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Pelvic Inflammatory Disease
⚠️ Key exam pearl: Lower abdominal pain and adnexal tenderness are the most consistent findings of PID. Always consider in sexually active women with pelvic pain, discharge, or fever.
📖 About
- Pelvic Inflammatory Disease (PID) is an infectious and inflammatory disorder of the upper female genital tract - uterus, fallopian tubes, ovaries ± peritoneum.
- Most often caused by ascending STIs from the cervix/vagina.
- Untreated PID can result in infertility, ectopic pregnancy, chronic pelvic pain.
🦠 Aetiology
PID is usually polymicrobial, often triggered by STIs and complicated by anaerobes.
- STIs: Chlamydia trachomatis, Neisseria gonorrhoeae.
- Other bacteria: anaerobes, Gardnerella, streptococci, staphylococci, E. coli.
- Risk factors: multiple partners, prior STI, IUCD insertion (esp. first 3 weeks).
🤒 Clinical Presentation
- Systemic: fever >38°C, malaise, nausea/vomiting.
- Pelvic: bilateral lower abdominal pain, deep dyspareunia, abnormal bleeding, offensive vaginal discharge.
- Exam findings: cervical motion tenderness (CMT), adnexal tenderness ± masses, uterine tenderness.
🧾 Differential Diagnosis
- Appendicitis
- Ectopic pregnancy
- Ovarian torsion/cyst rupture
- UTI or pyelonephritis
- IBD flare (Crohn’s/UC)
⚡ Complications
- Infertility (tubal scarring, 15–20%)
- Ectopic pregnancy (5–10× risk)
- Chronic pelvic pain
- Tubo-ovarian abscess → sepsis, rupture
- Fitz-Hugh–Curtis syndrome (perihepatitis)
🔬 Investigations
- Bedside: pregnancy test (exclude ectopic), speculum exam, swabs for NAAT (chlamydia/gonorrhoea).
- Bloods: FBC, CRP/ESR, LFTs, U&E.
- Imaging: pelvic US (abscess, hydrosalpinx), MRI if unclear.
- Laparoscopy: gold standard - direct visualisation, cultures.
💊 Management
- Empirical antibiotics (start immediately, don’t wait for swabs):
- IM Ceftriaxone 1 g stat + Doxycycline 100 mg PO BD 14 days ± Metronidazole 400 mg PO BD 14 days (covers anaerobes).
- Admission indications: severe illness, pregnancy, abscess, failed outpatient Rx, diagnostic uncertainty.
- Pain relief: NSAIDs, rest, fluids.
- Partner notification & treatment → essential to prevent reinfection.
- Surgery: drainage of tubo-ovarian abscess if no improvement in 72 hrs.
📉 Prognosis
- ✅ Early treatment: complete resolution in most women.
- ⚠️ Delayed treatment: tubal damage, infertility, ectopic pregnancy, chronic pelvic pain.
- 🔄 Recurrence risk: ~25% within 1 year if reinfected.
✅ Conclusion
PID is a preventable cause of infertility and ectopic pregnancy. Maintain a high index of suspicion in sexually active women with pelvic pain. Prompt antibiotics, partner treatment, and follow-up are key to reducing long-term harm.
📚 References
- CDC – Pelvic Inflammatory Disease
- NICE NG43: STIs & PID
- Wilson TJ, et al. BMJ 2018;361:k2135.