Login
Search

Search
Search

Pelvic Inflammatory Disease (PID)

NICE CKS Pelvic inflammatory disease. Last revised Jun 2024. BASHH PID 2019. Last updated Jan 2019.

Background Information

PID: ascending infection of the upper genital tract from the endocervix

PID is a general term that covers one or more of the following:
  • Endometritis — inflammation and infection of the uterus
  • Salpingitis — inflammation of the fallopian tubes
  • Parametritis — inflammation of the parametrium, the connective tissue of the pelvic floor
  • Oophoritis — inflammation of the content of one or both ovaries
  • Tubo-ovarian abscess — due to complex infection of the adnexae
  • Pelvic peritonitis — inflammation of the peritoneum.

Most commonly caused by STIs:
  • Chalmydia trachomatis - most common (14-35%)
  • Neisseria gonorrhoea
  • Mycoplasma genitalium

Risk factors related to sexual behaviour:
  • <25 y/o
  • Not using condoms
  • <15 y/o at onset of sexual activity
  • Multiple sexual partners
  • Recent new sexual partner (<3 months)
  • Previous PID
  • History of STI in the women / sexual partner

Recent uterus instrumentation from:
  • Termination of pregnancy
  • Insertion of IUDIntrauterine device (only increases risk for 3 weeks)
  • hysteroscopy / hysterosalpingography
  • IVFIn vitro fertilisation

Symptoms:
  • Lower abdominal pain (typically bilateral)
  • Deep dyspareunia
  • Abnormal vaginal bleeding
  • Secondary dysmenorrhoea


Signs:

  • Adnexal tenderness
  • Vaginal / cervical discharge (often purulent)
  • Cervical motion tenderness
  • Systemic upset (fever, nausea, vomiting, malaise) 

  • ↑ Risk of ectopic pregnancy 
  • Infertility
  • Chronic pelvic pain
  • Tubo-ovarian abscess
  • Perihepatitis ( Fitz-Hugh-Curtis syndrome)

Guidelines

PID is a clinical diagnosis. Antibiotics should not be delayed while awaiting laboratory test results.
  • BASHH recommends considering a diagnosis of PID and offering treatmnet in any <25 y/o women with recent onset, bilateral lower abdominal pain +  local tenderness on bimanual examination.


Consider the following tests (not needed for diagnosis):
 
Test Notes
Pregnancy test To exclude ectopic pregnancy
Blood tests ↑ Leukocyte / CRP / ESR may support diagnosis
Vaginal swabs for chalmydia + gonorrhoea + Mycoplasma genitalium -ve Swab does not rule out PID
STI screen Including HIV, hepatitis serology, and syphilis serology
Wet mount vaginal smear under microscope Good -ve predictive value (absence of pus cells means PID is unlikely)

 

In any female of reproductive age, a urinary pregnancy test should always be done initially to rule out ectopic pregnancy.

It is a quick bedside test and can rule out potentially life-threatening ruptured ectopic pregnancy.

 

BASHH recommends a low threshold for empirical PID treatment due to:
  • Lack of definitive diagnostic criteria, and
  • Delaying treatment is likely to increase risk of long-term complications

Patient should be advised to attend local specialist sexual health service if hospital admission not needed.
 

  • Clincially severe disease
  • Pregnant women
  • Tubo-ovarian abscess suspected
  • Pelvic peritonitis suspected 
  • Surgical emergency cannot be excluded
  • No response to oral therapy 
 

  • Paracetamol and/or ibuprofen
  • Avoid unprotected sexual intercourse until patient and partner(s) completed treatment and follow up
 

Removal of IUD is indicated if:
  • Severe symptoms at presentation
  • NOT clinically improving after antibitoics

IUD can remain in situ if mild-to-moderate symptoms + clinically improving within 48-72 hours of starting antibiotics

1st line → triple therapy:

  • IM ceftriaxone 1g single dose +
  • Oral doxycycline 100mg BD for 14 days +
  • Oral metronidazole 400mg BD for 14 days

If Mycoplasma genitalium +ve:
  • Oral moxifloxacin 400mg OD for 14 days

2nd line regimen:
  • IM ceftriaxone 1g single dose +
  • Oral azithromycin 1g per week for 14 days

Principle:
  • IV antibiotics until 24 hours after clinical improvement
  • Then, switch to oral antibitoics

Regimen (either):
  • IV ceftriaxone + IV doxycycline followed by oral doxycycline 100mg BD + oral metronidazole 400mg BD for 14 days
  • IV clindamycin + IV gentamicin followed by oral clindamycin / doxycycline + metronidazole for 14 days
 

  • Review within 72 hours after starting antibiotics
  • Consider further review 2-4 weeks after completion of antibiotics 
  • Advice on future use of barrier method of contraception

Test of cure indicated if:
  • +ve initial test for gonorrhoea / chlamydia / Mycoplasma genitalium
  • Persistent symptoms after completing antibiotics 
  • Initial test results showing unknown antibiotic sensitivity or resistance (for gonorrhoea / Mycoplasma genitalium)
  • Persistent / recurrent infection
  • Poor compliance with antibiotic / treatment not toelrated

Contact tracing + STI screening and treatment for:
  • Current partners
  • Recent (<6 months) partners

Whilst waiting for results, offer male partners doxycline 100mg BD for 1 week

References


Author: Adams Lau
Reviewer:
Last Edited: 09/04/25