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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Pelvic inflammatory disease

Obstetrics and gynaecology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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Exclude surgical and pregnancy emergencies

Haemodynamic instability, peritonism, severe systemic illness, pregnancy, a tubo-ovarian abscess or inability to tolerate oral treatment requires urgent hospital assessment rather than routine outpatient management.

Action: Check observations and hCG, assess for ectopic pregnancy and appendicitis, obtain cultures and imaging without delaying resuscitation, and involve acute gynaecology for parenteral antibiotics and source-control decisions.

Synopsis

Recognise and treat pelvic inflammatory disease at a deliberately low diagnostic threshold while excluding pregnancy emergencies, identifying severe disease and protecting reproductive health.

  • PID is a clinical syndrome of upper-genital-tract inflammation; no single history, examination, swab or scan reliably rules it in or out.
  • Use a low treatment threshold when lower abdominal or pelvic pain coexists with cervical motion, uterine or adnexal tenderness and no better explanation.
  • Always check pregnancy because ectopic pregnancy can mimic PID, and remember that PID can coexist with an intrauterine or early unlocalised pregnancy.
  • Take chlamydia and gonorrhoea NAAT, gonococcal culture before antibiotics where possible, and consider M. genitalium testing under local specialist protocols; negative lower-tract tests do not exclude PID.
  • Outpatient treatment is ceftriaxone 1 g intramuscularly once plus doxycycline 100 mg orally twice daily for 14 days plus metronidazole 400 mg orally twice daily for 14 days.
  • Review clinical response at 72 hours; lack of improvement triggers diagnostic reconsideration, pelvic imaging, parenteral therapy and possible surgical assessment.
  • Do not remove an intrauterine device automatically; consider removal if there is no improvement after 72 hours, balancing contraceptive needs and patient preference.
  • Abstain from sex until the patient and relevant partners have completed treatment and symptoms have resolved, with partner care driven by identified or suspected STI.

    • Key red flags

    A positive pregnancy test with unilateral pain, bleeding, syncope, shoulder-tip pain or peritoneal signs requires urgent ectopic-pregnancy assessment.

    Hypotension, tachycardia, high fever, rigors, vomiting, confusion or peritonism suggests sepsis, abscess rupture or another acute abdomen.

    A complex adnexal mass with fever or marked tenderness raises concern for tubo-ovarian abscess and needs urgent specialist management.

    Failure to improve within 72 hours of appropriate outpatient antibiotics requires reassessment, imaging and possible admission.

    Pregnancy, severe immunosuppression, unreliable oral absorption or inability to ensure follow-up lowers the threshold for inpatient care.

    Investigation priorities

    01
    Urine or serum hCGFirst step

    Identify pregnancy and prioritise ectopic-pregnancy localisation before routine outpatient care.

    Management branches

    PresentationTreat at a safe clinical threshold

    Pelvic pain is accompanied by cervical motion, uterine or adnexal tenderness without a better diagnosis.

    1. Record observations, obtain hCG and assess peritonism, severe illness, pregnancy and acute-surgical alternatives before choosing setting of care.
    2. Collect site-appropriate NAAT and gonococcal culture, but begin broad empirical antibiotics immediately when PID is clinically likely.
    3. Give written completion, abstinence, partner and deterioration advice and arrange an active 72-hour review rather than open-ended follow-up.

    Key medicines

    CeftriaxoneGive 1 g by intramuscular injection as one dose at the start of outpatient PID treatment.Check severe beta-lactam allergy and obtain gonococcal culture first when feasible, but do not delay treatment in clinically significant disease.
    DoxycyclineTake 100 mg orally twice daily for fourteen days as part of combination PID therapy.Avoid in pregnancy, counsel about oesophageal irritation and photosensitivity, separate interacting antacids and ensure the full course is completed.
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    Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
    Sources

    Sources and review status

    National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

    • BASHH pelvic inflammatory disease guideline
    • RCOG pelvic inflammatory disease information
    • NHS pelvic inflammatory disease guidance
    • NICE ectopic pregnancy and miscarriage guidance

    Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

    Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom