Clinical Review - Management of Pelvic inflammatory disease

A clinical review of the diagnosis and management of pelvic inflammatory disease. By Miss Prabha Sinha and Dr Suneeta Kochhar

Incidence of subfertility is 20% with a single episode of PID, due to tubal and ovarian adhesions (above) (Photograph: Dr Najeeb Layyous/SPL)
Incidence of subfertility is 20% with a single episode of PID, due to tubal and ovarian adhesions (above) (Photograph: Dr Najeeb Layyous/SPL)

Section 1: Epidemiology and aetiology
PID describes infection and inflammation of the female upper genital tract; it may involve the endometrium, fallopian tubes and/or ovaries, as well as the surrounding peritoneum.

PID is a common cause of morbidity and accounts for one in 60 GP consultations by women under the age of 45 years.1

With a single episode of PID, the incidence of subfertility is 20% due to tubal and ovarian adhesions. There is a risk of tubo-ovarian abscesses, chronic pelvic pain and a significantly increased risk of ectopic pregnancy.1

Repeated episodes of PID may exponentially increase the risk of permanent tubal damage. Clinically more severe disease is associated with a greater risk of adverse sequelae.2

Aetiology
Most cases of PID result from a vaginal or cervical STI that may be asymptomatic. Subsequently, there is direct ascent of micro-organisms from the vagina or cervix to the upper genital tract.2

On occasion PID may lead to Fitz-Hugh-Curtis syndrome, which occurs when the infection spreads along the upper peritoneum to the liver capsule, causing perihepatic adhesions, which may resemble violin strings.

It is thought that Chlamydia trachomatis and Neisseria gonorrhoeae are responsible for most cases of PID.3

Other potential micro-organisms include Gardnerella vaginalis, Mycoplasma hominis and Trichomonas vaginalis.1

HIV infection can be associated with an increased incidence of C trachomatis infection. Women with HIV infection have an increased risk of progression to PID and tubo-ovarian abscess formation.1

Sexually active women who are in their teens or early twenties are at increased risk of PID, as are women from lower socioeconomic backgrounds.

Presence of an STI, previous pelvic infections, unprotected sexual intercourse, sexual intercourse at an early age and multiple sexual partners are risk factors for PID.4

Less commonly, instrumentation of the cervix and/or of the uterus can result in endogenous bacteria inoculating the endometrium and consequently leading to PID.

The relative risk of PID is higher in IUD users, however the absolute risk remains very low, in the order of one in 1,000.4

Section 2: Making the diagnosis
At presentation, women with PID may range from asymptomatic to being systemically unwell. Ascending infection from the endocervix may cause endometritis, salpingitis, parametritis, oophoritis, tubo-ovarian abscess and/or pelvic peritonitis.1

PID attributed to chlamydial infection tends to be asymptomatic and diagnosis is retrospective when a patient presents with subfertility due to tubal adhesions. In contrast, PID caused by N gonorrhoeae tends to be acute.1

The most common presenting complaint is acute lower abdominal or pelvic pain in association with fever in a sexually active woman.4

Bilateral lower abdominal pain is typical with deep dyspareunia; abnormal vaginal or cervical discharge which is often purulent and abnormal vaginal bleeding, including postcoital.

Intermenstrual bleeding and menorrhagia are other associated features.5 Nausea and vomiting may be a feature in PID.

Clinical findings
On examination, there may be a mild tachycardia and fever. There is likely to be bilateral lower abdominal tenderness; rebound tenderness and guarding may be elicited. If there is right upper quadrant tenderness, Fitz-Hugh-Curtis syndrome should be suspected.

Bimanual examination may reveal adnexal tenderness and cervical excitation; there may be a tubo-ovarian abscess that may be appreciated on bimanual palpation.2

Mucopurulent discharge from the cervix or vagina may be seen on speculum examination, high vaginal and endocervical swabs should be taken.

An elevated WCC and CRP supports the diagnosis of PID in conjunction with the clinical findings.1 LFTs may be deranged in the presence of Fitz-Hugh-Curtis syndrome and in acute cases.

Differential diagnoses
Differential diagnoses may include appendicitis, diverticulitis, UTI, ectopic pregnancy, ovarian torsion or rupture. A pregnancy test is required. A diagnosis of PID should be made on clinical grounds.

