Clinical Information on Acute Pelvic Inflammatory Disease

Definition of Acute Pelvic Inflammatory Disease

  • An ascending infection of the cervix, which results in one or more of the following conditions endometritis, salpingitis, parametritis, ooforitis, tuboovariel abscess and / or peritonitis in the small pelvis
  • The acronym PID – pelvic inflammatory disease – often used


  • incidence
    • A frequent diagnosis, but there is no South African estimates of incidence
    • The incidence of hospitalizations in the diagnosis of PID are several 1,000 per year, but has declined in the past 10-20 years
    • In Norway, the incidence in the age group 15-44 year old for 10 to 20 per 100,000 (0.1-0.2%)
  • Age
    • The most frequent among young, sexually active women with multiple partners

Etiology and pathogenesis

  • In most cases the disease is caused by one ascending infection, but PID can occur by hematogenous spread
  • Often sexually transmitted, particularly among young
  • There are regional and national differences in the frequency of various pathogens
  • Most cases in South Africa caused by infection with Chlamydia trachomatis (see chlamydia infection ) recorded 30,000 chlamydia positive in South Africa each year, but there are no figures for how many leads to clinical symptoms
    • Mixing Infections with multiple microorganisms are common, eg: Gardner ella vaginalis, Mycoplasma, Haemophilus influenza, ß-hemolytic streptococci, staphylococci and e-coli
    • In particular, in complicated cases, there is often anaerobic gram-negative bacteria
    • Pelvic infection Gonococcal has been increasing since the 90s and are found around 3000 cases annually. The majority among men who have sex with men, almost 1/5 of these are women. There has since 2007 seen an increase in cases among heterosexual young

Predisposing factors

  • Factors related to sexual function: 1 , 2 
    • Young age – most common among 15-25 year olds
    • New (e) many and partner (s) with symptoms
    • Past sexually transmitted disease in a patient or partner
    • Use of contraceptive barrier methods provide some protection
  • Instrumentation of the uterus
    • Setting up the spiral increasing the risk the first months
    • Curettage and hysterosalpingography
    • In vitro fertilization and intra-uterine insemination
    • Abortion procedure, both medical and surgical
  • Postpartum (see puerperal fever / postpartum endometritis)


  • X71 Gonorrhea in woman
  • X74 Pelvic inflammatory disease
  • X92 Chlamydia infection of the genital tract in women


  • N70 inflammation of the fallopian tube and ovary
  • N700 Acute salpingitis electricity ooforitis
  • N709 Salpingitis electricity ooforitis UNS
  • N71 Inflammation of the uterus, except cervix
  • N710 Acute endometritis
  • N719 endometritis UNS
  • N72 Inflammation of the cervix
  • N73 Other forms of pelvic inflammatory disease
  • N730 Acute parametritis electricity cellulitis in the female pelvis
  • N732 parametritis electricity cellulitis in the female pelvis UNS
  • N733 Acute female pelveoperitonitis
  • N735 Female pelveoperitonitis UNS
  • N738 Other infection of the female pelvis
  • N739 infection in the female pelvis UNS
  • N74 Pelvic inflammatory disease V KA
  • N743 gonorrhoeal pelvic inflammatory disease
  • N744 Pelvic inflammatory disease fa chlamydia
  • N748 Wom. pelveoperitonitis v Diseases. KA
  • O045 Prov. Abortion before 12 weeks cycle, complete / unspecified, m underlivsinf
  • O071 Attempts to legalize abortion compl. m late el exc. bleeding
  • O86 Other infections partum
  • O85 Maternal Fever


diagnostic criteria

  • Pelvic inflammatory disease can cause symptoms, but can also be asymptomatic
  • The diagnosis is based on symptoms and objective findings
  • Both the sensitivity and specificity of the klinisike / paraklinisike diagnosis is limited
  • The following symptoms suggesting pelvic infection:
    • Soreness in the lower part of the abdomen, often bilaterally
    • Direct tenderness of the uterus and adnexer by vaginal exploration
    • Dislokationsømhed uterine cervix by moving the
  • In addition, at least one of the following criteria must be met:
    1. Temperature of> 38 ° C
    2. Elevated C-reactive protein (CRP) and / or leukocytosis (> 10,000)
    3. Purulent flour from the cervix
    4. Positive growth response
  • It is not possible at the clinical study to assess the bodies involved in the infection
  • In women at high risk of pelvic infection, recommended some to begin treatment on symptoms alone
  • If women repeatedly suspected of PID without accompanying bacteriological or para clinical findings, one should consider whether there may be other causes of symptoms such as myalgia of ileopsoas and pelvic floor


  • ectopic pregnancy
  • Spontaneous abortion
  • Endometriosis
  • appendicitis
  • acute pyelonephritis
  • Ovarian cysts – with torkvering, bleeding or rupture
  • Myomdegeneration
  • acute gastroenteritis
  • Diverticulitis of colon – spec. elderly
  • Bækkenmyoser

