Pelvic Infection With an IUD

Pelvic inflammatory disease in an intrauterine device user is infection of the upper genital tract, usually from chlamydia, gonorrhoea or mixed vaginal flora. Most cases within 20 days of insertion reflect infection present at the time of insertion, and the device itself does not raise long term risk beyond that period. The device does not need to be removed to treat the infection. Diagnosis rests on a low threshold for treatment.

Symptoms. Lower abdominal pain, abnormal vaginal discharge, intermenstrual or postcoital bleeding, dyspareunia, fever.

Signs. Lower abdominal tenderness, cervical motion tenderness, uterine or adnexal tenderness, purulent cervical discharge, temperature of 38 degrees or more.

History. Date of insertion, sexual history and partner symptoms, HIV status, previous infection, procedures, recent pregnancy or abortion.

Differential diagnosis. Ectopic pregnancy, miscarriage, uterine perforation, partial expulsion, appendicitis, endometriosis, urinary tract infection, ovarian cyst accident, tubo-ovarian abscess.

Investigations. Pregnancy test. High vaginal and endocervical swabs for chlamydia and gonorrhoea. HIV and syphilis testing with counselling. Full blood count. Ultrasound for adnexal mass, abscess or device position.

Criteria for admission. Pregnancy, unable to tolerate or take oral treatment, no response within 72 hours, severe illness with high fever, nausea or vomiting, suspected tubo-ovarian abscess, surgical emergency not excluded.

Outpatient regimen. Ceftriaxone 500 mg intramuscularly as a single dose, then doxycycline 100 mg orally twice daily for 14 days, with metronidazole 400 mg orally twice daily for 14 days. Doxycycline is avoided in pregnancy and used with caution in breastfeeding. Metronidazole is reduced in severe liver impairment. Avoid alcohol during metronidazole.

Inpatient regimen. Ceftriaxone 1 g intravenously once daily with doxycycline 100 mg twice daily and metronidazole 500 mg every 8 hours, changing to oral treatment 24 to 48 hours after clinical improvement to complete 14 days. Adjust for severe renal or liver impairment, and in pregnancy avoid doxycycline.

Analgesia. Paracetamol 1 g every 6 hours, maximum 4 g daily (3 g in liver disease or weight under 50 kg).

The device. No need to remove if the patient wishes to continue it. If symptoms do not improve after a few days of antibiotics, consider removal and continue antibiotics. Remove the device at once in pregnancy, or for tubo-ovarian abscess not responding.

Partners. Treat sexual partners for gonorrhoea and chlamydia with ceftriaxone 500 mg intramuscularly once and doxycycline 100 mg orally twice daily for 7 days, and advise abstinence or condoms until treatment is complete.

Condoms. Advise condoms during treatment, and dual protection afterwards.

Follow up. Review at 48 to 72 hours for response. Monitor until infection is fully resolved. Test of cure for gonorrhoea or chlamydia where indicated.

Method decisions. An intrauterine device can continue after recovery when the patient wishes. A new device is not placed during active infection. Counsel on dual protection and screen for infection before insertion where risk exists.

Referral and escalation. Refer for lack of response within 72 hours, tubo-ovarian abscess, peritonitis, pregnancy, and diagnostic doubt.