Negative swab results do not rule out a diagnosis of PID.2,5 A delay in diagnosis or treatment of PID can result in long-term sequelae, such as chronic pelvic pain. If a diagnosis of PID is made, testing for other STIs is recommended.4

Transvaginal ultrasound examination is not helpful in diagnosis but may demonstrate tubo-ovarian abscesses. If classic findings of PID are noted on ultrasound, no further imaging is required.6 If additional imaging is warranted, MRI is recommended over CT because its overall sensitivity is greater than 93% and it does not carry the risk of ionising radiation.6

Hospital admission is recommended if there is a suspicion of ectopic pregnancy or a surgical emergency, such as acute appendicitis, a tubo-ovarian abscess is suspected or there is diagnostic uncertainty. Severity of symptoms and signs, such as nausea, vomiting and a fever greater than 38°C may indicate that hospital admission may be necessary.3


A contraceptive IUD may need to be removed in a woman with PID (Photograph: Zephyr/SPL)

Section 3: Managing the condition
There are no widely accepted clinical criteria for PID, so early empirical treatment is common. Antibiotic regimens for the treatment of PID must cover C trachomatis, N gonorrhoeae, anaerobes, Gram-negative aerobes and streptococci.1

This provides cover for the most likely STIs as well as endogenous vaginal and lower GI flora. Preferably treatment should be started as early as possible to minimise the risk of future ectopic pregnancy and tubal infertility.

However, seeking medical attention may be delayed, because clinical features may not be apparent or appreciated by patients in the subclinical stage.

Outpatient therapy
Outpatient therapy is as effective as inpatient treatment for patients with clinically mild to moderate PID, however hospitalisation should be considered in selected cases.4,6

Antibiotic regimens that may be considered for outpatients are ofloxacin 400mg orally twice daily plus oral metronidazole 400mg twice daily, both for 14 days, or ceftriaxone 500mg as a single IM dose, plus oral doxycycline 100mg twice daily and oral metronidazole 400mg twice daily, both for 14 days.

Ofloxacin should be avoided in patients who are at high risk of gonococcal PID because of increasing quinolone resistance in the UK.1

A clinical review at 72 hours is recommended in those women with a moderate or severe clinical presentation of PID. There should be demonstrable clinical improvement at this review and if there has been little improvement, hospital admission or an alternative diagnosis should be considered.5

At this review antibiotic sensitivities from swab results are likely to be available. Treatment should be continued even in the absence of positive swab results. Ideally, sexual partners within the past six months should be seen in a GUM clinic so that screening, treatment and contact tracing may be implemented.5

Surgical management includes laparoscopy, which may help early resolution of the disease by dividing adhesions and draining pelvic abscesses. It has been suggested that ultrasound-guided aspiration of pelvic fluid collections may be equally effective. In the case of Fitz-Hugh-Curtis syndrome, adhesiolysis may be performed; however, there is no evidence as to whether this is superior to antibiotic therapy.5

It may be necessary to consider removing any contraceptive IUD after counselling about the risk of pregnancy. In this situation emergency hormonal contraception may be appropriate.1

MANAGEMENT SUMMARY
  • Antibiotic regimens must cover C trachomatis, N gonorrhoeae, anaerobes, Gram-negative aerobes and streptococci.
  • Treatment should be started as early as possible to minimise the risk of future ectopic pregnancy and tubal infertility.
  • A clinical review at 72 hours is recommended in those women with a moderate or severe clinical presentation.
  • Surgical management includes laparoscopy, which may help early resolution of the disease by dividing adhesions and draining pelvic abscesses.
  • It may be necessary to consider removing any contraceptive IUD.

Section 4: Prognosis
PID may be asymptomatic but may cause substantial morbidity. A low threshold for empirical treatment of PID is recommended because of the lack of definitive clinical diagnostic criteria and the potential consequences of not treating the condition.4

Patients should be advised to avoid unprotected intercourse until they, and their partner(s), have completed treatment and follow-up.1 Review at two to four weeks may be helpful to ensure clinical response in addition to screening and treatment of sexual contacts.5

Preventing infection
Preventing gonococcal and chlamydial infections represents the most effective means of reducing the incidence of PID. Educating women about the sequelae of untreated STIs, as well as emphasising how to prevent transmission of such infections, is important. For example, The National Chlamydia Screening Programme is targeted at the highest-risk group for chlamydia infection in England who are sexually active.

