Presentation notes about PID for medical students, undergraduate doctors and other health allied courses. It was prepared by medical doctor at Free Medicine.

1. PID
PELVIC INFLAMMATORY DISEASE
1
DR. LAITON, MD

2. OUTLINE
1. Introduction
2. Epidemiology
3. Risk Factors
4. Protective Factors
5. Etiology
6. Pathophysiology
7. Clinical Presentation
8. Physical Examination
9. Differential diagnosis
10. Investigations
11. Treatment
12. Complication
13. Prevention

3. 1. INTRODUCTION
• Pelvic Inflammatory Disease (PID) is an infectious and
inflammatory disorder of the upper female genital tract,
including the uterus, fallopian tubes, and adjacent pelvic
structures. PID is initiated with infection that ascends from
the vagina and cervix into upper genital tract.
• PID may spread to the abdomen, including perihepatic
structures (Fitz-Hugh-Curtis syndrome).
• High-risk patients are menstruating women younger than
25 years who has multiple sex partner, does not use
contraception (barrier), and lives in an area with a high
prevalence of STD.
• The most common presenting complaint is lower
abdominal pain and abnormal vaginal discharge.

4. 1. INTRODUCTION CONT.
• DDX: Appendicitis, cervicitis, UTI, endometriosis, ovarian
torsion, and adnexal tumors, for example: ectopic
pregnancy.
• To rule out ectopic pregnancy, UPT must be performed
for child bearing women with LAP.
• Complications of PID includes Tubo-ovarian abscess
(TOA), localized peritonitis, and perihepatitis (Fitz-Hugh-
Curtis syndrome).
• Acute rupture of TOA is the life threatening which may
result in diffuse peritonitis and necessitate urgent
abdominal surgery.
• Laparoscopy is the criterion standard for the diagnosis of
PID.

5. 2. EPIDEMIOLOGY
• The incidence and prevalence of PID is on the rise due to
the rise in STDs.
• The incidence varies from 1 – 2% per year among
sexually active women.
PID among Sexually Active Women
PID case
Healthy women

6. 2. EPIDEMIOLOGY CONT.
• About 85% are spontaneous infection in sexually active
female of reproductive age, via sexual intercourse.
• The remaining 15% follow procedures (include
endometrial biopsy, curettage, IUD and hysteroscopy).
Mode of Transmission of PID
Following Procedure
Spontaneous Infection

7. 2. EPIDEMIOLOGY CONT.
• Two thirds are restricted to young women of less than 25
years and the remaining one-third among older than 25
years.
Age distribution of PID
younger than 25 years
25 years and older

8. 3. RISK FACTORS
Risk factors for PID include:
1. Menstruating teens
2. Multiple sexual partners
3. Unprotected sex intercourse
4. History of prior STIs
5. Partner with history of recent STIs
6. History of sexual abuse
7. Vaginal douching
8. Gynaecological procedures
– Endometrial biopsy
– Curettage
– Hysteroscopy

9. 4. PROTECTIVE FACTORS
Protective factors for PID include:
1. Barrier methods
– Condom and diaphragm
2. Oral steroidal contraceptives
– Produce thick mucus plug and decrease duration of
menstruation preventing ascent of bacteria.
3. Monogamy
4. Abstinence and Celibacy
5. Pregnancy
– Minimum risk in first 12 weeks.
6. Menopause
7. Vaccines
– HPV and Hepatitis B Vaccine

10. 5. ETIOLOGY
• PID is a polymicrobial infection (30% - 40% of cases) that
is initiated with STIs that ascends from the vagina and
cervix into upper genital tract.
• Common organisms:
– Chlamydia trachomatis (predominant)
– Neisseria gonorrhoeae
• Other organisms:
– Trichomonas vaginalis
– Gardnerella vaginalis (linked with BV)
– Haemophilus influenzae
– Mycoplasma hominis and Mycoplasma genitalium
– Streptococcus agalactiae
– Bacteroides and anaerobes

