Pelvic inflammatory disease (PID) is a major clinical problem globally that is caused by ascending infections of the female upper genital tract. It accounts for 5-20% of gynecological hospital admissions worldwide. Risk factors include young age, multiple sexual partners, and sexually transmitted infections. Clinically, PID presents with abdominal pain, abnormal discharge, and fever. Management involves history, exam, testing for gonorrhea and chlamydia, and treating with antibiotics to prevent complications like infertility.

1. MANAGEMENT OF PELVIC INFLAMMATORY
DISEASE
By
Chidiebere Agbo Paschal

2. OUTLINE
• Introduction
• Burden of disease
• Epidemiology
• Risk factors
• Microbial etiology
• Pathophysiology
• Clinical presentation
• Management
• Complications
• References

3. INTRODUCTION
PID is an ascending infection of the female upper genital
tract from the endocervix causing edometritis, salpingitis,
parametritis, oophoritis, tubo-ovarian abscess and/or pelvic
peritonitis. Commonly assoc with sexually tramsmitted
organisms (polymicrobial in nature).
A major clinical and public health problem globally,
accounting for 5-20% of hospital admissions for
gynaecological complaints worldwide.
One of the most frequent and important infections that
occur among non-pregnant women of reproductive age.

4. Burden of the disease
• PID is a common cause of morbidity and accounts for one
in 60 general practitioner consultations by women under
the age of 45 years. Delays of only a few days in
receiving appropriate treatment markedly increase the risk
of sequelae, which include, menstrual
disturbances,pregnancy wastage, infertility, ectopic
pregnancy, low birth weight babies or chronic pelvic pain.
Sequelae may also have significant healthcare costs.

5. EPIDEMIOLOGY
• Howard Kelly discovered the relationship between sexual
activity and the development of PID in 1898.
• CDC has estimated that more than 1 million women
experience an episode of PID every year.
• PID globally accounts for 5-20% of hospital admissions
for gynaecological problems

6. Epidemiology of PID
• PID is a common cause of gynaecological morbidity
worldwide.
• Over 800,000 cases diagnosed annually in the United
States of America.
• In the United Kingdom, PID was found to contribute to
about 2% of annual visit to general practitioners.

7. Epidemiology of PID
• A Jamaican study reported a PID prevalence of 17%
among women of reproductive age with majority of them
from low socioeconomic status. The study also found PID
to be higher among those who were sexually assaulted.
This is supported by another study also in Jamaica which
found PID to be higher among sexually assaulted women
from low socio economic status.

8. EPIDEMIOLOGY OF PID
• Prevalence of PID in Nigeria is high, particularly among
young adults. A study done in Port Harcourt, Nigeria put
the prevalence among undergraduates at 11%.Prasad et
al in a similar study reported a prevalence of 14% among
young women in India. This is small compared to the
study by Olowe, Alabi and Akindele in Osogbo, South-
Western Nigeria which reported a PID prevalence of 70%
and that of Okon et al, in Nguru, North-Eastern Nigeria
reported a prevalence of 62.8%.

9. RISK FACTORS
• Young age
• Early coitarche
• Multiple sexual partners
• Previous hx of STI/previous hx of PID
• Inconsistent condomn use
• Inappropriate insertion of IUCD
• Low socio-economic status
• Induced abortion and being in school
• Unstable relationships

10. MICROBIAL AETIOLOGY
• Pelvic Inflammatory Disease commonly arises from
ascending infection from the lower genital tract. Lower
genital tract infection, if not properly treated, will lead to
cervicitis from ascension of the organisms to the cervix.
Further spread will affect the uterus, fallopian tubes and
peritoneum leading to endometritis, salpingitis and
peritonitis respectively. This is made worse by the fact
that the infection could go undetected (asymptomatic)
causing significant damage without the patient knowing.

11. MICROBIAL AETIOLOGY
• It is a polymicrobial infection with a wide variety of
organisms involved. According to Dayan, STls such as
gonorrhoea and chlamydia account for one-third to one-
half of PID infections. This is similar to the findings of
Barrett and Taylor, Risser and Risser as well as Tukur,
Shittu and Abdul who found the commonest cause of PID
to be Chlamydia trachomatis and Neisseria
gonorrhoe.Ugboma, Nwagwu and Jeremiah in their study
to determine the prevalence of chlamydia among
undergraduates in Port Harcourt further stated that
infection with Chlamydia accounted for over 50% of
cases of salpingitis as well as infertility

