QuestionSBA
QuestionChoice
This patient is presenting with features of severe pelvic inflammatory disease. The severity is a clinical diagnosis but fever, signs of pelvic peritonitis or tubo-ovarian abscess usually confer severe disease. These patients require 14 d of doxycycline and metronidazole plus IV ceftriaxone until there is a clinical improvement.
53094
c
Oral doxycycline and metronidazole (for 14 d)
QuestionChoice
This patient is presenting with features of severe pelvic inflammatory disease. The severity is a clinical diagnosis but fever, signs of pelvic peritonitis or tubo-ovarian abscess usually confer severe disease. These patients require 14 d of doxycycline and metronidazole plus IV ceftriaxone until there is a clinical improvement.
53096
e
Oral doxycycline (for 7 d)
QuestionChoice
This patient is presenting with features of severe pelvic inflammatory disease. The severity is a clinical diagnosis but fever, signs of pelvic peritonitis or tubo-ovarian abscess usually confer severe disease. These patients require 14 d of doxycycline and metronidazole, plus intravenous ceftriaxone until there is a clinical improvement.
53093
b
IM ceftriaxone (single dose)
QuestionChoice
This patient is presenting with features of severe pelvic inflammatory disease. The severity is a clinical diagnosis, but fever, signs of pelvic peritonitis or tubo-ovarian abscess usually confer severe disease. These patients require 14 d of doxycycline and metronidazole plus IV ceftriaxone until there is a clinical improvement.
53092
a
IV ceftriaxone (until improving clinically), oral doxycycline and metronidazole (for 14 d)
QuestionChoice
This patient is presenting with features of severe pelvic inflammatory disease. The severity is a clinical diagnosis but fever, signs of pelvic peritonitis or tubo-ovarian abscess usually confer severe disease. These patients require 14 d of doxycycline and metronidazole plus IV ceftriaxone until there is a clinical improvement. Intramuscular benzylpenicillin is used for suspected syphilis infection. This patient lacks symptoms of syphilis, such as a rash or genital ulcer.
53095
d
IM benzylpenicillin (single dose), oral doxycycline and metronidazole (for 14 d)
QuestionComment
is the ceftriaxone normally IV or can it be IM?
28887
QuestionComment
pretty sure it can be either, in this case youd probably want it IV if its severe PID 
55129
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GIMP101
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Nightshift Hypertension
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But it says she is not able to tolerate any oral intake?
28895
QuestionComment
I made the same mistake, the answer says IV until she's improving clinically, then the oral course of medication for 14 days. So by the time she's taking oral medication she should be able to tolerate it 
55585
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Thermoregulator Metabolism
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Relapse Otitis
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Messi 2012 type numbers
61147
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MetastaticMainoo
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# Summary


Pelvic Inflammatory Disease (PID) is a sexually transmitted infection that spreads from the vagina into the cervix and upper genital tract. The primary pathogens are Chlamydia trachomatis and Neisseria gonorrhoeae, though often, no pathogen can be isolated. Patients typically present with generalised abdominal pain, discharge, postcoital bleeding, adnexal tenderness, cervical motion tenderness, and sometimes right upper quadrant pain due to Fitz-Hugh-Curtis syndrome. The diagnostic approach includes pelvic examination, pregnancy test, swabs for gonorrhoea and chlamydia, blood tests, and transvaginal ultrasound. Management typically consists of a combination of antibiotics, usually administered in an outpatient setting, and analgesia as required.


# Definition


Pelvic inflammatory disease (PID) is a condition that arises when an infection spreads from the vagina to the cervix, and subsequently to the upper genital tract.


# Aetiology


While Gonorrhoea and Chlamydia contribute to approximately 20% of PID cases, various anaerobic bacteria are also implicated. In certain instances, no pathogen can be isolated. PID is predominantly spread via sexual contact.


