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Pelvic Inflammatory Disease PEER REVIEWED FEATURE 2 CPD POINTS Pelvic inflammatory disease Management of new- onset low abdominal pain in young women DEBORAH BATESON MA(Oxon), MSc(LSHTM), MB BS NATALIE EDMISTON MB BS, MPH, FAChSHM Pelvic inflammatory disease (PID) is a highly variable syndrome that should be considered in all young women presenting with new-onset low abdominal pain. Prompt antibiotic treatment is essential to prevent potentially serious complications. Tests are often negative for sexually transmitted infection but rapid clinical improvement with treatment supports the diagnosis of PID. elvic inflammatory disease (PID) considered in all young women who present is an upper genital tract inflamma- with new-onset low abdominal pain. tory syndrome of great variability, Untreated PID can lead to serious sequelae, which presents with symptoms including tubal infertility, ectopic preg- Pthat range from mild and manageable in nancy and chronic pain, with the risk primary care to severe, requiring inpatient increasing significantly with repeat infec- management. The diagnosis should be tions. Updated national management guidelines emphasise the clinical nature of disorders can vary in their severity from the diagnosis and advise prompt initiation mild disease, which may go undiagnosed, of treatment to prevent long-term damage to pelvic sepsis.2 Generally, women with to the fallopian tubes.1 more severe symptoms tend to have more serious disease and an increased risk of MedicineToday 2016; 17(7): 14-22 What is pelvic inflammatory long-term sequelae.3 The long-term effects disease? Clinical Associate Professor Bateson is Medical of PID include tubal infertility, ectopic 3-5 Director of Family Planning NSW, Sydney; and PID is a syndrome comprising a spectrum pregnancy and chronic pelvic pain. Clinical Associate Professor in the Discipline of of inflammatory disorders caused by infec- Evidence suggests that up to 17% of Obstetrics, Gynaecology and Neonatology at tion ascending from the vagina or cervix women experience enough tubal damage The University of Sydney, Sydney. to the pelvis. These disorders include from one episode of PID to become infertile Dr Edmiston is a Staff Specialist at the Lismore endometritis, salpingitis, tubo-ovarian and that the risk increases with each Sexual Health Service, Lismore, NSW. abscess and pelvic peritonitis. These episode.3-5 The risk of chronic pelvic pain 14 MedicineToday ❙ JULY 2016, VOLUME 17, NUMBER 7 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2016. KEY POINTS • Pelvic inflammatory disease (PID) is an upper genital tract inflammatory syndrome with highly variable symptoms. • The diagnosis of PID should be considered in all young women who present with new-onset low abdominal pain. • A urine pregnancy test is essential in all women of childbearing age with new-onset low abdominal pain to exclude ectopic pregnancy. • Prompt treatment of women with suspected PID with ceftriaxone, azithromycin, doxycycline and metronidazole to cover the potential polymicrobial causes is essential to prevent long-term complications. • Transfer to the nearest emergency department is warranted for women with severe symptoms or haemodynamic instability. • Sexual contacts should be tested and treated to prevent recurrence of PID. partner with a sexually transmitted infec- tion (STI) or symptoms suggestive of an STI. More rarely, PID can follow uterine instrumentation, such as a hysteroscopy or insertion of an intrauterine device (IUD). Note that the risk of infection is increased only in the first 20 days after an IUD is inserted, after which it returns to the woman’s baseline risk of acquiring PID through sexual transmission.14 It is impor- tant to be aware that PID can occur during pregnancy and although this is rare, it requires urgent attention to prevent serious outcomes for the woman and the pregnancy. PID occurs almost exclusively in women is increased fourfold by a recurrent episode underdiagnosed.8-10 PID accounted for who are sexually active. The upper genital of PID.4 Delay in initiation of treatment is approximately 0.05% of hospital admissions tract infection is polymicrobial; disruption associated with increased rates of infertility in NSW from 2001 to 2010, and the rate of of the cervical mucous barrier allows and chronic pelvic pain.5,6 hospitalisation for PID decreased over this vaginal or cervical organisms to ascend to The incidence of PID is difficult to deter- period.11 Likewise, the number of general the uterus and fallopian tubes. Organisms mine as the vast majority of women with practice encounters for PID has shown a detected in cases of PID include anaerobes PID are managed in outpatient ambulatory decreasing