Introduction
Pelvic inflammatory disease is an ascending pelvic infection involving the upper genital tract.
It usually involves sexually transmitted organisms e.g. Neisseria gonorrhoeae and Chlamydia trachomatis.
It may also be caused by organisms endogenous to the lower genital tract.
In severe cases, organisms may migrate via the peritoneum to the upper abdomen causing perihepatic adhesions: the so-called “violin strings” (Fitz-Hugh-Curtis syndrome).
Responsible for significant morbidity in
women, accounting for about 30% of all
gynaecological admissions in sub-Saharan Africa.
It is thought that 3% of women have Pelvic Disease Inflammatory (PID) during their lifetime
Risk factors
- Age:
- Peak incidence between 15-25 years
- Sexual activity:
- Multiplicity of sexual partners
- Use of intrauterine contraceptive devices:
- Usually within the first 4 months of use
- Previous episode(s) of PID
Clinical features
Major criteria (the Westrom triad):
- Lower abdominal pain and tenderness
- Cervical excitation tenderness
- Adnexal tenderness
Minor criteria
- Fever (38 degrees C)
- Leucocytosis
- Purulent vaginal discharge
- Adnexal mass
Diagnosis
- Based on the presence of the Westrom triad of symptomatology plus one of the minor criteria
- Confirmation by demonstration of causative organism(s) on microscopy, culture and sensitivity testing
Differential diagnoses
- Ovarian cyst accident
- Endometriosis
- Acute appendicitis
- Ectopic gestation
- Urinary tract infections
- Renal disorders (e.g. nephrolithiasis)
- Pelvic adhesions
- Lower lobe pneumonia
Complications
- Septicaemia
- Pelvic abscess
- Chronic pelvic pain
- Fitz-Hugh-Curtis syndrome
- Recurrence (about 25% rates)
- Infertility
- Ectopic gestation
Investigations
- Packed cell volume
- White Blood Cell count
- Endocervical swab
- High vaginal swab culture: to exclude trichomoniasis, bacterial vaginosis
- Haemoglobin genotype
- Blood Group
- Electrolytes and Urea
- Midstream urine microscopy, culture and sensitivity
- Urethral swab
- Ultrasound scan: to exclude cyesis, ectopic gestation, adnexal mass (e.g. ovarian mass)
Indications for admission
- Uncertain diagnosis
- Intolerance of oral medication or non response to outpatient therapy.
- Presence of an intrauterine device
- Presence of a pelvic mass
- Upper abdominal pain
- Non-adherence to therapy
- Pregnancy
- Nulliparity
Treatment objectives
- Rehydrate adequately
- Eradicate the infecting organism(s)
- Prevent complications.
Drug treatment
- Appropriate antibiotics for an adequate period
- The antibiotic chosen should cover all possible causative organisms while awaiting culture/sensitivity results
Outpatient therapy
(while awaiting culture results):
1. Ceftriaxone (or equivalent cephalosporin)
- 1g intramuscularly stat
Plus:
2. Doxycycline
- 100 mg orally every 12 hours for 14 days
Plus or minus:
2. Metronidazole
- 400 mg orally every 12 hours for 14 days
If no response in 48-72 hours, admit, re-evaluate and give appropriate intravenous therapy
Inpatient triple therapy
Ceftriaxone/ doxycycline/ metronidazole
Or:
Clindamycin/ gentamicin/ metronidazole
Triple antibiotic regimen to be continued for 48 hours after the patient improves clinically.
Subsequently, the patient should continue therapy with
Doxycycline
- 100 mg orally every 12 hours
Plus:
Metronidazole
- 400 mg orally every 8 hours for 10-14 days
Prevention
- Encourage the use of barrier contraceptive with spermicides
- Modify risky sexual behaviour: avoid, multiplicity of sexual partners
- Contact tracing: to break the existing chain of infection and prevent recurrence
- Prompt diagnosis and treatment to prevent long-term complications