Pathophysiology Acute inflammation of the upper genital tract – the uterus or adnexa – from an ascending infection – usually chlamydia or gonorrhea (25%). May lead to epithelial damage thus allowing further pathogen entry. Involves any combination of endometritis, salpingitis, tubo-ovarian abscess, or pelvic peritonitis. Rarer causes: Gardnerella vaginalis, H. influenzae, Strep agalactiae (Group B Strep), CMV. Often no pathogen is found. Signs and symptoms Symptoms: Varies from asymptomatic to severe. Pain: lower abdominal (often bilateral), lower back, and deep dyspareunia. Systemic: fever, nausea and vomiting. Discharge and bleeding: cervical or vaginal mucopurulent discharge, postcoital or intermenstrual bleeding. On bimanual examination, tenderness in the uterus, adnexa, and cervix ('cervical excitation').

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Pelvic inflammatory
disease (PID) salpingitis

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Pathophysiology
• Acute inflammation of the upper genital tract – the
uterus or adnexa – from an ascending infection –
usually chlamydia or gonorrhea (25%). May lead to
epithelial damage thus allowing further pathogen entry.
• Involves any combination of endometritis, salpingitis,
tubo-ovarian abscess, or pelvic peritonitis.
• Rarer causes: Gardnerella vaginalis, H. influenzae, Strep
agalactiae (Group B Strep), CMV.
• Often no pathogen is found.

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PID
Medicos
Slides:

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Signs and symptoms
 Symptoms:
• Varies from asymptomatic to severe.
• Pain: lower abdominal (often bilateral), lower back, and
deep dyspareunia.
• Systemic: fever, nausea and vomiting.
• Discharge and bleeding: cervical or vaginal mucopurulent
discharge, postcoital or intermenstrual bleeding.
 On bimanual examination, tenderness in the uterus,
adnexa, and cervix ('cervical excitation').

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Risk factors
• Sexually active, especially if unprotected.
• History of STIs.
• Age 18-25.
• IUCD

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Investigations
 Initial tests:
• Bloods: ↑WBC, ↑ESR/CRP.
• Vaginal or endocervical swabs: send for chlamydia and
gonorrhea nucleic acid amplification test.
• Urine: rule out UTI, and pregnancy test to rule out
ectopic.

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Investigations
 Optional further tests:
• Transvaginal US may show fluid-filled fallopian tubes,
endometrial thickening, or tubo-ovarian abscess. Also helps
rule out other conditions.
• Screen for other STIs.
• Consider pelvic CT or MRI if severe.
• Laparoscopy can help make the diagnosis and rule out
alternative causes, but is invasive and not routinely used.

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Investigations
 Diagnosis:
• Can often be made clinically, especially as swabs may be
negative even if PID present.
• However, PID is unlikely if WBC, ESR, and swabs are
normal.

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Medicos PDF app:

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Management
 Antibiotics:
• Ceftriaxone IM once, then doxycycline PO ± metronidazole PO for
2 weeks.
• If severe – >38°C, peritonitis, or abscess – give ceftriaxone IV +
metronidazole IV + doxycycline PO, then switch to metronidazole
PO + doxycycline PO.
• Screen and treat sexual contacts.
 Also:
• Analgesia
• Consider removing IUCD, but balance against risks of pregnancy.
• Repeat testing 3-6 months later to ensure no recurrence.

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Complications
• Scarring and adhesions to nearby tissue or organs,
causing chronic pain.
• Tubo-ovarian abscess.
• Fitz-Hugh Curtis syndrome (10%): RUQ pain due to
perihepatitis.
• Obstetric: infertility, ectopic pregnancy.

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