4.
Pelvic inflammatory disease.
| a. | is usually due to gonorrhoea | False |
| b. | carries a risk of sterility of < 10% after one attack | False |
| c. | has increased in incidence | True |
| d. | is best treated with a single broad spectrum antibiotic | False |
| e. | is a contraindication to the IUCD | True |
| f. | a pregnancy test should always be done | True |
return to the list of contents
go to the bottom of the page and other links
This is a very common problem: 1 in 16 of GP consultations for women < 45 years.
With devastating consequences if untreated:
infertility,
ectopic pregnancy,
chronic pelvic pain,
dyspareunia,
psychological disturbance.
return to the list of contents
go to the bottom of the page and other links
b.d: bis die: twice each day.
EC: emergency contraception.
hCG: human chorionic gonadotrophin.
CRP: c-reactive protein.
CT: computerised tomography.
ESR: erythrocyte sedimentation rate.
GP: General Practitioner.
I.m: intra-muscularly.
I.v: intra-venously.
IMB: inter-menstrual bleeding.
MR: magnetic resonance.
NAAT: nucleic acid amplification test.
PCB: post-coital bleeding.
PID: pelvic inflammatory disease.
Q.d.s: quater die sumendum: four times a day.
RCOGGT: RCOG’s Green-top Guideline No 32.
Stat: immediately
STD: sexually transmitted disease.
t.d.s: ter die sumendum: three times a day.
TOG: The Obstetrician and Gynaecologist.
TOP: termination of pregnancy.
TVS: transvaginal scanning.
UTI: urinary tract infection.
V/E: vaginal examination.
WCC: white cell count.
return to the list of contents
go to the bottom of the page and other links
PID is common: one GP consultation in 60 for women < 45 years old.
It predisposes to ectopic pregnancy, infertility, dyspareunia, pelvic pain and psychological upset.
One attack has been said to be enough to cause sterility in 20% of cases.
Multiple attacks increase the risks “exponentially” according to the RCOG guideline.
The severity of clinical disease and the interval to treatment adversely affect outcomes.
We treat actively, but there is no research evidence about the long-term benefits.
Chlamydia and gonorrhoea are the most common infective agents.
The infection most often ascends from the cervix.
All of the genital tract is liable to consequent infection, from endometrium up to the ovaries.
Peritonitis can ensue with adhesion formation.
Fitz-Hugh-Curtis syndrome is where there are peri-hepatic adhesions. (See MCQ 2, Q.32.)
A rare condition, but in the MCQ database.
There are no absolute diagnostic criteria for PID: you have to use your nous.
Clinical features include: abdominal pain, discharge, abnormal bleeding and pain on V/E.
The consequences of failure to treat can be severe.
Take interactions between antibiotics and oral contraception and other drugs into account.
There is no universally-agreed treatment regime or one of proven efficacy.
The RCOG’s recommendations are in the MRCOG section.
Ectopic pregnancy will almost always need to be excluded, so don’t forget a hCG.
Suspected cases should be screened for chlamydia and gonorrhoea.
STD clinic referral for screening for other STDs and contact tracing makes sense.
But negative bacteriology results do not exclude the diagnosis, so treatment should not be stopped without great thought.
Partners should be screened to treat any infection and reduce the risk of the woman suffering re-infection.
Criteria for hospital admission include:
severe disease,
pregnancy,
tubo-ovarian abscess,
failure to respond to outpatient treatment,
doubt about the diagnosis, especially possible surgical problems like appendicitis.
Outcomes after community and hospital treatment are the same for mild and moderate disease.
Follow-up includes:
education about the condition,
advice about avoiding repeat infection,
barrier contraception being effective.
The RCOGGT mentions a web address from which a patient information leaflet can be downloaded.
Women with HIV should be treated with the same antibiotic regimes.
return to the list of contents
go to the bottom of the page and other links
Recommended reading for the MRCOG.
The RCOG’s Green-top Guideline No 32 is mandatory reading for MRCOG candidates.
There is a good review article in emedicine.
There is a TOG article: 2004;6:3:138-144, a bit old now, but still useful.
return to the list of contents
go to the bottom of the page and other links
Expanded information for the MRCOG and to help facts stick.
PID is the source of one GP consultation in 60.
A single attack causes sterility in 20% of cases.
With more attacks, the risk of consequences rises “exponentially” according to the RCOGGT.
Do you understand “exponentially”?
Don’t worry, for our purposes it means at a fast and ever-increasing rate.
The RCOGGT says that: “it is likely that delaying treatment … increases the severity of the condition and the risk of long-term sequelae”.
It also says that: “delays of only a few days in .... treatment markedly increase the risk of sequelae”.
