History

Fact Explanation
Bilateral lower abdominal pain Pelvic inflammatory disease (PID) is an upper genital tract infection ascending from the endocervix. This leads to the development of endometritis, salpingitis, oophoritis, tuboovarian abcess and pelvic peritonitis. [1]
Per-vaginal discharge The vaginal discharge can be purulent and blood stained. It is usually offensive.[1]
Abnormal per-vaginal bleeding The patient can present with heavy menstrual bleeding, inter-menstrual bleeding and post coital bleeding.[2]
Deep dyspareunia Dyspareunia is pain during sexual intercourse. Inflammation of the upper genital tract will cause a deep seated pain during sexual intercourse. [3]
Fever Due to the systemic response from pelvic inflammatory disease.[1]
The patient may be asymptomatic. The spectrum of disease presentations can range from asymptomatic to life threatening complications such as tubo-ovarian abscesses.[4] Asymptomatic women may present with infertility.
Infertility, chronic pelvic pain etc. In addition to the acute presentation the patient may present with long term complications.[5]
Fitz-Hugh-Curtis syndrome This is a rare complication presenting with pleuritic type right upper quadrant pain & jaundice due to perihepatitis which occurs in some women with PID.[6][7]
References
  1. UK National Guideline for the Management of Pelvic Inflammatory Disease. Clinical Effectiveness Group British Association for Sexual Health and HIV, June 2011 [Viewed 17 April 2014]. Available from: http://www.bashh.org/documents/3572.pdf
  2. MONGA Ash, DOBBS Stephen. Gynaecology by Ten Teachers. 19th ed. London : Hodder Arnold, 2011.
  3. HEIM L.J. Evaluation and Differential Diagnosis of Dyspareunia. American Family Physician, 2001 Apr, 63(8), 1535-1545.
  4. GRADISON M. Pelvic inflammatory disease. Amercian Family physician,. 2012 Apr, 85(8), 791-796.
  5. LIPSCOMB GH, LING FW. Relationship of pelvic infection and chronic pelvic pain. Obstet Gynecol Clin North Am [online] 1993 Dec, 20(4):699-708 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8115085
  6. RIS HW. Perihepatitis (Fitz-Hugh--Curtis syndrome). A review and case presentation. Jounal of Adolescent Health Care, 1984 Oct, 5(4), 272-6.
  7. PETER NG, CLARK LR, JAEGER JR. Fitz-Hugh-Curtis syndrome: a diagnosis to consider in women with right upper quadrant pain. Cleveland Clinic Journal of Medicine, 2004 Mar, 71(3), 233-9.

Examination

Fact Explanation
General examination : fever(>38°C), tachycardia Due to the systemic response to infection. Some patients may develop a severe illness with generalized sepsis.[1]
Abdominal examination 1. Lower abdominal tenderness - The patient may exhibit pain on palpation of the lower abdomen due to inflammation of the pelvic organs. 2. Rebound tenderness and guarding – Features of peritonitis.[1]
Vaginal examination 1. Bilateral adnexal tenderness 2. Cervical motion tenderness – Pain upon moving of the cervix by the examiner's gloved finger. This is due to moving of the inflamed pelvic organs. This sign is characteristically seen in PID, ectopic pregnancy etc.[1][2] 3. Tender adnexal mass – Due to the formation of a tubo-ovarian abscess. 4. Tender pelvic mass – Pus collection in the pouch of Douglas may lead to formation of a pelvic abscess.
Speculum examination The per-vaginal discharge may be observed.[1]
References
  1. UK National Guideline for the Management of Pelvic Inflammatory Disease. Clinical Effectiveness Group British Association for Sexual Health and HIV, June 2011 [Viewed 17 April 2014]. Available from: http://www.bashh.org/documents/3572.pdf
  2. MONGA Ash, DOBBS Stephen. Gynaecology by Ten Teachers. 19th ed. London : Hodder Arnold, 2011.