11. 6. PATHOPHYSIOLOGY
Most cases of PID are presumed to occur in 2 stages.
1. Acquisition of a vaginal or cervical infection.
– This is infection is often sexually transmitted and may be
asymptomatic.
2. Direct ascent of microorganisms from vagina or cervix
to the upper genital tract.
– The exact mechanism of ascent is unclear, multiple factors are
involved.
– Cervical mucus provides a functional barrier against ascent.
– The efficacy of this barrier may be decreased by vaginal
inflammation, hormonal changes during ovulation and
menstruation, antibiotic treatment which disrupt normal
endogenous flora, opening of the cervix during menstruation
(+retrograde menstrual flow), and sexual intercourse (+sperm).

12. 6. PATHOPHYSIOLOGY CONT.
• In upper genital tract, a number of microbial and host factors
appear to influence the degree of inflammation and the
amount of subsequent scarring.
• Infection of fallopian tubes initially affects the mucosa, but
inflammation may rapidly become transmural, causing TOA
and hydrosalpinx.
• Inflammation may extend to uninfected parametrial
structures, including the bowel.
• Infection may extend via spillage of purulent materials from
the fallopian tubes or via lymphatic spread beyond pelvis to
produce acute peritonitis and acute perihepatitis (Fitz-Hugh-
Curtis syndrome).
• PID rarely occurs in pregnancy, however choriamnionitis can
occur in the first 12 weeks GA which may result in fetal loss.

13. 7. CLINICAL PRESENTATION
• Depending on the severity of the infection, patients with
PID may be minimally symptomatic or may present with
toxic symptoms.
• Those symptoms may include:
1. Lower abdominal pain
2. Abnormal vaginal discharge (75%)
3. Unanticipated vaginal bleeding, often postcoital (40%)
4. Fever of 38C and higher (38%)
5. Abnormal uterine bleeding (33%)
6. Nausea and vomiting (Late)
7. Pelvic pain
8. Painful coitus or pain after coitus
• Some cases of PID are asymptomatic (Silent PID).

14. 7. CLINICAL PRESENTATION CONT.
• Lower abdominal pain described:
SITE Suprapubic Region
ONSET
Gradual, it begins a few days after the onset of the last
menstrual period
CHARACTER Dull, aching or crampy, bilateral, and constant
RADIATION Lower pain and waist
ASSOCIATION Fever, abnormal PV discharge, nausea  vomiting
TIME
Last less than 7 days, if the pain last for more than 3
weeks, the diagnosis is unlikely to be PID
EXACERBATING Motion, exercise, or coitus
SEVERITY Depending of extend of ascent

15. 8. PHYSICLA EXAMINATION
The following are signs of PID:
1. Abdominal Examination:
– Pelvic or lower abdominal tenderness
– Rebound lower abdominal tenderness
– Involuntary muscle guarding
2. Pelvic Examination:
– Abnormal Cervical or vaginal mucopurulent discharge
– Cervical motion tenderness
– Uterine tenderness
– Adnexal tenderness
3. General Examination:
– Febrile (>38.3C)

16. 8. PHYSICLA EXAMINATION
• For complicated PID with peritonitis, the signs will be:
– Rebound lower abdominal tenderness
– Involuntary muscle guarding
• For complicated PID with TOA, the signsl be:
– Adnexal fullness
– Disproportionate unilateral adnexal tenderness
• For complicated PID with perihepatitis (Fitz-Hugh-
Curtis Syndrome), the signs be:
– RUQ tenderness
– Jaundice

17. 9. DIFFERENTIAL DIAGNOSIS
• Appendicitis
• Cervicitis
• UTI
• Endometriosis
• Ovarian Torsion
• Ovarian Cysts
• Interstitial Cystitis
• Adnexal Tumors
• Ectopic pregnancy
– All female patients of childbearing age with LAP require
pregnancy test. PID is the most common incorrect diagnosis in
missed ectopic pregnancy.

