1. Pelvic Inflammatory
Disease

2. Introduction
 Acute & subclinical infection of the upper female genital tract
 Uterus, fallopian tubes and ovaries (endometritis, salphingitis, oophoritis,
peritonitis, perihepatitis, or tubo-ovarian abscess)
 Disease of sexually active females

3. Etiology
 Neisseria gonorrhoeae & chlamydia trachomatis account for majority of the
cases
 Others - Mycoplasma genitalium, anaerobes, Gardnerella vaginalis,
Haemophilus influenzae, enteric gram-negative organisms, and
Streptococcus agalactiae
 Mycobacterium tuberculosis and actinomycosis
 Other causes -cytomegalovirus (CMV), Mycoplasma hominis, and Ureaplasma urealyticum
poly microbial infection

4. Pathogenesis
 Ascending lower genital tract infections
 Epithelial damage by the primary pathogens- opportunistic entry of
others
 Inflammation injury  late complications like adhesion and abscess
 Modalities that disrupt the barrier – promotes PID
 Initiated by a single microbe- later it becomes poly microbial

5. Clinical spectrum
 Ranges from acute, sub clinical to chronic
 Acute- mild, moderate and severe disease
 Sub clinical- exact proportion of sub clinical cases not known( 13% -30% or
more)
 Chronic
 low grade fever, weight loss, mild to moderate abdominal pain
 M. tuberculosis and actinomycosis

6. Factors associated with increased risk
 Young age at first sexual encounter
 Multiple sexual partners
 Recent new partner (within previous 3
months)
 Past history of STIs in the patient or
the partner
 Instrumentation of the uterus/
interruption of cervical barrier
 Termination of pregnancy
 Insertion of intrauterine devices
recently
 Hysterosalpingography
 Hysteroscopy
 Saline infusion sonography
 In vitro fertilization

7. Approach to a patient with PID
When to suspect ?
 All sexually active young women complaining of acute abdominal pain
which is bilateral – suspect PID
 Other causes of acute abdominal pain to be ruled out
 Maintaining low threshold for diagnosis

8. Minimum clinical criteria
CDC- 2015
 Cervical motion tenderness
 Uterine tenderness
 Adnexal tenderness

9. Imaging and
invasive tests
 Transvaginal ultrasound- also rules out other mimickers
 Tubal wall thickness > 5 mm
 Fluid in the cul-de-sac
 Cogwheel sign on cross section of the tubal view
 Pelvic CT
 Thickened uterosacral ligaments
 Inflammatory changes of the tubes or ovaries
 Abnormal fluid collection
 Pelvic MRI
 More sensitive

10. Laparoscopy
 Gold standard for
diagnosing PID
 Edematous,
erythematous tubes
 Purulent exudate
emanating from the
fimbrial end
 Peritubal adhesions
Intra-operative view of hydrosalpinx
Image source: Revzin MV et al, Radiographics. 2106;36:1579-96

11. Endometrial
biopsy
 Showing endometritis
 Confirming doubtful
cases
 Plenty of plasma cells
 High sensitivity – subtle
cases
Image source: Wikimedia commons

12. Differential diagnosis
 Ectopic pregnancy
 Acute appendicitis
 Ovarian cysts- ruptured/ torsion/ hemorrhage
 Endometriosis
 Any other acute abdomen

13. Treatment- oral/out patient
 Oral regimens for mild to moderate disease in out patient basis
 N. gonorrhoeae and C. trachomatis to be targeted
 Also to consider anaerobes, enteric gram negative rods in special
situations

14. Recommended oral regimen, CDC 2015
Recommended intramuscular/ oral regimen
1 Ceftriaxone 250mg IM single dose
plus
doxycycline 100mg orally BD x 14 days
with/without
metronidazole 500mg orally BD x 14 days
2 Cefoxitin 2g IM in single dose and probenecid, 1g orally administered concurrently single dose
Plus
doxycycline 100mg orally BD x 14 days
with/ without
metronidazole 500mg BD x 14 days
3 Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime)
PLUS
Doxycycline 100 mg orally BD x 14 days
with/ without
Metronidazole 500 mg orally BD x 14 days

15. NACO Guideline

16. Parenteral treatment
 Severe disease
 Hospitalized patients
 Who fail to show clinical improvement at 72 hours treatment with oral
regimens
 H/o severe allergic reactions to penicillin

17. Recommended IV Regimens, CDC 2015
Recommended parenteral regimen
1 Cefotetan 2g IV BD
PLUS
Doxycycline 100mg orally OR IV BD x 14 days
2 Cefoxitin 2g IV every 6 hours
PLUS
Doxycycline 100mg orally OR IV BD x 14 days
3 Clindamycin 900mg IV TDS
PLUS
Gentamicin loading dose IV or IM(2mg/kg), followed by maintenance dose
(1.5mg/kg) every 8 hours. Single daily dosing (3-5mg/kg) can be substituted.
4 Tubo ovarian abscess- clindamycin (450mg QID) or metronidazole (500mg BD)
should be used to complete at least 14 days of therapy with doxycycline- for
anaerobic coverage

18. Azithromycin based regimens
 Azithromycin as monotherapy (7 days)or in combination
with metronidazole also has equal cure rate as (metronidazole
with doxycycline, and cefoxitin) and ( doxycycline with
amoxicillin/clavulanate)
 Ceftriaxone IM combined with Azithromycin 1 g weekly X
2weeks equivalent to ceftriaxone IM combined with 14 days
of 100mg BD doxycycline
Savaris RF, Obstet Gynecol. 2007 Jul;110:53-60
Bevan CD et al, J Int Med Res. 2003 Jan;31:45-54

19. When to hospitalise?
 Other surgical emergencies cannot be ruled out
 Tubo ovarian abscess
 Pregnancy
 Severe illness
 Lack of clinical response/ unable to follow out-patient regimens
 No significant differences in outcome between out and inpatients in
mild and moderate diseases
Ness RB et al, Am J Obstet Gynecol. 2002 May;186:929-37

20. Complications
 Tubo ovarian abscess
 Infertility
 Chronic pelvic pain
 Ectopic pregnancy
 Ovarian cancer
 Fitz – Hugh – Curtiz syndrome

21. Fitz-Hugh-Curtis syndrome
Peri-hepatic inflammation Adhesions on the surface of the liver-
violin string appearance
Image source: Revzin MV et al, Radiographics. 2106;36:1579-96

22. Special situations - HIV
 Differences among sero -negative and positive individuals not well established
 Respond equally well to antibiotic regimens
 Microbial profile similar
 No recommendation for aggressive treatment/ hospitalization
Irwin KL et al, Obstet Gynecol. 2000 Apr;95:525-34

23. Special Situation - Pregnancy
 Extremely rare in pregnancy
 Requires hospitalization – for closer monitoring of pregnancy outcomes
 No studies to support increased risk to fetus

24. PID and intra uterine devices (IUD)
 Increased risk in the first 3 weeks of IUD insertion
 Removal of IUD not recommended routinely
 Recommended in case of lack of clinical response after 72 hours of
initiation of treatment
Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases
treatment guidelines, 2015. 2015 Jun 5;64(RR-03):1-137
Ross J et al. 2017 European guideline for the management of pelvic
inflammatory disease. Int J STD AIDS. 2018 Feb;29(2):108-14