Pelvic inflammatory disease (PID)

10/11/2021
PELVIC INFLAMMATORY
DISEASE
(PID)
DR VAIRAM

• What is PID
• How do women get PID
• Classification
• Grouping
• Risk and protective factors
• CDC criteria
• Symptoms
• Clinical evaluation
• Clinical features
• Diagnosis
• Differential diagnosis
• Treatment
• Follow-up
• Complications
• Management of sex partners
• Other management considerations
• Screening and prevention

Try answering these Q and
we shall discuss it at the end
of the presentation ;)
30seconds for each question

1. Pelvic inflammatory disease:
A 27-year-old woman presented ten days earlier with a fever, suprapubic tenderness, and vaginal
discharge. A diagnosis of pelvic inflammatory disease was made, and antibiotics commenced. She
initially improved but re-presents 10 days later with severe lower abdominal pain and a temperature of
39.5°C.
What is the SINGLE most appropriate initial investigation?
A. CT scan of pelvis
B. Abdominal X-ray
C. Endocervical swab
D. Cervical smear
E. Ultrasound scan

2. Abdominal pain and vaginal discharge:
A 23-year-old woman presents with lower abdominal pain, dysuria, dyspareunia, and purulent vaginal
discharge. You make a clinical diagnosis of pelvic inflammatory disease (PID).
Which of the following would be an indication for hospital admission? Select ONE answer only.
A. Concurrent pregnancy
B. Purulent vaginal discharge
C. Abnormal vaginal bleeding
D. Temperature of 37.5°C
E. Cervical motion tenderness

A 32-year-old woman presents with lower abdominal pain, dyspareunia, and purulent vaginal
discharge. A pregnancy test performed today is negative and her last menstrual period was 4 weeks
earlier. Her temperature today is 38.6°C.
What is the SINGLE most appropriate initial investigation?
A. Transvaginal ultrasound scan
B. Endocervical swab
C. Diagnostic laparoscopy
D. Abdominal X-ray
E. Blood cultures

A 23-year-old woman presents with lower abdominal pain, dysuria, dyspareunia, and purulent vaginal
discharge. A pregnancy test performed today is negative. She is afebrile and her observations are
normal. On examination, her abdomen is soft but she cervical motion tenderness on bimanual pelvic
examination.
What is the SINGLE most appropriate treatment regimen?
A. IM ceftriaxone plus oral doxycycline and metronidazole
B. IV ceftriaxone and metronidazole plus oral doxycycline
C. Oral doxycycline and metronidazole
D. Oral co-amoxiclav
E. IV cefuroxime and metronidazole

5. Abdominal pain:
A 27-year-old woman presented ten days earlier with a fever, suprapubic tenderness, and vaginal
discharge. A diagnosis of pelvic inflammatory disease was made and antibiotics commenced. She
initially improved but re-presents 10 days later with severe lower abdominal pain and a temperature of
39.5°C.
What is the SINGLE most likely diagnosis?
A. Urinary tract infection
B. Uterine perforation
C. Tubo-ovarian abscess
D. Psoas abscess
E. Pyelonephritis

A 32-year-old woman presents with lower abdominal pain, dyspareunia, and purulent vaginal
discharge. A pregnancy test performed today is negative and her last menstrual period was 4 weeks
earlier. Her temperature today is 38.6°C.
What is the SINGLE most likely diagnosis?
A. Ectopic pregnancy
B. Acute appendicitis
C. Pyelonephritis
D. Pelvic inflammatory disease
E. Endometriosis

What is PID?
• Infection causing inflammation of a woman’s reproductive organs*1
• Vagina - Colpitis
• Cervix - Endocervicitis
• Uterus - Endometritis
• Fallopian tubes - Salpingitis
• Ovaries - Oophoritis
• Tubo-ovarian abscess
• Pelvic peritonitis