12. MICROBIAL AETIOLOGY
• This claim was also supported by Okoror and colleagues
as well as Enwuru and Umeh in separate studies done in
South-Eastern Nigeria.
• Jaiyeoba, Lazenby and Soper reported that Neisseria
gonorrhoea, Chlamydia trachomatis and Mycoplasma
genitalium were recovered from the cervix, endometrium
and fallopian tubes of women with laparoscopically
proven acute salpingitis.
• Other implicated organisms: genital tract
mycoplamas(partiularly M. genitalium), anaerobic and
aerobic bacteria which comprise the endogenous vaginal
flora (e.g Prevotella spp, black-pigmented Gram-negative

13. MICROBIAL AETIOLOGY
anaerobic rods, Peptostreptocci spp, G. vaginalis, E. coli.
BV has also been commonly isolated from patients with
PID.
• Non sexually transmitted pathogensuchs such as TB also
play a role in endometritis, salpingitis and tubal factor
infertility, particularly in developing countries.

14. PATHOPHYSIOLOGY
Typically, acute PID is caused by ascending spread of
microorganisms from the vagina and/or endocervix to the
endometrium, fallopian tubes, and/or adjacent structures.
Infection of the cervix leads to damage to the endocervical
canal and breakdown of the mucus plug promoting the
ascension of infection. Haggerty and Ness in their study on
the epidemiology, pathogenesis and treatment of pelvic
inflammatory disease reported that, in addition to
endocervical damage by microorganisms as mentioned
above, microorganisms like Neisseria and Chlamydia also

15. PATHOPHYSIOLOGY
adhere to spermatozoa, potentially promoting their
ascension. The study also reported that the loss of mucus
plug associated with the onset of menses and retrograde
menstruation increases the ascension of microorganisms
and infection from the vagina and cervix into the upper
genital tract. This is in addition to younger women having a
larger cervical ectopy due to increased hormonal levels at
menarche that produces a larger attachment area for
bacterial pathogens. All these contribute to increased
susceptibility to infection leading to PID.

16. PATHOPHYSIOLOGY
• According to Soper, BV elaborates a variety of mucolytic
proteinases which degrade the cervical mucus plug and
the naturally occurring antimicrobials potentiating cervical
inflammation which facilitates the ascension of cervical
and vaginal microorganisms resulting in endometritis and
salpingitis.

17. PATHOPHYSIOLOGY
• Jaiyeoba and Soper in another study stated that once
infection-induced inflammation reached the fallopian tube,
epithelial degeneration and deciliation of ciliated cells
occurred along the fallopian tube mucosa in association
with a submucosal inflammatory cell infiltrate. This with
the associated oedema of the fallopian tube leads to
clubbing of the involved tube producing a dysfunctional,
partially or totally obstructed tube causing infertility or
ectopic pregnancy.

18. CLINICAL PRESENTATION
• Symptoms of PID vary from mild to severe necessitating a
high index of suspicion among clinicians to facilitate
diagnosis. Soper identified symptoms of PID to include
abdominal pain, abnormal vaginal discharge, inter-
menstrual bleeding, post-coital bleeding, fever, urinary
frequency, low back pain and nausea/vomiting. The
findings are similar to those of Jaiyeoba and Soper who
reported same symptoms. Some patients may present
with secondary dysmenorrhoea which is indicative of an
underlying disease condition like PID.

19. CLINICAL PRESENTATION
• Further assessment of patients with suspected PID
include general and pelvic examination including
bimanual examination. A study conducted by Jaiyeoba
and Soper identified the signs of PID to include fever with
temperature greater than 38.3oC, abnormal vaginal or
cervical mucopurulent discharge, abdominal tenderness
which may/may not be present particularly if there is no
peritonitis or patient is having endometritis or cervicitis
without salpingitis. This is similar to the findings of
Haggerty and Ness, and Risser and Risser. Risser and
Risser, in addition, noted that the presence of cervical
mucopus is an indication of cervical infection though

20. CLINICAL PRESENTATION
some studies cast doubt on its use in the diagnosisof PID.
Jaiyeoba and Soper further added that bimanual
examination would reveal pelvic tenderness such as uterine
tenderness in endometritis and adnexal tenderness in
salpingitis. Bartlett, Levison and Munday, in their study,
while agreeing with findings by Jaiyeola and Soper added
that there may also be cervical motion tenderness in
patients with PID.

21. MANAGEMENT
• Entails history and exam, investigation and treatment.
• History and exam as discussed above.
• Investigation

22. INVESTIGATION
• Risser and Risser noted that laboratory investigations to
confirm diagnosis of PID include endocervical swab for
N. gonorrhoea and using nucleic acid amplification test
(such as PCR, strand displacement amplification ) for C.
trachomatis where available.
• A pregnancy test should be done to exclude ectopic
pregnancy which is a strong differential of PID.