trend among young women.7 and other bacteria that are frequently care, where data collection is more dif- present in the vagina. Organisms associated ficult.7 The threshold for making a Risk factors for pelvic with bacterial vaginosis are particularly presumptive diagnosis of PID may vary inflammatory disease common, and bacterial vaginosis may between practitioners, and in some settings, The strongest risk factor for PID is young have a role in the pathogenesis of PID.15 such as among adolescents and in remote age.12,13 Other risk factors for PID include Chlamydia trachomatis, Neisseria gonor- KEVIN A. SOMERVILLE KEVIN A. © Australian communities, PID may be a recent change of partner or having a rhoeae and Mycoplasma genitalium are all MedicineToday ❙ JULY 2016, VOLUME 17, NUMBER 7 15 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2016. GP || PELVIC INFLAMMATORY DISEASE AN ALGORITHM FOR MANAGING YOUNG WOMEN WITH NEW-ONSET LOW ABDOMINAL PAIN*23 NEW ONSET PELVIC OR LOWER ABDOMINAL PAIN IN WOMEN OF REPRODUCTIVE AGE hCG ECTOPIC Urgent positive PREGNANCY ED or EPAS referral History incl. Pregnancy test sexual/menstrual URGENT STI tests Pulse, BP, temp TVUS Abdo examination Urinalysis INTRAUTERINE Threatened PREGNANCY Miscarriage or other β hCG negative pregnancy complication Any of the following Yes • Shock, hypotension Urgent No pregnancy • Profuse PV bleeding ED referral complications • Moderate to severe pain evident EPAS • Prominent nausea, anorexia referral No CONSIDER OTHER DIAGNOSIS See Figure 2 for differential diagnoses Other obvious diagnosis? No No cervical motion, uterine or adnexal tenderness Not done PID LIKELY PID not excluded PID UNLIKELY Speculum/bimanual examination recommended Treat and Review Cervical motion, TREATMENT • Paracetamol Refer for admission if uterine or adnexal Treat for PID as outpatient tenderness • Early review • systemically unwell found Initiate treatment before test results available • Consider TVUS • requires more than Ceftriaxone 500mg IMI stat paracetamol for analgesia Azithromycin 1g oral stat • tubo-ovarian abscess present Metronidazole 400mg oral bd for 14 days Doxycycline 100mg oral bd for 14 days* • pregnant *if pregnant, replace with an additional 1g Azithromycin, one week later Treat regular sexual partners with Azithromycin 1g stat. Arrange follow-up Contact trace past sexual partners if STI diagnosed within 2-3 days Developed in collaboration with the Statewide NSW Lower Abdominal Pain Working Group – January 2016 Figure 1. An algorithm for the management of new-onset low abdominal pain in young women*23 Abbreviations: Abdo = abdominal; bd = twice daily; BP = blood pressure; ED = emergency department; EPAS = early pregnancy assessment unit; hCG = human chorionic gonadotropin; IMI = intramuscular injection; PID = pelvic inflammatory disease; PV = per vagina; stat = immediately; STI = sexually transmitted infection; TVUS = transvaginal ultrasound. * Developed by the NSW STI Programs Unit and NSW PID Working Group and reproduced with permission, 2016 (http://stipu.nsw.gov.au). 16 MedicineToday ❙ JULY 2016, VOLUME 17, NUMBER 7 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2016. GP || DIFFERENTIAL DIAGNOSES Common causes of low abdominal (pelvic) pain in women of reproductive age This table is intended as a guide to assist with the diagnosis of a new onset of low abdominal (pelvic) pain among women of reproductive age but is not an exhaustive list. Note that concurrent diagnoses are common and may result in mixed signs and symptoms. Fever and raised WCC may be present among women presenting with acute pelvic pain from any cause, however these signs are non-specific and their presence or absence does not necessarily support or exclude a specific diagnosis. DIFFERENTIAL DEFINITIVE DIAGNOSIS TYPICAL PRESENTATION FINDINGS THAT SUPPORT THE DIAGNOSIS DIAGNOSTIC FINDINGS MEDICAL EMERGENCIES Ectopic • Pelvic pain and/or bleeding in the first trimester • Positive pregnancy test Ectopic pregnancy identified Pregnancy (typically 6 to 8 weeks) • Empty uterus on ultrasound on imaging and/or • Pain may localize to one side laparoscopy Appendicitis • Acute onset (hours to days) • Migration of pain from umbilicus to right iliac fossa Appendicitis confirmed • Migration of pain from peri umbilicus to RIF • Onset of pain not associated with menses on imaging, laparoscopic • Systemic symptoms present: anorexia, nausea, vomiting • McBurney’s point site of maximal tenderness and/or histological findings Ovarian cyst • Sudden onset of unilateral pelvic pain, more common • Adnexal mass felt on bimanual examination Ruptured ovarian cyst complications in the right iliac fossa identified on imaging (rupture /torsion) • May be associated
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