A 23-year-old woman presents with lower abdominal pain, dysuria, dyspareunia, and purulent vaginal discharge. A pregnancy test performed today is negative. She is afebrile and her observations are normal. On examination, her abdomen is soft but she cervical motion tenderness on bimanual pelvic examination.
- What is the most likely diagnosis?
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This patient is most likely to have a diagnosis of pelvic inflammatory disease (PID), which is a pelvic infection affecting the upper female reproductive tract (uterus, fallopian tubes, and ovaries). It usually occurs as an ascending infection from the cervix.
It is most frequently seen as a consequence of the sexually transmitted diseases chlamydia and gonorrhoea, with genital Chlamydia trachomatis infection the most common causative infection seen in UK genitourinary medicine clinics.
PID is frequently asymptomatic but the clinical features, when present, include the following:
- Lower abdominal pain and tenderness
- Fever
- Dysuria
- Dyspareunia
- Purulent vaginal discharge
- Abnormal vaginal bleeding
- Cervical motion tenderness and adnexal tenderness
- What is the appropriate initial investigation?
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The initial investigation of possible PID is with endocervical swabs for C.trachomatis and N.gonorrhoea, using nucleic acid amplication tests when available.
All patients presenting with symptoms suspicious of PID should also undergo a pregnancy test as the clinical presentation of ectopic pregnancy can be confused with PID.
- Does this patient require admission to hospital?
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Mild to moderate disease can generally be managed in the primary care or outpatient setting. Patients will clinically severe disease should be admitted to hospital for intravenous antibiotics. Signs of more severe clinical disease include:
- Fever above 38°C
- Clinical signs of tubo-ovarian abscess
- Signs of pelvic peritonitis
- Concurrent pregnancy
- How should this patient be treated?
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Empirical antibiotics should be commenced as soon as a presumptive diagnosis of PID is made clinically. Swab results should not be waited for.
The current recommendation for treatment of PID in the outpatient setting is:
- Ceftriaxone 500 mg as a single IM dose, followed by doxycycline 100 mg orally twice daily and metronidazole 400 mg twice daily for 14 days.
- An alternative regime is oral ofloxacin 400 mg twice daily and oral metronidazole 400 mg twice daily for 14 days.
The current recommendation for treatment of PID for severely ill patients in the inpatient setting is:
- Initial treatment with doxycycline, single-dose IV ceftriaxone and IV metronidazole
- Then change to oral doxycycline and metronidazole to complete 14 days of treatment.
In those who fail to respond to treatment, laparoscopy is essential to confirm the diagnosis or to make an alternative diagnosis.
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