, Issue 8. Art. No.: CD010285. DOI:0.1002/14651858.CD010285.pub3.
6. Public Health England (June 2021). Managing common infections: guidance for primary care