Pelvic Inflammatory Disease

A clinical syndrome resulting from infection or inflammation involving the usually sterile upper genital tract in women.

The old Green Top guidelines from RCOG have been archived and replaced by new guidance from BASHH, which can be found here.

PID may have serious sequelae:-

  • ectopic pregnancy
  • chronic pelvic pain,
  • infertility
  • adnexal abcess formation,
  • peri-hepatitis,
  • Reiter's syndome
  • Pre-term delivery.


Risk Factors for PID

  • STIs
  • Procedures or conditions involving disruption of the cervical barrier,
  • IUCD (in the first 3 weeks following insertion),


PID is usually the result of infection ascending from the endocervix causing endometritis,
salpingitis, parametritis, oophoritis, tuboovarian abcess and/or pelvic peritonitis.
• Neisseria gonorrhoeae and Chlamydia trachomatis have been identified as causative agents 1, 2
but account for only a quarter of cases in the UK, whilst Gardnerella vaginalis, anaerobes
(including Prevotella, Atopobium and Leptotrichia) and other organisms commonly found in the
vagina may also be implicated. Mycoplasma genitalium has also been associated with upper
genital tract infection in women3


  • No symptom or sign is pathognomic
  • Presentation depends partly on the location in the upper genital tract of the infection, e.g. endometritis, salpingitis, tubo-ovarian abcess, pelvic peritonitis.
  • It is recommended to treat women for PID if they are at-risk and have adnexal tenderness if no other cause is found.
  • The following features are suggestinve of a diagnosis of PID:-
  • lower abdominal pain - typically bilateral,
  • deep dyspareunia,
  • abnormal vaginal bleeding, including post-coiotal, inter-menstrual and menorrhgaia,
  • abnormal vaginal discharge or cervical discharge which is often purulent.


  • Assess risk factors for STIs:-
    • young age at first intercourse,
    • young age,
    • high frequency of intercourse,
    • multiple sexual partners,
    • non-barrier methods of contraception.
  • Ask about recent uterine instrumentation, including operative TOP
  • abnormal cervical or vaginal discharge,
  • abnormal vaginal bleeding
  • deep dyspareunia


  • bilateral lower abdominal tenderness (may lateralise, but this raises the possibuility of adnexal abcess)
  • fever > 38 degrees, (but absence does not exclude)
  • cervical motion tenderness on bimanual examination.
  • adnexal tenderness on bimanual examination.

A diagnosis of PID, and empirical antibiotic treatment, should be considered and usually offered in
any young (under 25) sexually active woman who has recent onset, bilateral lower abdominal pain
associated with local tenderness on bimanual vaginal examination, in whom pregnancy has been


  1. Haematology: wbc, esr, crp will be raised but lack sensitivity and specificity - support the diagnosis but not specific.
  2. Biochemistry: BHCG on all women of child-bearing age. PID rare in pregnancy but can have complications - pre-term delivery. Also useful to exclude an ectopic.
  3. Microbiology: endocervical swabs for microscopy, culture and PCR for N. gonorrhoea and Chlamydia. Testing for gonorrhoea and chlamydia in the lower genital tract is recommended since a positive result supports the diagnosis of PID. But the absence of infection at this site does not exclude!
  4. USS: transvaginal to exclude complications such as adnexal abcess,

Differential diagnosis:-
Other causes of pelvic pain!

  • endometriosis,
  • ectopic pregnancy,
  • ovarian cyst complications,
  • appendicitis,
  • diverticulitis,
  • UTI.


It is likely that delaying treatment increases the risk of long term sequelae such as ectopic pregnancy,
infertility and pelvic pain. Because of this, and the lack of definitive diagnostic criteria, a low
threshold for empiric treatment of PID is recommended. Broad spectrum antibiotic therapy is required
to cover N. gonorrhoeae, C. trachomatis and a variety of aerobic and anaerobic bacteria commonly
isolated from the upper genital tract in women with PID1

  • advise rest
  • analgesia,
  • iv therapy for those with more serious disease (e.g. pyrexia > 38 degrees, signs of tubo-ovarian abscess, signs of pelvic peritonitis.
  • advise patient to avoid intercourse until they and their partner have completed treatment and follow-up.

Information for Patients

  • explain the tratment and side-effects
  • advise that fertility is usually maintained but there is a risk of future infertility, chronic pelvic pain or ectopic pregnancy,
  • clinically more severe disease is associated with a higher risk of sequelae,
  • repeat episodes of PID are associated with an exponential rise in risk of infertility,
  • the earlier treatment is given, the lower the risk of future fertility problems,
  • future use of barrier contracpetion will significantly reduce the risk of PID,
  • sexual contacts need to be screened to prevent re-infectioon.

Outpatient therapy is as effective as inpatient treatment for patients with clinically mild to moderate
PID17. Admission for parenteral therapy, observation, further investigation and/or possible surgical
intervention should be considered in the following situations19:
• a surgical emergency cannot be excluded
• lack of response to oral therapy
• clinically severe disease
• presence of a tuboovarian abcess
• intolerance to oral therapy
• pregnancy

A patient advice leaflet can be found in here.

Remember need a general sexual health screening and possibly contact tracing.
Various regimes are evidence based - check local policy - but two of theose recommended in the guidelines are:-

  • im ceftraixone 500mg single dose followed by oral doxycycline 100mg bd plus metronidazole 400mg bd for 14 days. OR:
  • ofloxacin 400mg bd + metronidazole 400mg bd po for 14 days,
  • but check local policies.
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