How do women get PID?
• Usually the result of infection ascending from the endocervix to the contiguous pelvic
structure
Eg;
• Neisseria gonorrhoeae and Chlamydia trachomatis (STD) which accounts quarter of
cases in the UK are flagellated and can get into the uterus*2
Neisseria
gonorrhoeae under
electron microscopy -
note the flagella

Grouping
A. Etiology
• Specific -Neisseria gonorrhoeae / Chlamydia trachomatis / TB
• Non-specific - various other aerobic and anaerobic microorganisms (natural genital flora of females)
B. Clinical picture
• Acute - few days, unwell patient, may recur in episodes
• Chronic - months to years, progressive organ damage and change
C. Localisation
• Lower genital tract - vagina up to cervix
• Upper genital tract - above cervix
D. History of recent delivery
• Puerperal
• Non puerperal

Aetiology
• Most cases of PID are polymicrobial
• Most common pathogen are STD:
1) Chlamydia trachomatis ~30% - MOST COMMON IN UK
2) Neisseria gonorrhoeae ~30%
3) Mycoplasma hominis ~10%
• Secondary pathogens:
- Aerobic - non haemolytic strep, E.coli, group B strep, Staph
- Anaerobic - Becteroides sp. like fragilis & bivius, peptostreptococcus, peptococcus

Facts about PID
• 1 in 10 women with PID becomes infertile
• Ectopic pregnancy risk increases by 6-10 folds after PID
• Recurrence of PID is at least 25%

Risk & Protective Factors
Risk Factors
• Multiple sexual partners *3
• Have a sexually transmitted
infection (STIs), especially
gonorrhea or chlamydia *3
• Have had PID in the past *3
• Young age at onset of sexual
activity (younger than 15
years)*4
• Unprotected sexual
intercourse*4
• Intercourse with a symptomatic
partner, young age at onset of
sexual activity (younger than 15
years)*4
• Insertion of IUD (during active
infection) / Gynaecological
procedure
Protective Factors
• Barrier contraceptive
• Monogamy
• OCP - protect against
gonococcal*5
• Pregnancy - lactobacilli &
mucus plug

Facts about vaginal flora
• The normal vaginal flora is dominated by various lactobacillus species.
• Lactobacilli help to keep the vagina healthy by producing lactic acid, hydrogen
peroxide, and other substances that inhibit the growth of yeast and other unwanted
organisms
• Help maintain the vagina at a healthy pH of around 4(mildly acidic environment is
protective factor)

Symptoms
• Can be asymptomatic to having wide range of non-specific clinical symptoms
• Cardinal symptom : PV discharge +/- abrupt onset of lower abdominal or pelvic pain in
a sexually active woman
• Lower abdominal pain (dull) worsens with coitus
• Fever may also occur, but it is not the dominant symptom
• Lower UTI symptoms
• Right upper quadrant pain that is worse with movement and breathing is caused by
inflammation and adhesions of the liver capsule, such as in perihepatitis (i.e., Fitz-
Hugh–Curtis syndrome)
• Infertility
• Abnormal uterine bleeding
*4

Fitz-Hugh–Curtis
syndrome.
Note violin-string
appearance of
chronic
adhesion/fibrosis
which can occur
due to chlamydia or
gonorrhoea

Clinical Evaluation
• Abdominal exam, including palpation of the right upper quadrant
• Vaginal speculum examination:
— vulva - scratch mark / erythema
— vagina - ulcer / lesion (STD - chancer) / foul smell
— cervix - erosion / erythema (strawberry cervix - trichomoniasis)
• Bimanual exam, assessing for cervical motion (PID/ectopic), uterine, or adnexal
tenderness, as well as pelvic masses