There are also the considerable costs to the NHS involved in the management of the acute episodes and the sequelae.
return to the list of contents
go to the bottom of the page and other links
Chlamydia is the commonest cause of PID.
Not surprising really as it is thought that 1 young person in 10 has an asymptomatic chlamydial infection. (See MCQ1, question 20.)
The risk of sterility is possibly as high as 20 % after a single POD attack – scary stuff!.
The RCOGGT does not give figures in this regard.
The incidence of PID has risen, probably reflecting changing sexual behaviour and the use of non-barrier contraception.
Most of those infected are asymptomatic.
It is now a major public health problem, meriting a national screening programme. (See MCQ 1, question 20 for more details.)
Gonorrhoea has been reported to be present in 14% of cases in a recent survey.
Similarly, a patient with gonorrhoea is likely to have chlamydia too.
Other organisms include Mycoplasma genitalium and anaerobes.
return to the list of contents
go to the bottom of the page and other links
Here we are talking about acute PID, but remember to read any exam question carefully as it could also refer to chronic PID.
Most patients with acute PID will present with abdominal pain, perhaps with discharge, dyspareunia etc.
Ectopic pregnancy should be excluded by arranging an urgent beta-hCG.
Then you have to rely on your skills and judgement:
there are no definitive clinical features,
but you can’t delay treatment if you suspect the diagnosis because of the significant risk of long-term consequences.
The RCOGGT stresses the need for “a low threshold for the empiric treatment of PID”.
It should be “the empiric treatment of suspected PID”, but we won’t get bogged down in semantics.
Features pointing to the diagnosis are:
abdominal pain and tenderness,
pelvic pain and dyspareunia,
fever,
vaginal or cervical discharge,
abnormal bleeding which may be breakthrough bleeding on hormonal contraception, IMB or PCB.
Vaginal examination may show tenderness, particularly in the adnexae or on moving the cervix.
In rare cases you might find a pelvic mass.
This should trigger thoughts of all sorts of alternative diagnoses such as:
ectopic pregnancy,
torted, ruptured or bleeding ovarian cyst,
pedunculated fibroid that has twisted on its pedicle,
tubo-ovarian or other pelvic abscess,
e.g. appendix or diverticular,
and will mean prompt hospital admission.
The list of alternative diagnoses is huge:
UTI,
appendicitis,
endometriosis,
IBS.
The RCOGGT even includes “functional pain”, which, it rather coyly elaborates, is “pain of unknown physical origin”.
return to the list of contents
go to the bottom of the page and other links
Swabs should be taken to exclude chlamydia and gonorrhoea.
But remember that you can do all the swab tests known and get only negative results without being able to exclude the diagnosis of PID.
This is one of those negative statements that crop up in MCQs and get points in essays.
Testing for chlamydia should involve a NAAT on an endocervical swab.
Taking a swab from the urethra increases the detection rate.
There is evidence that rectal swabs further increase diagnostic accuracy, but they are not standard.
Testing for gonorrhoea can be by culture or NAAT on an endocervical swab.
NAAT will not give antibiotic sensitivity, so a separate swab should be taken for culture if NAAT is used.
This allows for the antibiotic regime to be changed if necessary.
The RCOGGT says that women at high risk of gonorrhoea, e.g.
those with a partner known to be infected,
those infected abroad,
those with severe disease,
should have a swab taken for culture.
I don’t understand this – with the above recommendation all women will have a swab taken, either as the primary investigation or as a secondary test if NAAT is used.
NAAT is more sensitive than culture.
A wet-mount smear with no pus cells correlates well with the absence of PID – 95% negative predictive value.
But the presence of pus cells does not confirm the diagnosis.
The positive predictive value is only 17% due to lower genital tract infections also generating pus cells.
Routine screening for other organisms known to cause PID, such as Mycoplasma genitalium, is not advocated.
This is due to lack of knowledge about key issues like prevalence, cost effectiveness of screening etc.
Endometrial biopsy sounds attractive but lacks supportive research evidence.
General tests for inflammation like elevated ESR or CRP and increased WCC are pointers but not diagnostic.
TVS with power Doppler may show dilated tubes and tubo-ovarian masses.
But it lacks the research evidence for routine use.
Similarly CT and MR scanning have some supportive evidence, but not enough for their routine deployment.
Laparoscopy has long been referred to as the “gold standard” investigation, but is not routine in the UK.
But even this may be negative in up to 30% of cases in which causative organisms are cultured from the Fallopian tubes.
It does allow assessment of the severity of the condition, bacteriology from the tubes and pelvis.
And, in most cases, exclusion of differential diagnoses such ectopic pregnancy and ovarian cyst accidents.
