Pelvic Inflammatory Disease

Grading of PID (Gainesville)

Diagnosis

Treatment

Discharging in-patients with PID

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May be mild in an ambulant patient or severe & require intensive care

Grading of PID (Gainesville)

• Grade I: Acute salpingitis without peritonitis
• Grade II: Acute salpingitis with peritonitis
• Grade III: Acute salpingitis with tubo-ovarian complex or tubal occlusion
• Grade IV: Ruptured tubo-ovarian complex &/or generalized peritonitis

Diagnosis

Patients with pelvic inflammatory disease (PID) may have - 

continuous LAP, dyspareunia, vaginal discharge (not always), dysmenorrhea, infertility, rigors, pyrexia, abdominal guarding or rebound tenderness, cervical excitation/motion tenderness (must be present), adnexal tenderness & there may be a pelvic mass. Mild cases may be apyrexial with only cervical & adnexal tenderness.

Patients with PID probably do not have -

significant urinary or bowel symptoms, amenorrhoea, & almost never a positive pregnancy test, unless it follows a procedure to evacuate the uterus (post abortal sepsis).

Notes on diagnosis 

• Pain may be perceived as unilateral, although PID is often
• bilateral
• Most chronic LAP is not caused by PID
• Painless intercourse during the time of symptoms suggests a diagnosis other than PID – how can the cervix be moved in intercourse and not elicit pain?
• There does not have to be an offensive vaginal discharge
• Cervical excitation tenderness is a ‘subjective sign’. It should not be ignored if present
• An early ongoing pregnancy & PID (as in: infection of the upper genital tract) cannot coexist

Treatment

Criteria for outpatient management

• Only grade I & selected patients with grade II disease
• Temperature <38⁰ C, pulse <100
• No palpable adnexal or pelvic mass (unless patient is well - chronic mass)
• Minimal or no abdominal signs
• The patient is systemically well

Outpatient management of PID

1. Ceftriaxone 250 mg IM stat (diluted in 0.9ml lidocaine 1%), plus Doxycycline 100 mg orally twice daily for 14 days, plus Metronidazole 400 mg orally twice daily for 14 days
2. Azithromycin 1G stat (repeated after 1 week) is an alternative to doxycycline.
3. Analgesia, e.g. Ibuprofen 400 mg orally 3 times daily for 5 days (unless there is renal dysfunction, history of a peptic ulcer)
4. Recommend treatment of the sexual partner
5. Advise the patient to return if she is feeling unwell or is not improving

Remember, if you are in doubt about the diagnosis, say so. Explain you are prescribing antibiotics in case it might be. A firm statement of the diagnosis carries a strong possibility of an infidelity. This may damage a sound relationship.

In-patient management of PID

For Grade II-III to IV disease:

1. Full clinical assessment including speculum examination. Feel for a mass if pain allows
2. FBC, U&E & HIV, ABG if indicated - unwell, nasal flaring, tachypnoea
3. Ultrasound scan
4. Antibiotics:
   • Ceftriaxone 250mg im stat
   • Penicillin G 6 million units IV 6 hourly or Ampicillin 500mg 6hourly
   • Gentamicin 240 mg IV daily or Amikacin 1 g IV daily
   • Metronidazole 1 g rectally twice daily or 500 mg IV 12 hourly, or 400 mg orally 6 hourly if tolerating oral medications
5. Analgesia: Ibuprofen 400 mg orally 3 times daily (unless kidney failure, history of peptic ulcer)
6. Close monitoring of vitals & physical signs & expect improvement
7. Surgical intervention & intensive care for seriously ill patients (below)

Poor prognostic indicators in PID

• High temperature (>38.5 degrees C)
• Tachypnoea & nasal flaring
• Hypotension
• Acute renal failure – poor urine output or abnormal biochemistry
• Evidence of disseminated intravascular coagulopathy
• Generalized peritonitis
• Dusky or necrotic cervix
• Metabolic acidosis
• HIV positive with a low CD4 count
• Systemic inflammatory response syndrome

Second-line antibiotics for non-responders or allergic patients

• Ceftriaxone 1 g IV  od
• Clindamycin 600 mg IV 6 hourly
• Tazocin (Piperacillin & Tazobactam) 4.5 g IV 12 hourly possibly

Patients who are severely ill or do not respond to treatment 

Consider surgery (drainage & very thorough washout, deroof adnexal masses, hysterectomy – if post abortal)

• For patients with a mass who are not responding to treatment (including 2^nd line antibiotics)
• For patients with a mass who have renal failure or thrombocytopenia
• When the cervix appears dusky or necrotic
• For generalized peritonitis – that does not improve, or in association with the unwell patient

Other considerations regarding surgery

• Decisions on surgery should be taken by a consultant
• Surgery in these patients may be difficult & consultant supervision is required. De-roofing a pelvic abscess & breaking down all loculations of pus is better than removing large amounts of tissue & risking bowel perforation. The exception is severe sepsis after abortion - may require hysterectomy
• These patients may require ICU admission, especially after surgery

Discharging in-patients with PID

1. Doxycycline 100 mg orally & Metronidazole 400 mg orally twice daily for 7 days
2. If treated with IV clindamycin, continue with 450 mg orally 8 hourly
3. Analgesia (ibuprofen 400 mg orally 3 times daily as required)
4. Recommend treatment of the sexual partner
5. Follow-up visits are not necessary as a routine