Pelvic Inflammatory Disease (PID)

Comments from Expert Advisory Committee

  • Pelvic Inflammatory Disease (PID) is usually the result of infection ascending from the endocervix causing endometritis, salpingitis, parametritis, oophoritis, tubo-ovarian abscess and/or pelvic peritonitis. Occasionally it is caused by local spread within the peritoneal cavity.
  • Chlamydia, gonorrhoea and Mycoplasma genitalium can lead to PID though many cases of PID are negative for these organisms. The presence of other commensal anaerobic genital tract bacteria is believed to be important in facilitating ascent of lower genital tract infections leading to PID.
  • Symptoms vary from mild to severe where hospitalisation and consideration for surgical intervention is required.
  • Mild symptoms include – lower abdominal/pelvic pain, deep dyspareunia, a change in vaginal discharge, post-coital bleeding
  • Severe symptoms include – all of the above and in addition, there may be evidence of sepsis, constitutional symptoms, shoulder tip pain, right upper quadrant pain (perihepatitis, Fitz-Hugh Curtis Syndrome)
  • In patients presenting with any of the symptoms above it is important to consider the diagnosis of PID and take a sexual history.
  • It is reasonable to refer all suspected cases of PID to a GUM clinic, sometimes patients will need to be referred to the Emergency Department depending on the severity of symptoms.
  • Features on examination include lower abdominal/pelvic tenderness, rebound tenderness, lower abdominal/pelvic mass (in the setting of a tubo-ovarian abscess), cervical excitation tenderness on bimanual examination.
  • All women presenting with symptoms and/or signs suggestive of PID should have a pregnancy test performed.
  • All women presenting with symptoms and/or signs suggestive of PID should have testing for STIs including HIV, Hepatitis B, syphilis, gonorrhoea, chlamydia and Mycoplasma genitalium.
  • Patients with positive Mycoplasma genitalium swabs should be referred to a specialist GUM clinic for management given the high prevalence of antimicrobial resistance seen in this organism. Further information on Mycoplasma genitalium  is available in Guidance on Mycoplasma genitalium testing and management in Ireland 
  • Hepatitis C testing should be considered part of routine sexual health screening in the following circumstances: MSM, People living with HIV; Commercial sex workers; PWID; People who inject drugs (PWID). Partners of the above should also be considered for HCV testing.
  • Individuals diagnosed with PID should be advised to abstain from sexual intercourse until treatment completed and where indicated their partner has been treated.
  • Where chlamydia or gonorrhoea have been diagnosed in patients with PID, these infections are notifiable diseases. Notification process is usually initiated by the testing laboratory

Treatment

Empiric antibiotic treatment should be directed against chlamydia, gonorrhoea and anaerobic organisms. Outpatient treatment with a combination of oral and IM antibiotics is appropriate for the majority of cases.
Admission to hospital and parenteral therapy is indicated in patients with evidence of sepsis, those unable to tolerate oral therapy, those likely to require surgical intervention (for example tubo-ovarian abscess).
Patients with a positive Mycoplasma genitalium result should be referred to a specialist GUM clinic. Please refer to the chlamydia and gonorrhoea pages for further management information.

PID table july 6 2021


Useful resources

Patient Information

Safe Prescribing (visit the safe prescribing page)

Reviewed June 2021

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