Referral to a sexually transmitted disease clinic for screening for other STDs and contact tracing will be appropriate in most cases.
We are encouraged to be more pro-active in trying to reduce the chlamydia “epidemic”.
Studies have shown a wide variation in the % of clinically suspected cases that are confirmed in theatre.
Most are around 70%, but the figure goes down to little more than 20%.
return to the list of contents
go to the bottom of the page and other links
Not all cases will have significant symptoms, so are at risk of going untreated and developing long-term complications.
If you suspect the diagnosis, err on the side of caution and start treatment.
Antibiotic therapy must cover the range of possible infecting organisms and several drugs are the norm to deal with chlamydia, gonorrhoea, anaerobes etc.
But there is no evidence-based best regime.
The RCOGGT was published in 2003 and updated in 2009 and includes the RCOG’s views on suitable treatments.
This is an important document for practice as well as the exam.
Remember the possible impact of antibiotic therapy on other drugs she might be taking, especially hormonal contraception.
Remember analgesia & the possible need for EC.
You need to do the basics: analgesia, rehydration etc.
Outpatient treatment is as effective as inpatient in mild and moderate disease.
Sorry to repeat the message, but the RCOGGT stresses the need to be active in treating suspected disease.
Especially in women < 25 years in whom the incidence is high and the sequelae potentially devastating.
This is repeated elsewhere in this document to make you remember it.
return to the list of contents
go to the bottom of the page and other links
The gonococcus may be resistant to ofloxacin, so a high risk of gonococcal infection is a contraindication.
The RCOGGT advises caution using oflaxacin in girls whose bones might still be growing.
This is based on animal data and the BNF says it is OK to use it if there is no better option.
Regime 3 has less supportive evidence than the others, but may be used.
Cefoxitin has better supportive research evidence than ceftriaxone, but it not easily available in the UK, so is not recommended.
Metronidazole may cause unacceptable side-effects.
The RCOGGT states that it can be stopped in mild and moderate cases with significant side-effects as there is limited evidence to show that it adds much to the above regimes.
Oral doxycycline + metronidazole has been used in the UK, but is not recommended due to lack of research support.
The guideline points out that there are no trials to support oral rather than i.m. use of cephalosporins and that tissue levels are likely to be lower with oral therapy.
return to the list of contents
go to the bottom of the page and other links
Admission should be arranged if there is:
severe disease,
suspicion of other pathology, e.g. appendicitis,
PID in association with pregnancy,
tubo-ovarian abscess,
or failure of oral treatment.
If the condition is mild an IUCD can be left in place.
If it is more severe, it should be removed.
Pelvic inflammatory disease is an absolute contra-indication to the insertion of an IUCD at the time.
Whether the patient might have one in the future would depend on circumstances:
her risk of further PID,
her desire to have further children,
her suitability for alternative contraception etc.
return to the list of contents
go to the bottom of the page and other links
The RCOGGT points out that the treatment used should pay heed to:
local patterns of infection and antibiotic sensitivity,
the severity of the disease,
the likely compliance of the patient,
the cost of the treatment etc.
Inpatient costs are vast compared with outpatient:
most hospital beds cost a couple of hundred pounds per day just to be sat on,
before anyone even says “Hello” or starts expensive investigations and treatments.
Remember analgesia, rehydration and the possible need for EC.
Antibiotics are given intravenously initially then orally.
The i.v. drugs are continued until there has been clinical improvement for at least 24 hours according to the RCOGGT.
“Clinical improvement” is rather meaningless:
it could be that she feels a bit better or that her temperature has fallen by a tiny amount.
In real life you would continue the i.v. drugs until she has become asymptomatic and apyrexial.
The following regimes are recommended in the RCOGGT:
1. ceftriaxone 2gm. by i.v. infusion daily + doxycycline100 mg. bd.
then doxycycline 100 mg. b.d. orally + metronidazole 400 mg. b.d.
the treatment should last 14 days.
oral doxycycline can be used instead of i.v. if well-tolerated.
2. clindamycin 900 mg. i.v., t.d.s + gentamycin (see dosage schedule below *)
then one of the following oral regimes, to extend the treatment to 14 days:
a. clindamycin 450 mg., q.d.s.,
b. doxycycline 100 mg., b.d. + metronidazole 400 mg.
3. ofloxacin 400 mg. i.v., b.d. + metronidazole 500 mg. i.v., t.d.s. for 14 days.
· * Gentamycin is given as a 2mg. / kg. loading dose
then 1.5 mg. / kg. t.d.s., for which you can substitute a single daily dose of 7 mg. / kg.
You need to monitor drug levels and renal function.
