Pelvic Inflammatory Disease

Infection/inflammation of upper female genital tract (endometrium, fallopian tubes, ovaries, adjacent structures), typically ascending from lower genital tract, most commonly Chlamydia trachomatis and Neisseria gonorrhoeae, also polymicrobial (anaerobes, Mycoplasma genitalium).

Significant fertility/chronic pain sequelae if untreated/delayed treatment.

Lower abdominal/pelvic pain (bilateral typically), deep dyspareunia, abnormal vaginal discharge, intermenstrual/postcoital bleeding, fever (variable, often absent/low-grade).

Examination: cervical motion tenderness, adnexal tenderness, cervicitis (mucopurulent discharge, friable cervix).

Fitz-Hugh-Curtis syndrome: perihepatic inflammation: RUQ pain, may mimic cholecystitis.

Complications: tubo-ovarian abscess (severe pain, palpable mass, systemic illness), infertility, ectopic pregnancy risk, chronic pelvic pain.

Clinical, low threshold to treat empirically given consequences of delayed treatment vs. relatively low risk of short empirical antibiotic course; do not wait for microbiology confirmation.

• NAAT for chlamydia/gonorrhea (endocervical/vulvovaginal swab), consider Mycoplasma genitalium testing where available

• Pregnancy test; mandatory (exclude ectopic)

• FBC, CRP/ESR; supportive, non-diagnostic

• Pelvic ultrasound: if tubo-ovarian abscess/adnexal mass suspected, or diagnostic uncertainty

• HIV/syphilis screening ; offer as part of full STI screen

Differentials: ectopic pregnancy (always exclude with pregnancy test), ovarian cyst rupture/torsion, appendicitis, endometriosis, UTI, IBS.

• Empirical antibiotics started promptly on clinical suspicion ; do not await swab results:

  • Outpatient: ceftriaxone 1g IM single dose + doxycycline 100mg PO bd × 14 days + metronidazole 400mg PO bd × 14 days (anaerobic cover, particularly if instrumentation/significant symptoms)

  • Severe disease/tubo-ovarian abscess/failed outpatient therapy/pregnancy: admit for IV therapy (e.g., IV ceftriaxone + doxycycline, transition to oral once improving)

• Analgesia

• Partner notification and treatment essential (empirical chlamydia/gonorrhea cover) : reinfection prevention

• Sexual abstinence until treatment complete (patient and partner)

• Remove IUD if present and symptoms not improving within 48-72h (controversial; individualize, many can retain IUD with treatment)

• Tubo-ovarian abscess: IV antibiotics, drainage (radiological/surgical) if not responding or large (>7-8cm) or rupture risk

• Follow-up at 72h to confirm clinical improvement (essential); repeat STI screening at 3 months

Referral: gynecology for tubo-ovarian abscess, failure to respond, diagnostic uncertainty; GUM/sexual health for full STI screening and contact tracing.