initiated if other diagnoses have

been excluded .

A

their sexual partners and provides options for how the patient can do

Investigations

Conduct a pregnancy test in all

this . Many patients will tell their partners directly , while others may inform their partners via an identi-

young women with recent onset low

fiable or anonymous text message

abdominal pain to exclude an ectopic

or email .

pregnancy . Perform STI testing for chlamydia , gonorrhoea and M . genitalium on endocervical swabs ( one

Follow-up care

Review all patients 2-3 days after

swab for chlamydia [ see figure 8 ] and

antibiotic initiation to assess their

gonorrhoea [ see figure 9 ], one swab

response to treatment . Improve-

for M . genitalium [ see figure 10 ]) col-

ment supports a diagnosis of PID .

lected during the speculum examina-

Persistent signs and symptoms may

tion , or on self-collected high vaginal

indicate an alternative diagnosis .

swabs or a first-pass urine specimen

Review on completion of treatment

if a speculum examination is not con-

is essential to check for complete res-

ducted . Take a high vaginal swab for

olution of symptoms and that sex-

microscopy , culture and sensitivi-

ual partner / s have been tested and

ties ; this is particularly important in

treated . Emphasise the importance

the presence of a mucopurulent dis-

of avoiding repeated STI infections

charge that could suggest gonorrhoea

to reduce the risk of infertility and

infection . A clean catch urine sam-

other long-term sequelae , includ-

ple can be tested for leucocytes and

ing advice to use condoms with new

nitrates and sent for microscopy and

sexual partners .

culture . It is important to bear

For women with an IUD , the IUD

in mind that leucocytes in the urine

can remain in situ if symptoms are

can be present from genital tract contamination . For more severe symptoms , other investigations may include serology for an FBC , urea ,

3 , 19 , 23 creatinine and electrolytes .

MANAGEMENT

START antibiotic treatment immediately after a provisional diagnosis of PID is made and without waiting for STI test results . Australian guidelines for STI management in primary care recommend an antibiotic regimen to cover chlamydia infection , gonorrhoeal infection and anaerobic bacteria ( for example , with bacterial vaginosis [ see table 2 ]). ²³

B

Image reproduced with permission Melbourne Sexual Health Centre .

improving within 2-3 days of starting treatment . Remove the IUD if the woman is not improving or if the patient requests it . A discussion about alternative contraception should accompany any discussion about IUD removal . Once treatment is completed and the woman is completely asymptomatic with no residual tenderness , insertion of another IUD can occur if desired .

PROGNOSIS

THE long-term sequelae of PID include chronic pelvic pain , infertility and ectopic pregnancy . These complications can have severe impacts .

Mild to moderate PID

Mild to moderately severe cases of

Chronic pelvic pain , defined as low abdominal pain lasting six months or more and causing functional dis-

PID can be managed in an ambulatory

ability , has been recorded in up to

setting . Similar outcomes have been reported for treatment of mild to moderate PID in outpatient compared with inpatient settings . ²⁵ The recommended treatment is an outpatient regimen of oral antibiotics ( doxycycline and metronidazole ) over 14 days

Figure 7 . Visualisation of the cervix . Figure 7A . Normal cervix .

Figure 7B . Mucopurulent cervicitis .

a third of women following treatment for PID . ²⁷ A previous diagnosis of PID appears to increase a woman ’ s risk of chronic pelvic pain after PID . ²⁷ Women with chronic pelvic pain after PID have reported reduced physical and mental health compared with

with a single dose of IM or IV ceftriax-

women without chronic pelvic pain

one given immediately to cover suspected or confirmed gonorrhoea . Also conduct antibiotic sensitivity testing

Table 2 . Antibiotic therapy for PID

PID type Recommended antibiotic treatment *

rest and simple analgesia as required , and to avoid unprotected sexual intercourse until a week

after PID . ²⁸ Fallopian tube scarring following

PID can result in tubal factor infertil-

for gonorrhoea . Metronidazole is recommended for anaerobic cover but may be poorly tolerated . ²³

For pregnant or breastfeeding women with mild to moderate infection , use azithromycin in place of doxycycline ( see table 2 ). Use of azithromycin as a single dose immediately and one week later in lieu of doxycycline is also recommended for women who may not adhere to a daily medication regimen .