23. INVESTIGATION
• Full blood count will show elevated white blood cell count;
this is not very reliable as only 60% of patients with PID
have elevated white blood cell count. Elevated erythrocyte
sedimentation rate (ESR) of greater than 15mm/hr is also
seen in patients with PID, though only 75% of PID
patients will have elevated ESR. C-Reactive Protein
(CRP) is also elevated in patients with PID and can be
used as a monitoring tool as its levels decreases to
normal sooner than ESR following effective antibiotic
therapy.

24. INVESTIGATION
• Endometrial biopsy showing neutrophils and plasma cells
in the endometrium is indicative of endometritis and has
been suggested for use in the diagnosis of PID. It is not
as invasive as laparoscopy but useful in diagnosing
endometritis and predicting salpingitis, as studies show
that 54 – 92% of patients with endometritis on biopsy
also have laparoscopically confirmed salpingitis.

25. INVESTIGATION
Transvaginal ultrasound scanning may be helpful when
there is diagnostic difficulty. When supported by power
Doppler, it can identify inflamed and dilated tubes and tubo-
ovarian masses. It may differentiate PID from acute
appendicitis in a minority of cases but there is insufficient
evidence to support its routine use. Computed tomography
and magnetic resonance imagingcan assist in making a
diagnosis but the evidence is limited.

26. INVESTIGATION
• Transvaginal sonography or MRI will show thickened, fluid
filled tubes with or without free pelvic or tubo-ovarian
complex while Doppler studies will show tubal
hyperaemia. Ultrasonography is useful in excluding other
diagnostic possibilities such as ectopic pregnancy,
ruptured or infected ovarian cyst. The use of MRI,
though more accurate than ultrasonography, is expensive
and not widely available in our setting.

27. DIAGNOSIS OF PID
• Sweet reported that no single symptom or sign could
reliably diagnose PID as most of the symptoms and signs
overlap and may also be present in other disease
conditions. He therefore concluded that diagnosis of PID
should be entertained and treatment instituted in patients
who are young and sexually active with lower
abdominal/pelvic pain in whom pelvic tenderness
(Cervical motion tenderness, uterine tenderness or
adnexal tenderness) is elicited on examination.

28. DIAGNOSIS OF PID
• This is in line with the guidelines by the American
Centres for Disease Control and Prevention (CDC) ,
RCOG and the World Health Organisation (WHO) which
also reported similar findings and arrived at same
conclusion that the threshold for agnosing PID should be
low in view of the significant morbidity and complications
associated with it when left untreated.

29. DIAGNOSIS OF PID
• Laparoscopy was identified by various studies as the gold
standard for diagnosis of salpingitis, however it was
neither recommended nor feasible for it to be routinely
used in the diagnosis of PID as it missed out endometritis
and cervicitis and was invasive and expensive and
required expertise, factors all lacking in resource poor
setting like ours.

30. DIAGNOSIS OF PID
• Laparoscopy enables specimens to be taken from the
fallopian tubes and the pouch of Douglas and can provide
information on the severity of the condition. Although it
has been considered the gold standard in many studies of
treatment regimens, 15–30% of suspected cases may
have no laparoscopic evidence of acute infection, despite
organisms being identified from the fallopian tubes. When
there is diagnostic doubt laparoscopy may, however, be
useful to exclude alternative pathologies.

31. DIFFERENTIAL DIAGNOSIS OF PID
• Ectopic pregnancy
• Acute appendicitis
• Endometriosis
• Irritable bowel syndrome
• Ovarian cyst complication, such as rupture or torsion
• UTI
• Functional pain(pain of unknown physical origin)

32. Diagnostic criteria
CDC diagnostic criteria for prompt PID treatment based on
clinical manifestations to minimize sequelae
a. Minimum criteria
b. Additional diagnostic criteria
c. Definitive diagnostic criteria

33. Minimum criteria (at least one must be present )
a. Cervical motion tenderness
b. Uterine tenderness
c. Adnexal tenderness

34. Additional diagnostic criteria(at least one must be
present ), increases the specificity
a. Oral temperature >101°F (>38.3°C)
b. Abnormal cervical mucopurulent discharge or cervical
friability
c. Presence of abundant numbers of WBC on saline
microscopy of vaginal fluid
d. Elevated erythrocyte sedimentation rate
e. Elevated C-reactive protein
f. Laboratory documentation of cervical infection (N.
gonorrhoeae or C. trachomatis )

