QuestionSBA
QuestionChoice
The gold standard test for pelvic inflammatory disease is a diagnostic laparoscopy, however this may be considered if symptoms do not resolve with antibiotic treatment, or another differential is being considered.
10017350
e
Arrange a diagnostic laparoscopy
QuestionChoice
This is clearly inappropriate; the likely diagnosis is pelvic inflammatory disease, which can progress to sepsis and lead to complications such as subfertility.
10017349
d
Administer analgesia and discharge
QuestionChoice
Contact tracing is required, but this should encompass a period of six months according to NICE, not one.
10017348
c
Trace sexual partners in the last month and inform them to undergo STI screening
QuestionChoice
The most likely diagnois is pelvic inflammatory disease (PID), as evidenced by dyspareunia, discharge, and right upper quadrant pain (Fitz-Hugh-Curtis syndrome). This should be treated empirically to limit the infection and reduce the risk of complications.
10017347
b
Await results of swabs and follow up in a week
QuestionChoice
The most likely diagnois is pelvic inflammatory disease (PID), as evidenced by dyspareunia, discharge, and right upper quadrant pain (Fitz-Hugh-Curtis syndrome). There are currently no indications for hospital admission as observations are stable and there are no concerns for another intra-abdominal pathology such as an ectopic pregnancy or appendicitis. Once PID is suspected, it should be treated empirically with a combination of antibiotics.
10017346
a
Administer IM ceftriaxone, PO doxycycline, PO metronidazole for 14 days
QuestionComment
Isn't the IM Ceftriaxone a one off? It makes it seem like you're getting them back every day for a daily IM dose of Ceftriaxone in the way the question is written 
43484
QuestionComment
Yeah it's one off. Pretty sure the doxy is just for 7 days as well, not sure about metro
53646
User
subscriber
Carl Sinoma
User
subscriber
Migraine Body
Concept
Chapter
# 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
16
Pelvic inflammatory disease
Topic
27
Genitourinary medicine
Video
Concept
16
Pelvic inflammatory disease
266
m1dh6dt
images/videos/GUM.png
Pelvic inflammatory disease 2
Video
Concept
16
Pelvic inflammatory disease
316
3TGYNJT
images/videos/GUM.png
Quesmed Tutorial: Genitourinary medicine and HIV SBAs
Video
Concept
16
Pelvic inflammatory disease
327
4Z9wAXx
images/videos/gynecology.png
Quesmed Tutorial: Obstetrics and Gynaecology
Video
Concept
16
Pelvic inflammatory disease
267
9C3jWJ3
images/videos/GUM.png
Pelvic inflammatory disease 3
Video
Concept
16
Pelvic inflammatory disease
302
L3XLqqB
images/videos/surgery.png
Quesmed Tutorial: Acute Abdomen
Video
Concept
16
Pelvic inflammatory disease
265
x73D9qJ
images/videos/GUM.png
Pelvic inflammatory disease 1
16013
The treatment for pelvic inflammatory disease (PID) typically includes IM ceftriaxone for gonorrhea, PO doxycycline for chlamydia and other pathogens, and PO metronidazole for anaerobic coverage, usually over 14 days.
A 23-year-old woman with a history of recurrent sexually transmitted infections visits a genitourinary medicine clinic with increasing vaginal discharge. She also has right upper quadrant pain and deep dyspareunia.

Observations are stable and a urine pregnancy test is negative. There is minimal tenderness to palpation of the abdomen.

High vaginal swabs and a urine NAAT for chlamydia, gonorrhoea, and mycoplasma are sent.

What is the most appropriate course of management?
a