• Microscopic evaluation of a sample of cervicovaginal discharge
Wet mount : A sample of the vaginal discharge is placed on a glass slide and mixed
with a salt solution. The slide is looked at under a microscope for bacteria, yeast
cells, trichomoniasis (trichomonads), white blood cells that show an infection,
or clue cells that show bacterial vaginosis.
KOH slide : A sample of the vaginal discharge is placed on a slide and mixed with a
solution of potassium hydroxide (KOH). The KOH makes it easier to see yeast cells.
Vaginal pH : The normal vaginal pH is 3.8 to 4.5. Bacterial vaginosis, trichomoniasis,
and atrophic vaginitis often cause a vaginal pH higher than 4.5.
Whiff test : Several drops of a potassium hydroxide (KOH) solution are added to a
sample of the vaginal discharge. A strong fishy odour from the mix means
bacterial vaginosis is present.
*8

Diagnosis
• Diagnosis of PID is clinical
• Imaging and more invasive studies
reserved for cases of diagnostic
uncertainty or concern for
complications (e.g., tubo-ovarian
abscess)
• Gold standard for establishing PID is
by laparoscopy
*4

*4
** Endometritis & tubo-ovarian
abscess is under PID spectrum

Out Patient Management
• IM or oral therapy can be considered for women with mild-to-moderate acute PID because the clinical
outcomes among women treated with these regimens are similar to those treated with IV therapy
• Women who do not respond to IM or oral therapy within 72 hours should be reevaluated to confirm the
diagnosis and be administered therapy IV
• These regimens provide coverage against frequent etiologic agents of PID; however, the optimal
choice of a cephalosporin is unclear. Cefoxitin, a second-generation cephalosporin, has better
anaerobic coverage than ceftriaxone, and, in combination with probenecid and doxycycline, has been
effective in short-term clinical response among women with PID. Ceftriaxone has better coverage
against N. gonorrhoeae. The addition of metronidazole to these regimens provides extended coverage
against anaerobic organisms and will also effectively treat BV, which is frequently associated with PID.
1)
*7

In the case of cephalosporin allergy;
• Use of either levofloxacin 500 mg orally once daily or moxifloxacin 400 mg orally once
daily with metronidazole 500 mg orally 2 times/day for 14 days
OR
• Azithromycin 500 mg IV daily for 1–2 doses, followed by 250 mg orally daily in
combination with metronidazole 500 mg 2 times/day for 12–14 days
*7

Follow-up
• Women should demonstrate clinical improvement (e.g., defervescence; reduction in
direct or rebound abdominal tenderness; and reduction in uterine, adnexal, and
cervical motion tenderness) <3 days after therapy initiation
• If no clinical improvement has occurred <72 hours after outpatient IM or oral therapy,
then hospitalization, assessment of the antimicrobial regimen, and additional
diagnostics, including consideration of diagnostic laparoscopy for alternative
diagnoses, are recommended
• All women who have received a diagnosis of chlamydial or gonococcal PID should be
retested 3 months after treatment, regardless of whether their sex partners have been
treated. If retesting at 3 months is not possible, these women should be retested
whenever they next seek medical care <12 months after treatment
*7

Complications
• Immediate
- pelvic / generalised peritonitis
- septicemia
• Late
- infertility (12%, increases to 25% after 2 episodes & 50% after 3 episodes) due to tubal
damage or tubo-ovarian mass
- chronic PID (recurrent or associated pyogenic infection)
- recurrent PID
- post PID syndrome (chronic abdominal pain due to adhesion)
- increased risk of ectopic pregnancy (due to scarring)
- dyspareunia

Management of Sex Partner(s)
• Persons who have had sexual contact with a partner with PID during the 60 days
preceding symptom onset should be evaluated, tested, and presumptively treated for
chlamydia and gonorrhea, regardless of the PID etiology or pathogens isolated *7
• If the last sexual intercourse was >60 days before symptom onset or diagnosis, the
most recent sex partner should be treated. Sex partners of persons who have PID
caused by C. trachomatis or N. gonorrhoeae frequently are asymptomatic *7
• Partners should be instructed to abstain from sexual intercourse until they and their
sex partners have been treated (i.e., until therapy is completed and symptoms have
resolved, if originally present) *7 (Should wait a week after finishing antibiotics before resuming sex. Doing so will
help prevent re-infection)*3

