Pelvic inflammatory disease

Inflammation of part or all of female upper genital tract usually caused by STI

• Common cause of lower abdominal pain in non-pregnant women at high risk of STIs (15–34 years). Often missed. Can cause serious problems
• In pregnancy PID can cause miscarriage and increase morbidity
• Diagnosed through clinical history and examination
• Decision to manage as PID is based on clinical assessment even if laboratory or POC Test results negative
• Always suspect if new onset lower abdominal pain and young age

Ask and check file notes

• Age — higher risk if 15–34 years, highest risk under 25 years
• History of STIs, PID, ectopic pregnancy, urinary infections
• Recent operations on genital tract
• Recent insertion of intrauterine device (IUD)
• Recent childbirth — see Infections after childbirth
• Date and results of last STI check and cervical screening

Ask

• Abdominal pain — where, when, how long, what makes worse or better
• Can stay as ongoing mild pain or get worse
• Often starts with period
• Menstrual periods
• Last normal period
• Change — more or less bleeding, bleeding between periods, pain with period, ongoing pain
• Fever, nausea, vomiting, feeling generally unwell
• Sexually active
• Pain deep inside when having sex
• Bleeding after sex
• Ask about names of contacts if possible
• Vaginal discharge — amount, colour, smell, how long
• Urinary problems — pain, frequency, blood in urine
• IUD

Check

• If urinary symptoms or pregnant — always do midstream urine for dipstick and MC&S
• See Lower abdominal pain for other causes of pain

 Do

• Full STI check
• If pregnant — medical consult about diagnosis, treatment, sending to hospital
• If not pregnant — Flowchart 5.1

Do — if severe PID or diagnosis uncertain

• Medical consult send to hospital
• Do not let woman eat or drink anything — may need operation
• Put in IV cannula — largest possible, insert 2 if time
• Blood for FBC and blood culture, syphilis and HIV serology — send in with patient
• Normal saline 1L at 125mL/hour or as directed by doctor
• Give ceftriaxone IV — adult 2g, single dose. If no IV access give IM — 2 x 1g vials, each mixed with  lidocaine (lignocaine) 1% and injected into separate buttocks, not more than 1g ceftriaxone in each buttock
• AND azithromycin oral — adult 1g, single dose
• AND metronidazole IV  — adult 500mg, single dose
• If allergy — medical consult

Do — if mild–moderate PID

• If not pregnant  treat and follow-up in community
• Start treatment straight away. Do not wait for STI results

Day 1

• Give  ceftriaxone IM — adult 500mg, single dose mixed with lidocaine (lignocaine) 1%
  
• AND doxycycline oral  — adult 100mg, twice a day (bd) for 14 days. Do not use if pregnant 
• OR azithromycin oral — adult 1g, single dose — second dose 1 week later
• AND metronidazole oral — adult 400mg, twice a day (bd) for 14 days 
• If allergy — medical consult
• If pain relief needed — see Pain management 
• Contact trace and provide partner/s with treatment for gonorrhea and chlamydia — men, women
• STI and safer sex education
• Consider discussing contraception

Day 3

• Examine woman, ask if symptoms improving
• If improving — PID likely. Explain important to finish treatment, do contact tracing
• If not improving — medical consult send to hospital

Day 8

• If using azithromycin — give azithromycin oral — adult 1g, single dose

Day 14

• Examine woman and ask if symptoms improving
• If still has symptoms, tenderness on abdominal or bimanual exam (do if skilled) — medical consult

Do also — if IUD

• Medical consult. Doctor should talk with gynaecologist
• Mild PID can be managed in community without removing IUD
• Very careful follow-up — must be seen daily for 3 days
• If not improving — medical consult
• If IUD removed
• Take 2 swabs from IUD for MC&S, NAAT for gonorrhoea, chlamydia, trichomonas
• Put IUD in yellow-top jar and send for MC&S

Follow-up

• Check that partner/s have been treated
• If woman treated in hospital — check if follow-up needed (eg pelvic ultrasound)
• If positive test result re-test in 3 months — standard STI check

Follow-up if ongoing symptoms

• Check treatment and compliance (if all medicine taken)
• Check partner/s have been treated
• Medical consult about further testing including NAAT for mycoplasma genitalium