Pelvic inflammatory disease

Synopsis

Recognise the low-threshold clinical syndrome of upper-genital-tract infection, exclude pregnancy and surgical emergencies, treat before results return, and connect index treatment with contraception, partner care and later reproductive health.

Ask about pain onset, bleeding, last menstrual period, pregnancy possibility, contraception, recent procedures, genital symptoms and exposure; then test pregnancy before accepting an uncomplicated PID label.
Offer empirical treatment for recent pelvic pain with cervical-motion, uterine or adnexal tenderness when no stronger diagnosis explains the presentation; mild disease has no reliable exclusion test.
Collect vaginal or cervical chlamydia and gonorrhoea NAAT and relevant extragenital samples, but remember that a negative lower-tract test does not clear upper-tract infection.

Key red flags

Treat pelvic pain plus pregnancy, bleeding, syncope or shoulder-tip pain as an ectopic-pregnancy pathway until urgent assessment localises the pregnancy.

Admit when haemodynamics, fever, vomiting, peritonism or pain severity make oral outpatient treatment unsafe.

Image and involve gynaecology when focal adnexal tenderness, a mass or continuing fever raises tubo-ovarian abscess or torsion.

Assess hepatobiliary, pleural and abdominal alternatives as well as perihepatitis when right upper-quadrant pain accompanies the pelvic syndrome.

A patient not clearly better within 72 hours needs repeat diagnosis, adherence and microbiology review, pelvic imaging and possible source control.

Pregnancy emergency pattern

A late period or positive test with unilateral pain, bleeding, shoulder-tip pain, dizziness or collapse needs immediate early-pregnancy assessment before outpatient PID care.

Collection or severe infection

High fever, persistent vomiting, peritoneal signs, focal adnexal fullness or a palpable mass makes tubo-ovarian abscess, rupture or another complicated process more likely.

Failure at 72 hours

Little improvement after three days is a diagnostic event: revisit pregnancy, adherence, antimicrobial susceptibility, abscess, torsion, appendicitis and the need for inpatient care.

Investigation priorities

Immediate pregnancy testing and localisation when indicatedFirst step

Detect the ectopic-pregnancy pathway and adapt medicines, imaging and admission.

Management branches

FIRST CONTACTExclude danger and cross the clinical treatment threshold

Recent pelvic pain is accompanied by genital symptoms, exposure risk or pelvic tenderness.

Record observations, pain pattern, last menstrual period, pregnancy possibility, contraception, bleeding and collapse symptoms before routine syndrome work.
Perform pregnancy testing and arrange urgent gynaecology or surgical assessment for positive pregnancy, focal severe pain, peritonism, sepsis or mass.

OUTPATIENTTreat broadly and make the 72-hour review real

PID is clinically likely, observations are stable and pregnancy, abscess and surgical emergencies are not driving admission.

Key medicines

Ceftriaxone, doxycycline and metronidazoleGive ceftriaxone 1 g intramuscularly once, doxycycline 100 mg orally twice daily for 14 days and metronidazole 400 mg orally twice daily for 14 days.Check pregnancy and severe beta-lactam allergy; explain completion, doxycycline oesophageal and photosensitivity precautions, and formulation-specific metronidazole interaction advice.

Ceftriaxone plus doxycycline inpatient regimenGive ceftriaxone 2 g intravenously once daily plus doxycycline 100 mg orally or intravenously twice daily until improvement, then complete 14 days with doxycycline and metronidazole.Coordinate pregnancy or major allergy with specialists, monitor organ function as severity requires and ensure metronidazole is included in the oral completion phase.

Open full textbook →Answer 2 questions

Find your next topic