Differential Diagnoses

Fact Explanation
Ectopic pregnancy The patient usually presents with lower abdominal pain with per vaginal bleeding.[1] The bleeding is dark colored due to altered blood. Most of patients will have a period of amenorrhoea. The patient may present in a collapsed state due to hemorrhage from a ruptured ectopic pregnancy. Features such as fever, mucopurulent vaginal discharge, dyspareunia are absent. Examination usually reveals no specific signs but cervical motion tenderness, adnexal tenderness may be present occasionally. Diagnosis is made by ultrasound scan and beta- hCG measurements.[2]
Complications of an ovarian cyst Ovarian cysts may undergo torsion, rupture or hemorrhage.[3][4] The patient presents with acute abdominal pain and nausea/ vomiting. Examination will reveal a pelvic mass separate from the uterus. Diagnosis can be made by ultrasound assessment of the abdomen.
Urinary tract infection Urinary symptoms such as dysuria, haematuria are more prominent compared to lower abdominal pain. The patient may have fever. Examination will be normal with a normal vaginal examination. For diagnosis a mid stream urine sample is collected.[5] Urine microscopy, dipstick assessment and urine culture will enable diagnosis & identification of the causative organism.
Acute appendicitis Acute inflammation of the appendix will lead to a migratory type abdominal pain, nausea/ vomiting & anorexia. The abdominal pain is initially a diffuse dull pain located in the peri-umbilical area which localizes to the right iliac fossa (RIF) with involvement of the parietal peritoneum. A mild temperature (<38) may be present. Abdominal examination will reveal rebound tenderness and guarding in the RIF. A diagnosis is arrived at based on the clinical presentation supported by ultrasound scan assessment.[6]
References
  1. Tubal Pregnancy, Management (Green-top 21). Royal College of Obstetricians and Gynaecologists, May 2004 [Viewed on 17 April 2014]. Available from : http://www.rcog.org.uk/womens-health/clinical-guidance/management-tubal-pregnancy-21-may-2004
  2. Ectopic pregnancy and miscarriage. National institute for health and care excellence, December 2012 [Viewed on 18 April 2014]. Available from : http://publications.nice.org.uk/ectopic-pregnancy-and-miscarriage-cg154
  3. GRAHAM L. ACOG Releases Guidelines on Management of Adnexal Masses. American Family Physician, 2008 May, 77(9), 1320-1323.
  4. MONGA Ash, DOBBS Stephen. Gynaecology by Ten Teachers. 19th ed. London : Hodder Arnold, 2011.
  5. Management of suspected bacterial urinary tract infection in adults. Scottish Intercollegiate Guidelines Network, July 2012 [Viewed on 19 April 2014]. Available from : http://www.sign.ac.uk/pdf/sign88.pdf
  6. ARMSTRONG C. ACEP Releases Guidelines on Evaluation of Suspected Acute Appendicitis. American Family Physician, 2010 Apr, 81(8), 1043-1044.

Investigations - for Diagnosis

Fact Explanation
Full blood count A raised white cell count will be seen due to the acute inflammatory process. A neutropenia can be seen in severe infections.[1]
C reactive protein / erythrocyte sedimentation rate Markers of inflammation will be elevated.[1]
Mid stream urine for urinalysis To exclude a urine tract infection.[1]
High vaginal swab/ Endocervical swab To detect the causative organism.[2] Neisseria gonorrhoea & Chlamydia have a propensity to involve the endocervical mucosa. A positive test result supports a PID diagnosis but a negative result does not exclude it. The presence of pus cells in these specimens supports the diagnosis.
Ultrasound scan (USS) of abdomen USS may detect an adnexal mass in the presence of a tubo-ovarian abscess.[1]
Laparoscopy Laparoscopy is considered the gold standard in the diagnosis of pelvic inflammatory disease.[3] Features that are observed for are tubal wall edema, tubal surface hyperemia, presence of exudate along tubes, tubo-ovarian abscesses & hepatic adhesions.[4] Specimens can be obtained for microbiological and histological analysis. Adequate expertise and facilities are required for conducting this invasive investigation. Inability to view the interior of pelvic organs is a disadvantage. It is not recommended for mild disease.
References
  1. UK National Guideline for the Management of Pelvic Inflammatory Disease. Clinical Effectiveness Group British Association for Sexual Health and HIV, June 2011 [Viewed 17 April 2014]. Available from: http://www.bashh.org/documents/3572.pdf
  2. GRADISON M. Pelvic Inflammatory Disease. American Family Physician. 2012 April , 85(8), 791-796
  3. PEIPERT J.F, SOPER D.E. Diagnostic Evaluation of Pelvic Inflammatory Disease. Infectious Diseases in Obstetrics & Gynecology, 1994, 2(1), 38–48.
  4. JACOBSON L, Westrom L. Objectivized diagnosis of acute pelvic inflammatory disease: Diagnostic and prognostic value of routine laparoscopy. American Journal of Obstetrics & Gynecology, 1969, 105, 1088-1098.

Investigations - Screening/Staging

Fact Explanation
Exclude pregnancy – urinary beta-hCG All patients suspected with PID need to have a pregnancy test. [1]
Screening for sexually transmitted infections (STIs) including HIV These patients are at risk of having other sexually transmitted infections that need to be screened for and treated.[2]
References
  1. Pelvic inflammatory disease. National institute for health & care excellence, March 2013 [Viewed on 18 April 2014]. Available from : http://cks.nice.org.uk/pelvic-inflammatory-disease#!diagnosissub:3
  2. UK National Guideline for the Management of Pelvic Inflammatory Disease. Clinical Effectiveness Group British Association for Sexual Health and HIV, June 2011 [Viewed 17 April 2014]. Available from: http://www.bashh.org/documents/3572.pdf

Management - General Measures

Fact Explanation
Patient education and counseling Information should be provided about the source of infection, natural course of the disease and the complications associated. The patient’s partner should also be involved in the management plan.[1]
Advise on adequate physical rest in severe disease.[1] Patients who are severely ill require adequate rest which promotes quick resolution.[1]
Analgesia For pain relief. Non-steroidal anti-inflammatory drugs (NSAIDs) can be used.[1]
Patients should be advised to avoid unprotected sexual intercourse until the treatment course is complete. Both the patient and the partner need to be treated completely due to the risk of reinfection.[2] Repeated infection carries a higher risk of development of complications such as infertility, ectopic pregnancy, chronic pelvic pain etc
References
  1. UK National Guideline for the Management of Pelvic Inflammatory Disease. Clinical Effectiveness Group British Association for Sexual Health and HIV, June 2011 [Viewed 17 April 2014]. Available from: http://www.bashh.org/documents/3572.pdf
  2. MONGA Ash, DOBBS Stephen. Gynaecology by Ten Teachers. 19th ed. London : Hodder Arnold, 2011.

