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Pelvic Inflammatory Disease

Checked: 26-01-2024 by 6 Sandi Littler Next Review: 26-01-2026

Overview

See the BASHH - management of pelvic inflammatory disease guidelines (1).

Local prescribing advice is also provided on the BNSSG Antimicrobial guidelines

Points to note:

  • Always test for chlamydia and gonorrhoea using a NAAT AND culture for gonorrhoea.
  • The absence of positive swab results does not exclude PID.
  • All women diagnosed with PID should also be referred to Unity Sexual Health.
  • All contacts should also be referred to Unity for treatment.
  • Partners and index patient should be advised to avoid intercourse until they have completed the treatment course.

Diagnosis and Management

A diagnosis of Pelvic Inflammatory Disease [PID] should be made on clinical grounds. Do not delay making a diagnosis and initiating treatment whilst waiting for the results of laboratory tests. Negative swab results do not rule out a diagnosis of PID. Only a quarter of cases are caused by Chlamydia (CT) and Gonorrhoea (GC) with Mycoplasma genitalium causing up to 15% and other bacteria, including those that commonly live in the vagina, causing the rest.

  Pelvic  Systemic
Symptoms

Lower abdominal pain, usually bilateral +/- deep dyspareunia
(particularly <3 weeks duration)

+/- abnormal vaginal discharge
+/- abnormal bleeding (intermenstrual/post-coital/menorrhagia)

Vomiting
Signs

Lower abdominal tenderness (usually bilateral)


Adnexal tenderness / cervical motion tenderness on bimanual 

Fever

 

Investigations

  • Pregnancy test (PT) – Pregnancy must always be excluded prior to examination
  • Urinalysis +/- culture
  • NAAT for GC and CT
  • Consider endocervical swab for GC Culture if high risk for GC
  • Bloods – HIV and Syphilis. Consider inflammatory markers if unwell

Treatment – no need to await swab results

First line recommended treatment

  • Ceftriaxone 1g (with 3.5mls 1% lidocaine) IM Stat followed by oral Doxycycline 100mg bd 14 days plus oral Metronidazole 400mg bd for 10-14 days.

This is first line treatment recommended by BASHH in view of quinolone side effects and broad spectrum antimicrobial efficacy including against Mycoplasma genitalium. A quinolone regimen is permissible providing; risks are discussed with the patient, if IM Ceftriaxone is not available and patient does not want to attend Unity. However, >40% of gonorrhoea isolates now resistant to quinolones in BNSSG.

Second line recommended treatment

  • Oral Ofloxacin 400mg bd 14 days plus oral Metronidazole 400mg bd 10-14 days

Delay in treatment (>3 days) increases the risk of long term complications such as ectopic pregnancy, chronic pelvic pain and infertility, a low threshold for empirical treatment of PID is recommended.

Sexual Partners

Current partner(s) should be contacted and offered screening for Chlamydia and Gonorrhoea (+/- other infections if symptomatic). As the majority of cases of PID are not associated with GC, CT or Mycoplasma genitalium, broad spectrum antibiotics should be offered empirically to partners - Doxycycline 100mg bd 7 days.

If the patient tests positive for GC or CT, appropriate partner notification (PN) should be undertaken.

Advise the patient to abstain from sex (including oral sex/sex with condoms) for duration of treatment and until current partner(s) are treated.

Patients with intrauterine contraception (IUC) and PID

There is an increased risk of PID in patients that have had uterine instrumentation in the preceding 4-6weeks e.g. after surgical termination of pregnancy or hysteroscopy. There is limited evidence for whether an IUC should be left in situ or removed in patients with PID. A practical approach is to review after 48–72 hours and remove if no improvement in symptoms. The decision to remove the IUC needs to be balanced against the risk of pregnancy. If there has been unprotected sex in the last 7 days inform the patient that there is a risk of pregnancy. Consider hormonal emergency contraception if the IUC is removed.

Guidelines for the Management of Pelvic Infection and Perihepatitis (2)

Swabs for suspected STI

The samples recommended for each scenario are illustrated below (see full information in letter in Resources section):

Scenario

Samples required

Requests

 

 

Symptomatic, high risk of STI (pregnant/non-pregnant)

Aptima® NAAT multi-test swab

N.gonorrhoeae NAAT

C.trachomatis NAAT

T.vaginalis NAAT

High vaginal liquid swab

Routine culture

Symptomatic, pregnant, low risk of STI

Aptima® NAAT multi-test swab

High vaginal liquid swab

T.vaginalis NAAT

Routine culture

Symptomatic, non-pregnant, low risk of STI

High vaginal liquid swab

Routine culture

Concerns about TV (e.g., ongoing symptoms with negative routine culture)

Aptima® NAAT multi-test swab

T.vaginalis NAAT

 

For the full guidelines in PDF form see TV testing Update letter August 2023 (3).

Red Flags

Consider admission to gynaecology in any of the following circumstances:

  • Pyrexia >38⁰C
  • Signs of Tubo-ovarian abscess – adnexal mass/tenderness, fever and leucocytosis
  • Pelvic peritonitis
  • Pregnancy

Referral

If no red flags then consider referral to Unity Sexual Health in the following circumstances:

  • IM Ceftriaxone is indicated and unable to administer in primary care.
  • Diagnostic uncertainty
  • Severe clinical disease/failure to improve.

Pregnancy

  • All pregnant women with PID will require urgent discussion with obstetrics/gynaecology. PID in pregnancy is uncommon but associated with an increase in both maternal and foetal morbidity, therefore parenteral therapy is advised

For advice on referral for further assessment and contact tracing please go to the Unity website - Clinical Services and How to Refer.

Resources

(1) BASHH Guidelines - links to BASHH website guidelines page.

(2) Guidelines for the Management of Pelvic Infection and Perihepatitis (2019)-pdf

(3) TV testing Update letter August 2023 Change to the existing arrangements for the laboratory diagnosis of Trichomonas vaginalis (TV) 

Patient Information/ Leaflets

PID Leaflet  pid_pil_mobile-pdf.pdf (bashhguidelines.org)

A guide to Partner Notification - pn_pil_digital_2016.pdf (bashhguidelines.org)

Links to websites

BASHH – PID Clinical Guidelines - BASHH Guidelines

BNSSG Formulary - https://remedy.bnssgccg.nhs.uk/formulary-adult/local-guidelines/5-infections-guidelines/

NICE CKS – PID - Background information | Pelvic inflammatory disease | CKS | NICE



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