The BNF highlights the following major side-effects:
vestibular, auditory and kidney damage.
it also mentions nausea, vomiting, rash, blood disorders, colitis, stomatitis and hypomagnesaemia.
my old dad was given a course to deal with an abscess
and ending up needing a hearing aid, a significant side-effect for someone who was a fine pianist and organist.
return to "inpatient treatments"
· i.v. doxycline is available from IDIS World Medicines.
return to the list of contents
go to the bottom of the page and other links
The evidence is limited.
The RCOGGT suggests that removal may be beneficial in terms of short-term outcomes, particularly if symptoms have not resolved within 72 hours.
But this has to be balanced against the risk of pregnancy.
Some women may need emergency contraception if the IUCD is removed.
I would have thought that this would have been good grounds for leaving it in situ!
Questions about PID and IUCDs need to be read carefully.
In this case the statement was simply "PID is a contraindication to the IUCD".
It certainly is at the time of insertion, so the answer is "true".
But a differently worded question might get a different answer.
For example: "IUCDs should be removed when PID is diagnosed".
return to the list of contents
go to the bottom of the page and other links
The possibility of pregnancy raises immediate issues about EC and excluding ectopic pregnancy.
PID is rare with a healthy intra-uterine pregnancy – I did not see a case in nearly 40 years of practice.
The RCOGGT states that cervicitis can occur with increased maternal and fetal morbidity.
Though it says the biggest problem lies with septic “abortion” – I had thought that the RCOG advocated we stop using this word!
If we are dealing with sepsis after miscarriage or TOP, then you need to isolate the associated bugs and find their antibiotic sensitivity.
The RCOGGT says that the risk of the above drug regimes in very early pregnancy is low as it will simply result in failed implantation.
This seems a bit blasé!
A woman keen to be pregnant might well take dismal view of someone poisoning her pregnancy.
And the woman who believes that life starts with fertilisation would see it as unacceptable.
I suspect that what the authors were trying to say is that giving the drugs before pregnancy was suspected or confirmed would have this outcome.
In the rare event of PID and a viable or potentially viable pregnancy, you would
get the best advice available about the drugs you proposed to use
and avoid those that could be toxic.
The guideline suggests azithromycin, cefotoxamine plus metronidazole for 14 days.
return to the list of contents
go to the bottom of the page and other links
Treatment of women < 25 years.
The RCOGGT highlights the need for a low threshold for diagnosing and treatment in this age group:
they have a higher incidence of PID than other age groups,
the possible consequences can be devastating.
return to the list of contents
go to the bottom of the page and other links
This will sometimes be necessary in cases of abscesses
particularly if antibiotic treatment is not resolving the problem.
The guideline mentions that ultrasound-guided aspiration of fluid collections is feasible.
And that laparoscopy can be used for abscess drainage and division of adhesions.
If there is an abscess, remember that it could have arisen elsewhere:
the appendix,
bowel diverticulae etc.
Consider having a surgeon on standby and the need for bowel prep.
return to the list of contents
go to the bottom of the page and other links
Before discharge the woman needs verbal and written information about:
the condition,
what it is
how it is transmitted and prevented, particularly barrier contraception,
the risk of repeated attacks and severe disease,
its possible sequelae,
infertility, ectopic pregnancy, pelvic pain,
the treatment she has had and is having and possible side-effects,
the need for screening of her sexual partners,
and how to prevent recurrence.
Women treated as outpatients should be reviewed after 72 hours.
If they are not significantly better, you have to review the accuracy of the diagnosis.
And consider admission as a case of failed outpatient treatment.
All women should be reviewed at 4 - 6 weeks to ensure:
clinical improvement,
compliance with the treatment,
contact screening has been done,
a repeat pregnancy test is done if appropriate.
At follow-up some women will have been exposed to possible re-infection.
They will need repeat screening.
return to the list of contents
go to the bottom of the page and other links
The current partner obviously needs referral to a STD clinic for screening for STDs and contact tracing. So, they should be contacted and given the offer. Sexual intercourse should be avoided until both partners have completed the course of treatment. All other partners in the previous 6 months should be dealt with likewise. If screening can’t be done, treatment for chlamydia and gonorrhoea should be offered.
return to the list of contents
go to the bottom of the page and other links
Can the prevalence of PID be reduced?
Scandinavian countries are doing better via health education in reducing the incidence of PID and its sequelae.I hope we will catch up and the national screening programme (see question 20 in this paper) is a major step forward.
Though its efficacy remains to be demonstrated.
return to the list of contents
go to the bottom of the page and other links
| Next question |
| Return to MCQ Paper 1, Q.20. "Chlamydia" |
| Return to "Hot topics" |
| Return to DRCOG Page |