18. 10. INVESTIGATIONS
1. Laparoscopy
– The criterion standard for the diagnosis of PID.
2. Transvaginal USS or MRI
– Showing thickened, fluid-filled tubes with or without free
pelvic fluid or tubo-ovarian abscess (TOA).
– Help to rule out some ddx.
3. Endometrial biopsy
– Showing endometritis.
4. Examination of abnormal vaginal discharge
– Wet preparation
– Gram stain
– Culture and sensitivity
– Microscopy – abundant white blood cells and other cells
5. Elevated ESR and CRP

19. 20. INVESTIGATIONS CONT.
6. ELISA and Nucleic Acid Amplification Test (NAAT)
– Evidence of cervical infection with Neisseria gonorrhoeae or
Chlamydia trachomatis.
7. Qualitative and quantitative PCR
– To DNA of with N gonorrhoeae or C trachomatis.
8. Urine Pregnancy Test (UPT)
– If positive, rule out Ectopic Pregnancy
– UPT will also help in selection of antibiotic regimen
9. Complete Blood Count (CBC)
– WBC > 10,000/L
10. Rapid Protein Reagin (RPR) test for syphillis
11. Hepatitis virus and HIV
12. Urinalysis to help exclude UTI

20. 10. INVESTIGATIONS CONT.
Laparoscopic findings and severity of PID:
• Mild: Tubal oedema, erythematic tube, no purulent
exudates and mobile.
• Moderate: Purulent exudates from fimbrial ends, tubes
not mobile.
• Severe: Pyosalpinx, inflammatory complex,
Hydrosalpinx, tubo-ovarian abscess
• Violin string like adhesions in the pelvis and around the
liver suggests chlamydial infection.

21. 10. INVESTIGATIONS CONT.
Laparoscopic findings showing adhesions around the uterus

22. 10. INVESTIGATIONS CONT.
Laparoscopic findings showing violin string like adhesion
(perihepatic adhesion) in Fitz-Hugh-Curtis Syndrome.

23. 11. TREATMENT
• Aims of Treatment:
1. Relief of acute symptoms
2. Eradication of current infection
3. Minimize the risk of long-term sequalae
4. Reduce the risk of transmission to sexual partners
• Antibiotic therapy alone is successful in 33% - 75% of cases,
while surgical therapy is need in 20% cases.
• It is recommended that IUDs to be left in place, except if
IUDs was put in place recently.
• Patients who do not improve in 72 hours should be re-
evaluated for possible laparoscopic or surgical intervention
and for reconsideration of other possible diagnoses.
• Most TOAs (80%) resolve with antibiotics administration.

24. 11. TREATMENT CONT.
• Indications for Hospitalization:
1. Uncertain diagnosis
2. Pelvic abscess on USS
3. Pregnancy
4. Inability to tolerate oral antibiotic regimen
5. Severe illness, vomiting, temperature > 38C
6. Immunodeficiency (HIV patient with low CD4 count or patient
who are using immunosuppressive medications)
7. Failure to improve clinically after 72 hours of outpatient
therapy
8. Suspected tubo-ovarian abscess (TOA)
• More than 90% of HIV-positive patient with PID are
treated as outpatients, with same antibiotic regimen.

25. 11. TREATMENT – OUTPATIENT.
REGIMEN A
Ceftriaxone 250 mg IM or IV single dose PLUS
Doxycycline 100 mg PO BID for 14 days PLUS
Metronidazole 400 mg PO TID for 14 days
REGIMEN B
Cefixime 400 mg PO single dose PLUS
Doxycycline 100 mg PO BID for 14 days PLUS
Metronidazole 400 mg PO TID for 14 days

26. 11. TREATMENT – OUTPATIENT.
• Oral doxycycline can be replaced by oral azithromycin.
– Azithromycin 2g PO single dose or
– Azithromycin 500mg PO OD for 3 days.
• Oral therapy should include clindamycin or
metronidazole in patient with TOA and recent
gynaecological instrumentation in 2-3 weeks.
– Metronidazole 400 mg PO TID for 14 days
– Clindamycin 600 – 900 mg PO TID for 14 days