Management - Specific Treatments

Fact Explanation
Empirical treatment should be started on clinical suspicion without delay. Prompt treatment will reduce incidence of complications such as sub-fertility, chronic pelvic pain etc. Management depends on the severity of the disease. Mild/moderate disease is managed in the out-patient setting while severe disease needs hospitalization & parenteral therapy.[1]
Management of mild/moderate disease Symptomatic treatment & oral antibiotics are used. Commonly used antibiotic regimes include 1. oral ofloxacin 400mg twice daily plus oral metronidazole 400mg twice daily for 14 days. 2. Intramuscular ceftriaxone 500mg single dose followed by oral doxycycline 100mg twice daily plus metronidazole 400mg twice daily for 14 days. 3. Intramuscular ceftriaxone 500 mg single dose followed by azithromycin 1 g/week for 2 weeks. 4. Oral moxifloxacin 400mg once daily for 14 days.[2][3]
Management of severe infection Hospitalization should be considered when the patient exhibits features of generalized sepsis, features of intra-abdominal abscess formation & experiences severe abdominal pain with poor response to oral antibiotics.[4] Patients who are pregnant are best managed in the hospital setting. Intravenous therapy is continued for 24 hours after clinical improvement and then switched to oral therapy. Management steps include 1. Analgesia for pain relief. 2. Monitoring & maintaining adequate fluid intake. 3. Intravenous antibiotic therapy- Recommended treatment regimes are 1. Intravenous ceftriaxone 2g daily plus i.v./ oral doxycycline 100mg twice daily followed by oral doxycycline 100mg twice daily plus oral metronidazole 400mg twice daily for a total of 14 days. 2. Intravenous clindamycin 900mg three times daily plus i.v. gentamicin (2mg/kg loading dose) followed by 1.5mg/kg three times daily followed by either oral clindamycin 450mg 4 times daily or oral doxycycline 100mg twice daily plus oral metronidazole 400mg twice daily to complete 14 days. 3. I.v. ofloxacin 400mg twice a day plus i.v. metronidazole 500mg three times a day for 14 days.[2][3]
Surgical management Laparoscopy can be used for adhesiolysis and drainage of abscesses.[5] The adhesions associated with perihepatitis can also be divided. In severe disease the affected fallopian tube or ovary may need to be removed. Drainage of a pelvic abscess can also be achieved by ultrasound guided percutaneous aspiration.
Treatment for sexual partners The current male partner and recent sexual contacts need to be traced and screened gonorrhoea and Chlamydia. Patients found positive for gonorrhea and chlamydia need to be treated appropriately. Male partners are also treated empirically with azithromycin 1g single dose. The patient and the partner are advised to avoid intercourse until completion of treatment.[2]
Pelvic inflammatory disease in a pregnant woman Parenteral therapy with a combination of cefotaxime, azithromycin & metronidazole is used. Doxycycline, gentamycin & ofloxacin are avoided in this situation. A regime used includes intramuscular ceftriaxone plus oral or i.v. erythromycin, with the addition of oral or i.v. metronidazole 500mg three times daily in clinically severe disease.[2]
Follow up Review the patient in 2 to 4 weeks to assess the adequacy of the clinical response to treatment, compliance with oral antibiotics & screening and treatment of sexual contacts.[2]
References
  1. NESS RB, SOPER DE, HOLLEY RL et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. American Journal of Obstetrics & Gynecology, 2002, 186(5), 929-937.
  2. UK National Guideline for the Management of Pelvic Inflammatory Disease. Clinical Effectiveness Group British Association for Sexual Health and HIV, June 2011 [Viewed 17 April 2014]. Available from: http://www.bashh.org/documents/3572.pdf
  3. HEMSELL DL, LITTLE BB, FARO S et al. Comparison of three regimens recommended by the Centers for Disease Control and Prevention for the treatment of women hospitalized with acute pelvic inflammatory disease. Clinical Infectious Diseases, 1994, 19(4), 720-727.
  4. Pelvic Inflammatory Disease. Centers for Disease Control and Prevention, 2010 [Viewed on 17 April 2014]. Available from : http://www.cdc.gov/std/treatment/2010/pid.htm
  5. REICH H, MCGLYNN F. Laparoscopic treatment of tuboovarian and pelvic abscess. Journal of Reproductive Medicine, 1987, 32(10), 747-752.