Other Management Considerations
• All women who receive a diagnosis of PID should be tested for gonorrhea,
chlamydia, HIV, and syphilis
• All contraceptive methods can be continued during treatment.
• Pregnant women suspected of having PID are at high risk for maternal morbidity and
preterm delivery. These women should be hospitalized and treated with IV
antimicrobials in consultation with an infectious disease specialist.
• The risk for PID associated with IUD use is primarily confined to the first 3 weeks
after insertion. If an IUD user receives a diagnosis of PID, the IUD does not need to
be removed. However, the woman should receive treatment according to these
recommendations and should have close clinical follow-up. If no clinical improvement
occurs within 48–72 hours of initiating treatment, providers should consider removing
the IUD.
*7

Screening and Prevention
• No specific screening recommendation exists for PID*4
• Testing for chlamydia and gonorrhea has been shown to decrease the incidence of
PID in high-risk populations. It also applies to all sexually active women, including
pregnant women.*4
• Annual screening for chlamydia and gonorrhea is recommended for all sexually active
women younger than 25 years and for women at increased risk. Additionally, all
pregnant women at high risk for STIs should be rescreened in the third trimester.*4
• Use of condom
• Patient education to prevent reinfection
• Tracing and treating of sexual partner(s)

References
• CDC - https://www.cdc.gov/std/pid/stdfact-pid.htm *1
• UK National Guideline for the Management of Pelvic Inflammatory Disease 2011 *2
• Cleveland Clinic - https://my.clevelandclinic.org/health/diseases/9129-pelvic-
inflammatory-disease-pid *3
• AAFP - https://www.aafp.org/afp/2019/0915/p357.html *4
• PUBMED - https://pubmed.ncbi.nlm.nih.gov/12281124/ *5
• NCBI - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3843151/ *6
• CDC - https://www.cdc.gov/std/treatment-guidelines/pid.htm *7
• University of Michigan Health - https://www.uofmhealth.org/health-library/hw6026 *8

Case Discussion
• Mdm J, 24yo Female who reports lower abdominal pain, cramping, slight fever, and
dysuria for 4 days
• G1P1, LMP two weeks ago (regular without dysmenorrhea)
• Uses OCP (for the last 2 years)
• Reports gradual onset of symptoms of lower bilateral abdominal discomfort, dysuria (no
gross hematuria), abdominal cramping and slight low grade fever in the evenings for 4
days.
• Discomfort has gradually worsened
• Denies GI disturbances or constipation
• Denies vaginal discharge
• Stated that she’s happily married in monogamous relation. Plans for another pregnancy in
about 6 months.
• No condom use
• No history of STD, reports occasional yeast infection
• Douches regularly after menses and intercourse, last douched this morning

1. What are the differential diagnosis?
2. How will you proceed? (Clinical & Imaging/Lab)

Physical examination:
• Vital sign: BP 104/72, HR 84, Temp 38 Celsius, Weight 51kg
• Neck, chest, breast, heart, lungs NAD
• No costovertebral angel tenderness
• P/A + tenderness over lower quadrants, few inguinal lymph-nodes palpable bilaterally
• Vaginal examination: VV: NAD, no discharge
PSE: minimal vaginal discharge with small amount of
visible cervical mucopus
Bimanual: Uterine and adnexal tenderness as well as pain
with cervical motion. Uterus is not enlarged.
Lab:
• UPT: negative
• UFEME: NAD
• Vaginal saline mount: Ph 4.5, microscopy showed WBC > 10 per HPF, no clue cells,
no trichomonads, KOH wet mount negative for budding yeast and hyphae

1. What will be the clinical diagnosis now?
2. How will you manage this patient? - plan of treatment
3. When will you see back this patient in clinic?