High levels of azithromycin resistance have led to Australian guidelines recommending a 14-day course of moxifloxacin for cases of PID with a confirmed M . genitalium infection ( note that moxifloxacin is not on the PBS ). ²³ GPs are advised to consult with their laboratory or local sexual health clinic regarding management of PID from M . genitalium .

Severe PID

Referral to ED and / or inpatient management

including IV antibiotics may

Mild to moderate outpatient treatment

Severe inpatient treatment

Mild to moderate in pregnant women

Ceftriaxone 500mg in 2mL of 1 % lignocaine IM , or 500mg IV PLUS Oral metronidazole 400mg bd for 14 days PLUS Oral doxycycline 100mg bd for 14 days

Ceftriaxone 2g IV daily OR Cefotaxime 2g IV tds PLUS Azithromycin 500mg IV daily PLUS Metronidazole 500mg IV bd

Ceftriaxone 500mg in 2mL of 1 % lignocaine IM , or 500mg IV PLUS Oral metronidazole 400mg bd for 14 days PLUS Azithromycin 1g PO stat PLUS Azithromycin 1g PO stat , one week later

* If M . genitalium is confirmed , consult with laboratory or local sexual health clinic for advice regarding antibiotic treatment . Moxifloxacin 400mg daily for 14 days is recommended for M . genitalium associated PID cases . As M . genitalium results are often received about a week after PID treatment has begun , it may be reasonable to shorten the course of moxifloxacin to 10 days , because of the cost and potential toxicity of this drug .

Source : Australasian Sexual Health Alliance 2018 ²³

after treatment completion or until symptoms have resolved . Provide advice and education ( including written information ) that includes how PID was acquired , the potential long-term consequences , how to take the antibiotics and how repeated infections can be prevented . The Australian STI Management Guidelines links to several PID factsheets for patients online .

Whether or not an STI is diagnosed , most PID is sexually transmitted . Therefore , notifying and treating sexual contacts is necessary . Australian contact tracing guidelines recommend treatment of current sexual partners to cover chlamydia and gonorrhoea irrespective of test results . ²⁶ For women with chlamydia , gonorrhoea or M . genitalium associated PID , sexual partners from the past six months ( chlamydia ) or two months ( gonorrhoea ) should be contacted and offered testing and treatment .

ity and increases the risk of ectopic pregnancy . While the relationship between PID , tubal infertility and ectopic pregnancy is well known , quantifying the relationship between PID and these outcomes is difficult because of inconsistencies around the diagnosis of PID and the long follow-up needed to measure these outcomes . Cohort studies have reported higher infertility and ectopic pregnancy rates for women with PID compared with those without . ²⁹ Among women treated for mild to moderate PID , 19 % were infertile , and less than 1 % experienced an ectopic pregnancy over the next three years . Women experiencing repeated episodes of

13 , 25

PID had a higher risk of infertility .

THE FUTURE

CLINICAL diagnosis of PID remains

challenging . A research priority in this area is development of a non-invasive and objective diagnostic test for PID that is both sensitive and specific for

be indicated for women with severe

Where no pathogen is identified ,

detecting female upper genital tract

or complicated PID , including for

indicated if there is a poor response

they have not improved within 2-3

current sexual partners should be

inflammation . There have been sev-

severe and systemic signs and symptoms , suspected tubo-ovarian abscess or pregnancy with suspected PID . Additionally , inpatient care may be

to outpatient treatment or intolerance to oral therapy . For women with an IUD , consider removal ( along with alternative contraceptive advice ) if

3 , 19 , 23 days .

General management

Advise all women with PID about

treated to cover chlamydia ( and gonorrhoea if likely ). The diagnosing clinician initiates a discussion with their patient about notifying

eral reports of identification of biomarkers associated with upper genital tract inflammation in humans ; however , they have not been PAGE 22