Pelvic inflammatory disease (PID) is infection of the organs of the female genital tract, including the uterus, fallopian tubes and surrounding structures. It is a significant and common concern in women’s health and can lead to infertility, chronic pain, and an increased risk of ectopic pregnancy, necessitating timely recognition and management.
Most cases of PID are due to sexually transmitted infections (STIs) such as Neisseria gonorrhoeae, Chlamydia trachomatis, and Mycoplasma genitalium, however other bacteria can also contribute, and in 70 per cent of cases, no organism is found.
Women at greater risk of PID include those who have had unprotected sex and women who have recently had an intrauterine device (IUD) insertion, dilatation and curettage or surgical termination of pregnancy.
Symptoms of PID may include vaginal discharge, abdominal or pelvic pain, dyspareunia, and unusual bleeding such as postcoital, intermenstrual or heavy bleeding. PID can also occur without symptoms, and fever, nausea and vomiting suggest severe infection.
A high index of suspicion should be held, particularly in young, sexually active women, and the key to successful management is early diagnosis and treatment.
PID is a clinical diagnosis; therefore, physical examination, including bimanual and speculum exams, is essential in suspected cases. Key diagnostic signs include cervical motion tenderness, adnexal tenderness and presence of mucopurulent vaginal discharge.
Investigations should consist of a urinary pregnancy test in women at risk of pregnancy, an endocervical swab for chlamydia and gonorrhoea, and a high vaginal swab for broader microbial culture. For cases where there is diagnostic uncertainty or where tubo-ovarian abscess is suspected, a pelvic ultrasound should be carried out. A full blood count and c-reactive protein may be useful in assessing severity. Laparoscopy is the definitive diagnostic procedure but is not recommended for routine diagnosis.
Where PID is clinically suspected, empirical therapy should be initiated without delay to reduce the risk of complications. First-line outpatient therapy typically involves Ceftriaxone 500 mg intramuscularly as a single dose, combined with Doxycycline 100 mg orally twice daily for 14 days and Metronidazole 400 mg orally twice daily for 14 days. Alternative regimes are more appropriate for pregnant or breastfeeding women.
Hospital admission and intravenous antibiotics should be considered in severe cases or where complications are suspected. If the woman has an IUD in situ, removal should be considered on a case-by-case basis.
Women with PID should be advised to abstain from sexual contact until treatment is completed and symptoms have resolved. Where outpatient therapy is initiated, women should be followed up within 48-72 hours of treatment to assess clinical response.
Partner notification is essential to avoid reinfection, and women should be supported to contact recent partners. Current partners should receive empirical therapy according to guidelines.
A test of cure should be performed at least three weeks following treatment completion in cases with positive microbiology.
Women should be counselled on the potential long-term complications of PID, including tubal infertility, which occurs in approximately 18 per cent of affected women, and chronic pelvic pain, which occurs in approximately 30 per cent of cases. Preventative advice should be given, including the promotion of condoms and encouraging regular STI testing for at-risk individuals.
Effective management of PID requires early diagnosis, prompt treatment, partner notification and patient education. Given the potential for adverse reproductive outcomes following PID, general practitioners play a key role in mitigating the impact of PID by promoting prevention.
Dr Samantha Miller, MBChB
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