35. Definitive diagnostic criteria
a. Endometrial biopsy with histopathological evidence of
endometritis
b. Transvaginal ultrasound or MRI showing thickened, fluid-
filled tubes with or without free pelvic fluid or tubo-
ovarian complex, or doppler studies suggesting pelvic
infection (e.g., tubal hyperemia)
c. Laporoscopic findings consistent with PID

36. TREATMENT OF PID
• Can be on outpatient or inpatient basis
• OUTPATIENT: Outpatient antibiotic should be
commenced as soon as the diagnosis of PID is
suspected.
• Outpatient antibiotic Rx should be based on one of the
following regimens:
• Oral ofloxaxin 400mg twice daily plus oral metronidazole
400mg twice daily for 14 days
• I.M ceftriaxone 250mg single dose, followed by oral

37. TREATMENT OF PID
doxycycline 100mg twice dailyplus metronidazole 400mg
twice daily for 14 days.
*cefoxitin has better evidence base for the Rx of PID but is
not readily available*.
Broad-spectrum antibiotic therapy is generally required to
cover N. gonorrhoeae, C. trachomatis and anaerobic
infection.

38. TREATMENT OF PID
• INPATIENT Rx:
• Indication for inpatient treatment:
I. Lack of response to oral therapy
II. Intolerance to oral therapy
III. PID in pregnancy
IV. Tubo-ovarian abscess
V. Clinically severe disease
VI. Surgical emergency cannot be excluded

39. TREATMENT OF PID
Inpatient antibiotic therapy should be based on I.V therapy
which should be continued until 24hr after clinical
improvement and followed by oral therapy.
RECOMMENDED REGIMENS:
• I.V ceftriaxone 2g daily plus I.V doxycycline 100mg twice
daily followed by oral doxycycline 100mg twice daily plus
oral metronidazole 400mg twice daily for a total of 14
days
• I.V clindamycin 900mg three times daily plus i.v
gentamicin followed by either oral clindamycin 450mg four
times daily to complete 14 days

40. TREATMENT OF PID
OR
• oral doxycycline 100mg twice daily plus oral
metronidazole 400mg twice daily to complete 14 days
*gentamicin should be given as a 2mg/kg loading dose
followed by 1.5mg/kg three times daily[or a single daily
dose of 7mg/kg may be substitued]
• I.V ofloxacin 400mg twice daily plus I.V metronidazole
500mg three times daily for 14 days

41. TREATMENT OF PID
• The choice of an appropriate treatment regimen will be
influenced by robust evidence on local antimicrobial
sensitivity patterns,robust evidence on the local
epidemiology of specific infections,cost,the woman’s
preference and compliance and severity of disease.
• Evidence of the efficacy of antibiotic therapy in preventing
the long-term complications of PID is currently limited.

42. TREATMENT OF PID IN PREGNANCY
• A pregnancy test should be performed in all women
suspected of having PID to help exclude an ectopic
pregnancy.When the risk of ectopic pregnancy is judged
clinically to be high,the pregnancy test should be repeated
21 days after the date of last unprotected intercourse.
• The risk of giving any of the recommended antibiotic
regimens in very early pregnancy (before a positive
pregnancy test) is low,since significant drug toxicity
results in failed implantation (UK National Teratology
Information Service).

43. TREATMENT OF PID IN PREGNANCY
• PID is rare in women with an intrauterine pregnancy
except in the case of septic abortion.In septic abortion,the
infective organism is unlikely to be a sexually transmitted
pathogen.Cervicitis may,however,occur in a pregnancy
and is associated with increased maternal and fetal
morbidity.Treatment regimens will be dependent upon the
organisms isolated. Drugs known to be toxic in
pregnancy,such as tetracyclines,should be avoided.

44. TREATMENT OF PID IN PREGNANCY
• A combination of cefotaxime,azithromycin and
metronidazole for 14 days may be used.The risks
associated with metronidazole are uncertain but no
confirmed associations with adverse outcomes have been
reported.

45. TREAMENT OF PID IN A WOMAN WITH IUCD
• Consideration should be given to removing an intrauterine
contraceptive device (IUD) in women presenting with PID,
especially if symptoms have not resolved within 72 hours.
• The randomised controlled trial evidence for whether an
IUD should be left in place or removed in women
presenting with PID is limited. Removal of the IUD should
be considered and may be associated with better short-
term clinical outcomes but the decision to remove it needs
to be balanced against the risk of pregnancy in those who
have had otherwise unprotected intercourse in the
preceding 7 days. Hormonal emergency contraception
may be appropriate for some women in this situation.

