PID - definition
Infection of upper genital tract
PID - incidence
1-3% of sexually active young women
PID - causes (3)
- Most commonly caused by ascending infection from endocervix, but may also occur from descending infection from organs such as the appendix
Multiple causative organisms.
- 25% of cases estimated to be caused by Chlamydia trachomatis and Neisseria gonorrhoeae. Also mycoplasma genitalium
- Anaerobes and endogenous agents (either aerobic or facultative) - may be responsible for the remainder
Differentiating sexually acquired from non-sexually acquired infection depends on clinical judgement and patient history. A sexually acquired infection is more likely in patients who have had unprotected sex, particularly with a new partner.
Non-sexually acquired infection is likely if there has been mechanical disruption of the cervical barrier (e.g. due to pregnancy termination or after delivery; surgery; following insertion of an intrauterine contraceptive device [IUCD]). If the diagnosis is uncertain, use the empirical regimen for sexually acquired PID until the results of investigations are available
PID - RFs
- Age
PID - symptoms
May be relatively asymptomatic with dx made retrospectively during ix of subfertility
Symptoms may include:
- Pelvic pain (may be unilateral; constant or intermittent), or deep dyspareunia
- Vaginal discharge (usually due to concurrent vaginal infection)
- Irregular and/or more painful menses
- IMB/PCB
- Fever (unusual in mild/chronic PID)
PID - ex
Perform:
- Abdominal examination to elicit the site and severity of the pain
- Speculum and vaginal examination to assess for adnexal masses, vaginal discharge, or cervical excitation
Signs (at least one should be present when making dx of PID)
- Cervical motion pain (cervical excitation)
- Adnexal tenderness (commonly bilateral, but may be unilateral)
- Fever (unusual in mild/chronic infection)
PID - ix
- Endocervical swab for NAAT for C. trachomatis, N. gonorrhoeae, and M. genitalium. Aso endocervical swab for Gram stain and culture of N. gonorrhoeae for susceptibility testing
- If speculum examination not possible, a self-collected low vaginal swab is more sensitive than a first-void urine sample for C. trachomatis, N. gonorrhoeae and M. genitalium
- WCC and CRP may be elevated
- U/S may be indicated if a tubo-ovarian abscess is suspected
- Laparoscopy is the gold standard test; however, it is invasive and only used where diagnosis is uncertain.
PID - complications
- Tubo-ovarian abscess
- Fitz-Hugh–Curtis syndrome (adhesions around the liver causing chronic pain)
- Recurrent PID
- Ectopic pregnancy
- Infertility
PID - mx
- Early empirical tx
* Sexually acquired infection
- Mild to moderate infection = cetriaxone 500mg IM or IV as single dose + metronidazole 400mg BD 14d + azithromycin 1g orally as single dose + either doxycycline 100mg orally BD 14d or azythromicin 1g orally as single dose 1 week later (for women who are pregnant or pts suspected to be non-adherent to doxycycline)
- Severe infection = cetriaxone 2g IV daily or cefotaxime 2g IV TDS + azithromycin 500mg IV daily + metronidazole 500mg IV BD
- Non-sexually acquired infection
- Remove retained products of conception if appropriate. Consider removal of IUD
- Mild to moderate = amoxycillin + clavulanate 875 + 125mg orally BD 14d + doxycycline 100mg orally BD 14d
- Severe infection related to pregnancy or surgery that is unlikely to be sexually acquired = amoxicillin 2g IV QID + gentamicin IV (dose variable) + metronidazole 500mg IV BD
- Review after 72h to ensure adequate response. Modify therapy based on results of ix and response to tx
- Contact tracing and treatment of partners is essential.
- Inpatient treatment may be required if symptoms are severe, fail to respond, or abscess is suspected.
- If there is USS evidence of a tubo-ovarian abscess, drainage may be required either by ultrasonic guided aspiration or at laparoscopy.