27. 11. TREATMENT – INTPATIENT.
REGIMEN A
Ceftriaxone 1 g IV OD for 5 – 7 days PLUS
Doxycycline 100 mg PO BID for 7 - 14 days PLUS
Metronidazole 500 mg IV TID for 7 - 14 days
REGIMEN B
Cefixime 400 mg PO BID for 7 – 14 days PLUS
Doxycycline 1000 mg PO BID for 7 - 14 days PLUS
Metronidazole 500 mg IV TID for 7 - 14 days

28. 11. TREATMENT – INTPATIENT.
REGIMEN C
Clindamycin 900 mg IV TID for 7 – 14 days PLUS
Gentamicin 1.5 mg/Kg TID for 7 – 14 days
ALTERNATIVE REGIMEN
Ampicillin-sulbactam 3 g IV QID for 7 – 14 days PLUS
Doxycycline 100mg IV or PO BID for 7 – 14 days

29. 11. TREATMENT - SURGERY
• Indications of surgery:
1. Generalized peritonitis
2. Pelvic abscess
3. TOA which doesn’t response to medication in 72 hours
4. Infertility due to tubal obstruction
• Surgical therapy can be through laparoscopy or
laparotomy approach.
• Laparoscopic approach can be:
– Laparoscopic pelvic lavage
– Laparoscopic abscess drainage, and
– Laparoscopic adhesiolysis.

30. 11. TREATMENT - SURGERY
• Laparotomy approach aiming to preserve reproductive
potential can be:
 Simple drainage
 Adhesiolysis, and copious irrigation
 Unilateral adnexectomy
 Unilateral salpingo-oophorectomy
• Laparotomy approach without reproductive potential
can be:
 Bilateral salpingo-oophorectomy
 hysterectomy

31. 12. COMPLICATIONS
Immediate complication of PID includes:
1. Pelvic peritonitis
2. Generalised peritonitis
3. Septicaemia producing arthritis and myocarditis
Immediate complication of PID includes:
1. Dyspareunia
2. Tubo-ovarian abscess (TOA)
3. Hydrosalpinx
4. Chronic pelvic pain
5. Ectopic pregnancy
6. Tubal factor infertility (TFI)
7. Implantation failure with in IVF
8. Formation of adhesions

32. 12. PREVENTION
Primary Prevention:
1. Reduce number of sexual partners.
2. Avoiding unsafe sexual practices.
3. Avoid sexual practices with high risk partners.
4. Routinely using appropriate barrier protection.
5. Delay in sexual activity until age 16 years or older.
Secondary Prevention:
1. Screening for infections in high risk population.
2. Rapid diagnosis and effective treatment of STDs and UTI.
Tertiary Prevention:
1. Early intervention and complete treatment.

33. 13. REFERENCES
1. Williams Gynaecology Third Edition
2. Dutta’s Textbook of Gynaecology Eighth Edition
3. Pelvic Inflammatory Disease (PID). eMedicine:
https://emedicine.medscape.com/article/256448-overview
4. Uptodate (2021). Pelvic Inflammatory Disease:
https://www.uptodate.com/contents/pelvic-inflammatory-disease-
treatment-in-adults-and-adolescents
5. CDC (2022). Pelvic Inflammatory Disease:
https://www.cdc.gov/std/treatment-guidelines/pid.htm
6. Wikipedia (2022). Pelvic inflammatory disease:
https://en.wikipedia.org/wiki/Pelvic_inflammatory_disease#:~:text=Pelv
ic%20inflammatory%20disease%2C%20also%20known
7. Muni Venkatesh (2015). Pelvic inflammatory diseases:
https://www.slideshare.net/munivenkatesh420/pelvic-inflammatory-
diseases

34. “Life is A Sexually Transmitted Disease and
The Mortality Rate of One Hundred Percent”
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