Box 1 . Risk factors for PID

• Younger age .

• Recent change of sexual partner .

• Having a current STI ( Chlamydia trachomatis , Neisseria gonorrhoea , Mycoplasma genitalium ).

• History of previous STI / repeat STI infection .

• Having a partner with an STI .

• Inconsistent use of barrier contraception .

• Recent uterine instrumentation .

• Bacterial vaginosis .

PID . A population-based study

in Canada demonstrated that each repeat chlamydia infection increases the risk of PID by 20 %, with an up to fourfold increased risk in younger

Image reproduced with permission Melbourne Sexual Health Centre .

Box 2 . Clinical features of PID

• Mild to moderate PID :

— Recent onset ( less than 30 days ’ duration ) mild to moderate low abdominal pain . — Abnormal vaginal discharge . — Intermenstrual bleeding . — Post-coital bleeding . — Deep dyspareunia .

• Severe PID : — Severe abdominal pain , guarding , peritonitis .

— Systemic features including fever , nausea , vomiting .

— Elevated inflammatory markers ( white blood cell count , erythrocyte sedimentation rate , C-reactive protein ).

— Right upper quadrant pain .

women ( under 16 ) and a greater than

twofold increased risk for women 16-19 years . ¹² Worryingly , repeat episodes of PID also increases the risk of fallopian tube damage , infertility and chronic pain considerably . ¹³

A list of the major risk factors for PID is provided in box 1 . These include recent partner change , inconsistent use of barrier contraception , having a current STI , as well as recent uterine instrumentation such as for intra-uterine device ( IUD ) insertion . Bacteria associated with bacterial vaginosis or other dysbiosis can potentially be introduced into the endometrial cavity from the vagina or cervix . ⁶ It is therefore essential to treat clinical bacterial vaginosis ( see figure 2 ) at the time of uterine instrumentation , including IUD insertion , dilatation and curettage , and surgical termination of pregnancy . Importantly , the risk of PID associated with uterine instrumentation is limited to around three weeks post-procedure and is higher for women who have an STI or bacterial vaginosis at the time of the procedure . ¹⁴ Socioeconomic and ethnic disparities in rates of PID have been reported and are likely

Figure 2 . Bacterial vaginosis .

Image reproduced with permission Melbourne Sexual Health Centre .

Box 3 . PID diagnostic criteria

• Minimum criteria :

— In sexually active young or other women with recent onset pelvic pain and where no other cause is identified , any one of :

• Uterine tenderness .

• Cervical motion tenderness .

• Adnexal tenderness .

• Additional supportive criteria : — Lower genital tract chlamydia , gonorrhoea or M . genitalium infection . — Elevated temperature . — Cervical friability or mucopurulent discharge . — Elevated ESR or C-reactive protein . — Abundant vaginal leukocytes .

Source : Centers for Disease Control and Prevention 2015 ¹⁹

to even mildly symptomatic infection . ^{1 , 2 , 20} In contrast , the mechanism

to reflect a higher STI incidence for

of gonorrhoeal PID is more direct .

some groups , while barriers to access-

Gonorrhoeal infection causes an

ing healthcare for timely STI diagno-

acute inflammatory response that is

sis and management are also likely to contribute to PID risk . ^{4 , 15}

Susceptibility to STIs , and therefore to PID , is additionally increased by other factors , particularly for

Figure 3 . Laparoscopic view showing typical ‘ violin string ’ adhesions .

thought to directly damage the epithelial lining of the fallopian tubes and causes an abrupt onset of severe symptoms in many PID cases . ^{1 , 2} Australian data have shown that gonor-

younger women . These include disruption to the vaginal microbiome ( for example , by recent antibiotic use ) leading to increased vaginal pH and bacterial vaginosis ; ¹⁶ thinner , less viscous cervical mucus during the follicular phase of the menstrual cycle , which has been postulated to facilitate pathogen ascent ; and cervical ectopy , which is more common for adolescents , in pregnancy and with

17 , 18 the use of hormonal contraception .

CLINICAL FEATURES

THE clinical picture of PID varies

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rhoeal infection poses a higher risk of hospitalisation for PID than chlamydia infection . ¹¹ The clinical picture of M . genitalium PID appears similar to chlamydial PID . Women with M . genitalium PID generally present with milder symptoms than those with gonorrhoeal PID . ^{7 , 21} M . genitalium is also associated with an increased risk of infertility . ⁷

DIAGNOSIS OF PID

THE case study in figure 5 provides

detail of the clinical consultation , investigations , diagnosis and man-

widely . The main clinical features are

agement of PID and the key points

listed in box 2 . For most women , the

to document .

key presenting feature is recent onset

Prompt diagnosis and effective

( less than 30 days ’ duration ) lower

antimicrobial management of PID are

abdominal pain that is mild to mod-

imperative to reduce the risk of infer-

erate in severity and often bilateral .

tility or other sequelae . Most diag-

Other symptoms can include abnor-

noses of PID are clinical , based on

mal vaginal discharge , intermenstrual

history and physical examination .

bleeding , post-coital bleeding or deep

1-3 , 19 dyspareunia . Most cases of PID can be managed

Figure 4 . Tubo-ovarian abscess .

However , the diagnosis can be challenging because of its varying severity and because there is no objective ,

in primary care , but around 5-10 %

pain and signs of peritonitis , and may

perihepatitis ( also termed Fitz-Hugh-

progression of PID can also dif-

non-invasive diagnostic test or com-

are severe and may require inpatient care . ¹ Severe PID involves a systemic response , with features such as fever , nausea , vomiting , severe

be associated with raised inflammatory markers including white blood cell count , ESR and CRP . ¹ Right upper quadrant pain associated with

Curtis syndrome , see figure 3 ) and tubo-ovarian abscess ( see figure 4 ) can also occur in severe PID . ^{1 , 2}

The clinical presentation and

fer by pathogen . Chlamydial PID is often associated with mild symptoms , but severe tubal damage can occur as part of the immune response

bination of signs and symptoms that is both sensitive and specific to a diagnosis of PID . ¹⁹ While laparoscopy is considered the gold standard , as it