46. OTHER MODES OF TREATMENT
• Surgical treatment should be considered in severe cases
or where there is clear evidence of a pelvic abscess.
• Consider drainage of an abscess and in noting its
position, the possibility that the abscess may have arisen
from the appendix or colon.
• Laparoscopy may help early resolution of the disease by
division of adhesions and drainage of pelvic abscesses.
Ultrasound-guided aspiration of pelvic fluid collections is
less invasive and may be equally effective.

47. MANAGENT OF SEXUAL PARTNER OF PATIENT
WITH PID
• When a sexually transmitted infection is either proven or
likely to be the cause of PID, the current sexual partner(s)
should be contacted and offered health advice and
screening for gonorrhoea and chlamydia.

48. TREATMENT OF SEXUAL PARTNER OF PATIENT
WITH PID
• Other recent sexual partners may also be offered
screening.Tracing of sexual partners within a 6-month
period of the onset of symptoms is recommended but this
time period may be influenced by the sexual history.The
risk of detecting STIs in the partners of women with PID is
high.2Women should be advised to avoid intercourse until
they and their partner have completed the treatment
course.Gonorrhoea diagnosed in their sexual partner
should be treated appropriately and concurrently with the
index woman.

49. TREATMENT OF SEXUAL PARTNER OF PATIENT
WITH PID
• Concurrent empirical treatment for chlamydia is
recommended for all sexual partners, owing to the
variable sensitivity of currently available diagnostic tests.If
adequate screening for gonorrhoea and chlamydia in the
sexual partner(s) is not possible, empirical therapy for
both gonorrhoea and chlamydia should be given.
Currently recommended regimens are available at
www.bashh.org.Tracing of sexual partners is not required
where a non-sexually transmitted pathogen has been
clearly identified as the cause of infection.

50. TREATMENT OF PID IN HIV INFECTED WOMEN
• Women with PID who are also infected with HIV should
be treated with the same antibiotic regimens as women
who are HIV negative.
• Women who are infected with HIV may have clinically
more severe PID but respond equally well to treatment as
women who are not infected.

51. TREATMENT OF PID IN HIV INFECTED WOMEN
• Standard antibiotic treatment as outlined above is
therefore appropriate and hospital admission is only
required for those with clinically severe disease.Potential
interactions between antibiotics and antiretroviral
medication need to be considered on an individual basis
(information on drug interactions with antiretroviral drugs
is available at www.hiv-druginteractions.org).
• Women with HIV should be managed in conjunction with
their HIV physician.

52. COMPLICATIONS OF PID
A. Fitz-Hugh Curtis Syndrome: perihepatitis is an
inflammation of the liver capsule which is followed by
adhesions btw the liver and parietal peritoneum. The
treatment is achieved with antibiotics. Differential
diagnosis may include: pneumonia, cholecystitis,
pyelonephritis, and appendicitis. Laparoscopy or
laparotomy may be needed to exclude any of these.
B. Chronic PID: results from inappropriate Rx of acute PID.
Xterised by chronic pelvic pain, dysmenorrhoea,
dyspareunia and infertility due to tubal blockage and
peritubal adhesions. The pelvis may be frozen as all the
organs may be matted together in dense adhesions. Rx
is by analgesics and surgery to release the adhesions or
correct tubes.

53. COMPLICATIONS OF PID
C. Acute pelvic abscess: may follow acute exacerbation of
chronic PID. Admission is warranted and I.V fluid and
antibiotics should be administered, blood transfusion(if need
be), serum electrolytes correction and frequent appraisal of
the patients are necessary.
Posterior colpotomy is done for an abscess the presents in
the POD. Criteria: the abscess must be midline or nearly so;
it should be adherent to the POD peritoneum; it should be
cystic or fluctuant. Prolonged drainage by inserting Malecot
catheter for 48-72hr is advisable.

54. COMPLICATIONS OF PID
• Extraperitoneal abdominal drainage is necessary if the
abscess does not present in the POD. It is indicated in
ruptured tubo-ovarian abscess. Salpingo-oophorectomy
must be performed for tubo-ovarian abscess. This may be
unilateral or bilateral and may be accompanied by
hysterectomy

55. COMPLICATIONS OF PID
D. Septic pelvic thrombophlebitis: current treatment is use
of antibiotics and heparin
E. Septic shock

56. CONCLUSION
• PID is one of the most frequent and important infections
that occur among women of reproductive age
• The burden of the disease is quite enormous
• Low threshold in diagnosis and treatment is key to
preventing its complications which impact on future fertility
of affected women.

57. REFERENCES

58. • THANKS FOR LISTENING