This group may be offered opportunistic screening in general practice.7

Furthermore, women on hormonal contraception presenting with breakthrough bleeding should be screened for STIs.


The National Chlamydia Screening Programme targets those at risk (Photograph: Ashley Cooper, Visuals Unlimited/SPL)

Section 5: Case study
A 21-year-old woman presented with two days' history of lower abdominal tenderness that was dull in nature. There was no radiation and the pain was worse on movement.

She felt nauseous but there was no history of vomiting. She complained of feeling hot and cold and had noticed vaginal discharge. She had had a subdermal progestogen-only contraceptive implant fitted two years ago. There was a history of unprotected sexual intercourse in the past three months.

On clinical examination, her temperature was 37.6°C, heart rate was 80bpm and BP was 110/70mmHg. Her abdomen was soft with bilateral lower abdominal tenderness with guarding.

On speculum examination a purulent discharge was seen, therefore endocervical and high vaginal swabs were taken. There was cervical excitation and adnexal tenderness on bimanual vaginal examination. No masses were palpable. A provisional diagnosis of PID was made.

The patient was given a 14-day course of ofloxacin and metronidazole. An appointment was made for three days' time for further assessment.

The patient was advised to avoid sexual intercourse until treatment and follow-up were completed. She made an appointment for her partner to be assessed at the GUM clinic.

The patient was reassessed three days later; she reported that she felt better and that she was experiencing minimal lower abdominal pains. Her examination showed clinical improvement.

Her partner had been assessed and contact tracing had been initiated. The patient was given advice regarding barrier contraception and opportunistic testing for chlamydia.

Section 6: Evidence base
Clinical trials

  • Ness RB, Soper DE, Holley RL et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol 2002; 186: 929-37

A multicentre randomised clinical trial where women received inpatient treatment (IV cefoxitin and doxycycline) or outpatient treatment that consisted of an IM injection of cefoxitin and oral doxycycline.

Short-term clinical improvement and recurrence of PID was similar between the groups. Pregnancy rates were equivalent in the two groups after a mean follow-up period of 35 months.

In women with mild-to-moderate PID, there was no difference in reproductive outcomes between women randomised to inpatient treatment versus those randomised to outpatient treatment.

  • Oakeshott P, Kerry S, Aghaizu A et al. Randomised controlled trial of screening for Chlamydia trachomatis to prevent pelvic inflammatory disease: the POPI (prevention of pelvic infection) trial. 2010. BMJ 340: c1642

While screening and treatment of chlamydial infection might reduce the risk of clinical PID over 12 months, this trial showed that most cases of PID occurred in women who tested negative for chlamydia at baseline, suggesting incident infection.

Therefore the effectiveness of a single chlamydia test in preventing PID over 12 months might have been overestimated. This would suggest that more frequent testing might be necessary in women who are at higher risk of the condition.

Guidelines

Curriculum
This topic falls under section 10.1 of the GP curriculum, Women's Health. gponline.com/curriculum

Online

References

1. RCOG. Green-top Guideline No 32: Management of Acute Pelvic Inflammatory Disease. 2008.

2. Ross JDC. Sex Transm Infect 2002 78: 18-19.

3. Simms I, Warburton F, Westrom L. Sex Transm Infect 2003; 79: 491-4.

4. Crossman SH. Am Fam Physician 2006; 73: 859-64.

5. Clinical Effectiveness Group - British Association for Sexual Health and HIV (2011) UK National Guideline for the Management of Pelvic Inflammatory Disease 2011.

6. Jaiyeoba O, Soper DE. Infect Dis Obstet Gynecol 2006; 1-6.

7. Oakeshott P et al. BMJ 2010; 340: c1642.

CPD IMPACT: EARN MORE CREDITS

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Audit the number of patients with PID who have been screened for HIV in the past year.
  • Write a clinical algorithm for PID management for your practice.
  • Ask your patient participation group its views on how to screen young people for chlamydia.

Save this article and add notes with your free online CPD organiser at gponline.com/cpd

Take clinical tests and claim certificates for CPD at myCME.com

Contributed by Miss Prabha Sinha, obstetrician, Conquest Hospital, Hastings, and Dr Suneeta Kochhar, GP, Churchwood Medical Practice, St Leonards on Sea.

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