Updated guidance from the British Association of Sexual and HIV (BASSH) recommends that testing for PID is extended to include Mycoplasma genitalium to direct the choice of antibiotics. Until access to this test is routinely available to primary care in Devon, patients with suspected PID should be referred to specialist Genito-Urinary Medicine (GUM) services for full assessment; including testing, contact tracing, and treatment management.

Diagnosis

A diagnosis of PID should be considered and referral to the GUM services for full assessment, in any sexually active woman who has recent onset, lower abdominal pain associated with local tenderness on bimanual vaginal examination, in whom pregnancy has been excluded and no other cause for the pain has been identified. The risk of PID is highest in women aged under 25 not using barrier contraception and with a history of a new sexual partner. The diagnosis of PID based only on positive examination findings, in the absence of lower abdominal pain, should only be made with caution

Clinical features

Symptoms

The following features are suggestive of a diagnosis of PID

• lower abdominal pain which is typically bilateral (but can be unilateral)
• abnormal vaginal or cervical discharge which is often purulent
• deep dyspareunia
• abnormal vaginal bleeding, including post coital bleeding, inter-menstrual bleeding and menorrhagia
• secondary dysmenorrhoea

Signs

• lower abdominal tenderness which is usually bilateral
• adnexal tenderness on bimanual vaginal examination – a tender mass is sometimes present
• cervical motion tenderness on bimanual vaginal examination
• fever (>38°C) in moderate to severe disease

The differential diagnosis of lower abdominal pain in a young woman includes:

• ectopic pregnancy – pregnancy should be excluded in all women suspected of having PID
• acute appendicitis – nausea and vomiting occurs in most patients with appendicitis but only 50% of those with PID. Cervical movement pain will occur in about a quarter of women with appendicitis
• endometriosis – the relationship between symptoms and the menstrual cycle may be helpful in establishing a diagnosis
• complications of an ovarian cyst e.g. torsion or rupture – symptoms are often of sudden onset
• urinary tract infection – often associated with dysuria and/or urinary frequency
• irritable bowel syndrome – disturbance in bowel habit and persistence of symptoms over a prolonged time period are common. Acute bowel infection or diverticular disease can also cause lower abdominal pain usually in association with other gastrointestinal symptoms.
• functional pain (pain of unknown aetiology) – may be associated with longstanding symptoms

Sexual Health Contact Details:

• Devon Sexual Health (Barnstaple, Exeter, and Torbay)
  • A patient can self-refer by phoning 0300 303 3989 for a consultation within 24 hours. Please give relevant treatment information to the patient to bring to clinics, i.e. results of previous cultures and any treatments
  • electronic referral system is also available
• SHiP (Sexual Health in Plymouth)
  • A patient can self-refer by phoning 01752 431124

Current and recent partners (within the last 6 months) of women with PID should be contacted and offered advice, screening, treatment, and contact tracing, this may include empirical therapy for partners e.g. doxycycline 100mg twice daily for 7 days.

All patients should be advised not to have sex until they and any current partners have completed antibiotic treatment.

Refer to hospital for inpatient management if the patient:

• cannot take oral antibiotics
• shows signs of moderate or severe disease
• is pregnant

Antibiotic treatment

Exclude pregnancy prior to consideration of antibiotic treatment.

Patients with suspected PID should be referred to specialist GUM services for 1st line treatment with ceftriaxone IM plus oral doxycycline and metronidazole. The GUM service will conduct testing and contact tracing.

If the person declines, or is unable to attend a GUM service, and either intramuscular administration of ceftriaxone is not possible in primary care or is not clinically appropriate, the oral only antibiotic regimen below may be considered.

If the patient is to be treated in primary care, the following steps should be taken:

Before starting treatment:

• Using a vulvovaginal swab, arrange a dual test for Neisseria gonorrhoeae and Chlamydia trachomatis (gonorrhoea must be specifically requested for the laboratory to test)
• Complete an endocervical swab (for gonorrhoea culture and sensitivity)
• Offer blood tests for HIV and syphilis if testing for gonorrhoea and chlamydia

Recommended regimen

Ceftriaxone IM

• 1g intramuscularly as a single dose (off-label dose)
• Do not delay treatment whilst awaiting culture result
  

PLUS

Doxycycline Oral

• 100mg orally twice daily for 14 days

PLUS

Metronidazole Oral

• 400mg orally twice daily for 14 days

Oral only regimen

Doxycycline Oral

• 100mg orally twice daily for 14 days

Metronidazole Oral

• 400mg orally twice daily for 14 days

See sections 5.1.2 Cephalosporins, carbapenems, and other beta-lactams, 5.1.3 Tetracyclines, and 5.1.11 Metronidazole

Review the patient at 72 hours. If no improvement, consider a referral to hospital.

Consider further review, either in clinic or by phone, 2 weeks after treatment to assess clinical response, compliance and partner treatment. If symptoms have not resolved, refer to the GUM service for assessment.

Test of cure is only necessary if initial testing for gonorrhoea was positive; see Management of gonorrhoea.