On follow-up:
Mdm J had improved clinically, no more fever, lower abdominal pain or LUTS
Test result reviewed showed:
• Nucleic acid amplification test (NAAT) for gonorrhoea was positive
• NAAT for chlamydia was negative
How will you proceed now?

Key information (summary)
Pelvic Inflammatory Disease (PID), is a pelvic infection affecting the upper female reproductive tract (uterus,
fallopian tubes, and ovaries). It usually occurs as an ascending infection from the cervix.
It is most frequently seen as a consequence of the sexually transmitted diseases chlamydia and gonorrhoea, with
genital Chlamydia trachomatis infection the most common causative infection seen in UK genitourinary medicine
clinics.
Clinical features
PID is frequently asymptomatic but the clinical features, when present, include the following:
 Lower abdominal pain and tenderness
 Fever
 Dysuria
 Dyspareunia
 Purulent vaginal discharge
 Abnormal vaginal bleeding
 Cervical motion tenderness and adnexal tenderness

Investigations
All patients presenting with symptoms suspicious of PID should undergo a pregnancy test as the clinical
presentation of ectopic pregnancy can be confused with PID.
The initial investigation of possible PID is with endocervical swabs for C.trachomatisand N.gonorrhoea, using
nucleic acid amplification tests when available.
Mycoplasma genitalium testing is also now recommended. Local availability of M. genitalium testing currently
varies, but the implementation of testing is strongly recommended to guide the choice of appropriate treatment
Management
Mild-to-moderate disease can generally be managed in the primary care or outpatient setting. Patients will
clinically severe disease should be admitted to hospital for intravenous antibiotics. Signs of more severe clinical
disease include:
 Fever above 38°C
 Clinical signs of tubo-ovarian abscess
 Signs of pelvic peritonitis
 Concurrent pregnancy
Empirical antibiotics should be commenced as soon as a presumptive diagnosis of PID is made clinically. Swab
results should not be waited for.

If the risk of gonococcal infection is low, prescribe any of the following first-line regimens (taking into account
factors such as the age of the person, contraindications and cautions, possible adverse effects, and local
antimicrobial sensitivity patterns):
 Ceftriaxone 500 mg as a single intramuscular (IM) dose, followed by oral doxycycline 100 mg twice daily plus
oral metronidazole 400 mg twice daily for 14 days
 Oral ofloxacin 400 mg twice daily plus oral metronidazole 400 mg twice daily for 14 days. Levofloxacin (500 mg
once daily for 14 days) may be used as a more convenient alternative to ofloxacin
 Oral moxifloxacin 400mg once daily for 14 days
 If the initial test for Mycoplasma genitalium is positive, treatment with moxifloxacin is recommended as
it currently has good microbiological activity against M. genitalium.
If none of the first-line regimens are suitable, consider the following alternative regimen:
 Ceftriaxone 500 mg as a single IM dose, followed by oral azithromycin 1 g per week for 2 weeks. There is less
evidence to support this regimen.
If the risk of gonococcal infection is high (for example, the woman's partner has gonorrhoea, her symptoms
and signs are clinically severe, or she has had sexual contact while abroad):
 Prescribe ceftriaxone 500 mg as a single IM dose, followed by oral doxycycline 100 mg twice daily plus oral
metronidazole 400 mg twice daily for 14 days

The current recommendation for treatment of PID for severely ill patients in the inpatient setting is:
 Initial treatment with doxycycline, single-dose IV ceftriaxone and IV metronidazole
 Then change to oral doxycycline and metronidazole to complete 14 days of treatment.
In those who fail to respond to treatment, laparoscopy is essential to confirm the diagnosis or to make an
alternative diagnosis.
Referral
The patient should be referred urgently for admission if:
 Ectopic pregnancy cannot be ruled out, or the woman is pregnant
 Symptoms and signs are severe (such as nausea, vomiting, and a fever greater than 38°C)
 There are signs of pelvic peritonitis
 A surgical emergency (such as acute appendicitis) cannot be ruled out
 A tubo-ovarian abscess is suspected
 The woman is unwell, and there is diagnostic doubt
 The woman is unable to follow or tolerate an outpatient treatment regime.