# Signs and Symptoms


PID is typically diagnosed based on clinical symptoms and signs. These include:


- Bilateral abdominal pain
- Vaginal discharge
- Post-coital bleeding
- Adnexal tenderness
- Cervical motion tenderness upon bi-manual examination
- Fever


Approximately 10% of patients present with right upper quadrant pain, secondary to inflammation of the liver capsule. This condition is referred to as Fitz-Hugh-Curtis syndrome (see below).


# Differential Diagnosis


Several conditions may present similarly to PID and should be considered in the differential diagnosis:


- **Appendicitis:** Presents with right lower quadrant abdominal pain, fever, nausea, and vomiting.
- **Ectopic Pregnancy:** Symptoms may include unilateral lower abdominal pain and vaginal bleeding. A positive pregnancy test is a key distinguishing factor.
- **Endometriosis:** Chronic pelvic pain, dysmenorrhea, and dyspareunia are common. Pain typically worsens during menstruation.
- **Ovarian Cyst:** Symptoms can include unilateral lower abdominal pain, bloating, and a palpable mass on examination.
- **Urinary Tract Infection:** Symptoms usually include dysuria, frequency, urgency, suprapubic pain, and possible fever.


# Investigations


The following investigations are usually carried out to diagnose PID:


**Bedside:**


- Bimanual examination, which may show cervical motion tenderness
- Pregnancy test
- Swabs for gonorrhoea and chlamydia, or urinary NAAT testing 


**Bloods:**


- FBC, including WCC 
- CRP 


**Imaging:**  

- Transvaginal ultrasound


# Management


Treatment of PID is **medical** involves a combination of antibiotics, the first-line being:

- Ceftriaxone (given intramuscularly) + doxycycline + metronidazole


If the infection is mild/moderate, these antibiotics are given orally (except ceftriaxone which is intramuscularly) and in an outpatient setting. 
If the infection is severe, all three antibiotics are given intravenously (and may later be converted to oral) in an inpatient setting.




In addition, it is important to avoid unprotected intercourse whilst PID is untreated to prevent spread of infection to sexual partners.


# Complications


The potential complications associated with PID are:


- Chronic pelvic pain: This is likely a result of tubal damage, secondary to inflammation. 
- Infertility: Occurs as a result of tubal damage, impairing passage of an ovum and/or sperm for fertilisation to occur. 
- Ectopic pregnancy: Occurs as a result of tubal damage and scarring causing impaired passage of a fertilised ovum through to the endometrium. 
- Fitz-Hugh-Curtis Syndrome (see below). 

# Fitz-Hugh-Curtis Syndrome


Fitz-Hugh-Curtis syndrome occurs when adhesions form between the anterior liver capsule and the anterior abdominal wall or diaphragm in the context of PID. Despite this, liver function tests are usually normal. An abdominal ultrasound should be performed to rule out the presence of stones. A definitive diagnosis and treatment typically require laparoscopy and administration of antibiotics.


# NICE Guidelines

[Click here to see information on NICE about PID](https://cks.nice.org.uk/topics/pelvic-inflammatory-disease/)

# References


[Patient Info](https://patient.info/womens-health/pelvic-pain-in-women/pelvic-inflammatory-disease)
15
2088
Pelvic inflammatory disease
Topic
38
Obstetrics
Condition
511
Pelvic inflammatory disease
UkmlaTopic
18
Obstetrics and gynaecology
10679
Severe pelvic inflammatory disease requires intravenous ceftriaxone initially, followed by a 14-day course of doxycycline and metronidazole for complete treatment.
A 28-year-old woman presents to A&E with 3 d of fever, lower abdominal pain and deep dyspareunia. She tells you she has recently had treatment 1 month ago for *Chlamydia*,* but did not complete the course of antibiotics. She has had at least 7 sexual partners in the last 3 months and has not used any barrier methods of contraception. She has no other medical history and has no drug allergies. On examination, she is vomiting and unable to tolerate any oral intake. She has a fever of 38.9 °C.

Which of the following is the best treatment?
a