Tubo-ovarian abscess
Tubo-ovarian abscess (TOA) is a complication of pelvic inflammatory disease, where an encapsulated pocket of
pus forms in the fallopian tube and/or ovary. TOA can be life-threatening if the abscess ruptures and results in
sepsis.
Transabdominal and endovaginal ultrasound is the initial imaging modality of choice, and often shows multilocular
complex retro-uterine/adnexal mass(es) with debris, septations, and irregular thick walls. These masses can also
be bilateral.
Urgent hospital admission is required, and management is usually with drainage of the abscess along with the
administration of intravenous antibiotics. Drainage of the abscess can be guided by ultrasound or CT scanning.
Laparotomy or laparoscopy with drainage of abscess may be required in some cases.

This patient is highly likely to have developed a tubo-ovarian abscess (TOA). It is a complication of pelvic
inflammatory disease, where an encapsulated pocket of pus forms in the fallopian tube and/or ovary. TOA
can be life-threatening if the abscess ruptures and results in sepsis.
Transabdominal and endovaginal ultrasound is the initial imaging modality of choice, and often shows
multilocular complex retro-uterine/adnexal mass(es) with debris, septations, and irregular thick walls. These
masses can also be bilateral.
Urgent hospital admission is required and management is usually with drainage of the abscess along with
the administration of intravenous antibiotics. Drainage of the abscess can be guided by ultrasound or CT
scanning.
Laparotomy or laparoscopy with drainage of abscess may be required in some cases.

Pelvic inflammatory disease (PID) is a pelvic infection affecting the upper female reproductive tract (uterus,
fallopian tubes, and ovaries). It usually occurs as an ascending infection from the cervix.
It is most frequently seen as a consequence of the sexually transmitted diseases chlamydia and gonorrhoea,
with genital Chlamydia trachomatis infection the most common causative infection seen in UK genitourinary
medicine clinics.
PID is frequently asymptomatic but the clinical features, when present, include the following:
 Lower abdominal pain and tenderness
 Fever
 Dysuria
 Dyspareunia
 Purulent vaginal discharge
 Abnormal vaginal bleeding
 Cervical motion tenderness and adnexal tenderness
All patients presenting with symptoms suspicious of PID should undergo a pregnancy test as the clinical
presentation of ectopic pregnancy can be confused with PID.
The initial investigation of possible PID is with endocervical swabs for C.trachomatis and N.gonorrhoea, using
nucleic acid amplication tests when available.

Mild to moderate disease can generally be managed in the primary care or outpatient setting. Patients will clinically
severe disease should be admitted to hospital for intravenous antibiotics. Signs of more severe clinical disease
include:
 Fever above 38°C
 Clinical signs of tubo-ovarian abscess
 Signs of pelvic peritonitis
 Concurrent pregnancy
Empirical antibiotics should be commenced as soon as a presumptive diagnosis of PID is made clinically. Swab
results should not be waited for.
The current recommendation for treatment of PID in the outpatient setting is:
 Ceftriaxone 500 mg as a single IM dose, followed by doxycycline 100 mg orally twice daily and metronidazole 400 mg twice daily for 14 days.
 An alternative regime is oral ofloxacin 400 mg twice daily and oral metronidazole 400 mg twice daily for 14 days.
The current recommendation for treatment of PID for severely ill patients in the inpatient setting is:
 Initial treatment with doxycycline, single-dose IV ceftriaxone and IV metronidazole
 Then change to oral doxycycline and metronidazole to complete 14 days of treatment.
In those who fail to respond to treatment, laparoscopy is essential to confirm the diagnosis or to make an alternative
diagnosis.

Pelvic inflammatory disease (PID)

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