Medical history

  • The symptoms vary in intensity, particularly gives chlamydia infection often modest to moderate symptoms, while gonorrhea can give significant pain

typical symptoms

  • Pain in the lower abdomen, often bilaterally if necessary. radiating into the lumbar
  • Pain that worsens with movement
  • Dyspareunia – especially newcomer 3
  • purulent discharge
  • Bleeding disorders, both contact hemorrhage, and heavy menstrual bleeding intermenstruelle
  • dysuria
  • Possibly. chills and fever
  • Accompanying pain in the upper right quadrant of the abdomen may indicate perihepatit

clinical findings

  • The clinical findings may be more or less convincing, especially providing chlamydia infection often modest or moderate findings

typical findings

  • Discharge
  • Almost always injected with cervicitis and edematous portio
  • Strikingly palpation tenderness in adnexae, and the uterus is palpations- and rokkeøm
  • Filling and infiltrates in adnekser can be seen later in the process

additional studies

  • infection counts:
    • CRP is the best indicator, values> 50 are typically, but CRP be normal in mild cases
    • In the acute phase is often leukocytosis
    • CRP normalized later than leukocytosen and clinical symptoms
  • HCG test to exclude pregnancy
  • Grafting from the cervix and urethra and cultivation of chlamydia and possible. gonorrhea

other studies

at the hospital

  • transvaginal ultrasound
    • Typical manifestations of acute pelvic inflammatory disease is the thickening of the tubal wall to> 5 mm, dilated incomplete septae in the fallopian tubes (cog drawing) and fluid in the fossa Dougalssi and possible. pyosalpinges
    • Abscesses may involve both ovaries and salpinges
  • CT or MRI?
    • In some cases, may be of differential diagnostic reasons supplemented by CT or MRI
  • Laparoscopy?
    • Is in the acute phase only indicated by uncertainty about the diagnosis
  • bacteriology
    • Abscesindhold or biopsy for cultivation

When to refer the patient?

  • Mild cases can be treated in the primary sector
  • Hospitalization is recommended for
    • severe cases
    • Upon failure of the primary treatment
    • On suspicion of tuboovariel abscess
    • By undecided diagnosis
    • Pregnant and lactating


Treatment goals

  • clear the infection
  • Prevent permanent damage to the genitalia interna

Generally about the treatment

  • Early diagnosis and treatment is essential to prevent sequelae
    • For example, recommends US Food and empirical therapy in women with risk of pelvic infection if there are dislokaltionsømhed of the uterus at the gynecological examination
  • In severe cases, are treated with antibiotics, which are primarily intended to cover both chlamydia infection, gonococci and anaerobic bacteria
  • In severe cases recommended bed rest, but there is scant evidence of this in mild cases
  • When treatment failure after 1-2 days of hospitalization should be considered

What can the patient do?

  • Bed rest – as long as there is pain and fever
  • Sexual abstinence to the patient is completely recovered

Medical treatment


  • Treatment should cover
    • Chlamydia (e.g.,  tetracyclines , macrolides )
    • anaerobic bacteria (e.g.,  metronidazole )
    • and on suspicion of gonorrhea (eg  cephalosporins , see document on gonorrhea)
    • There is good evidence for a regime in relation to others – but factors such as epidemiology, resistance, allergies, compliance and cost the same conjunction with the severity of symptoms to be considered
  • Treatment in primary health care:
    • Mild cases are treated orally, in severe cases, selecting a broad-spectrum intravenous treatment
    • Metronidazole  tbl: 500 mg x 2-3 for 7 days – and one of the following
    • Doxycycline  tbl: 100 mg x 2 for 14 days – or
    • Ofloxacin tbl: 400 mg x 2 for 14 days
  • There is some evidence that mild cases can be treated without metronidazole and metronidazole may be discontinued at rapid response to treatment
  • In the case of pelvic inflammatory disease secondary to instrumentation of the uterus is often anaerobic organisms, and treatment with metronidazole is always advisable in such cases

Severe infection of the small pelvis, in hospital

  • In severe cases, there is often more microorganisms involved and anaerobic bacteria frequently
  • Given an intravenous treatment with e.g.
    • Ampicillin  2 gx 3 IV;
    • Metronidazole  1.5 gx 1 day 1, then 1 gx 1 IV
    • Possibly. supplemented with an aminoglycoside ( gentamicin , netilmicin ortobramycin ) 1.7-2 mg / kg x 3 per day iv or im
  • Allergy to penicillin
    • Ampicillin replaced with clindamycin  600 mg x 3 IV
    • NB: enterococci are not sensitive to clindamycin and aminoglycosides
  • In case of established abscess aminoglycoside replaced by a fluoroquinolones , e.g., ciprofloxacin  400-600 mg x 2 IV
  • The intravenous treatment should continue for a day after clinical improvement and then replaced by oral treatment

other treatment

  • Sick leave until the temperature has returned to normal and the symptoms subsided
  • There may be a need for analgesic treatment
  • In moderate to severe cases, control of the treatment after 1-3 days indicated
  • Treatment of partner is important
    • Some recommend routine of partner, although special microbes were not detected
    • Other processing routine partner if a patient has chlamydia infection

preventive treatment

  • condom
  • Chlamydia Screening of young women?
    • In South Africa the chlamydia screening of all abortion seekers before spiral warehousing in adolescents and pre vaginalinstrumentering by symptoms (vaginal discharge, spotting symptoms of pelvic inflammatory disease).
    • Sexually active women under 25 years can halve their risk of PID by annual chlamydia screenings.
    • Among women over 25, routine screening is not recommended and should be targeted; women at increased risk.
      • It is by infection with chlamydia or gonorrhea in the last two years, more than one sexual partner in the last 12 months, new partner the last 3 months, partner over the last 12 months who have had multiple sexual contacts over the same period 4 

Course, complications and prognosis


  • From very mild to considerably painful and protracted cases
  • Spontaneous recovery occurs in many


  • After pelvic get about 20% damage to the fallopian tubes
  • The risk of tubal damage increases with the number of pelvic infections and their severity
  • Tuba Injury increasing the risk of infertility and ectopic pregnancy (RR up to 10 times greater)
  • pelvic
    • Can often be treated by transvaginal drainage and possible. rinsing with antibiotics
    • May require operating decontamination. In older perhaps. with the removal of the affected adnex
    • Rupture of the abscess with peritonitis is the most severe complication
  • Can cause chronic pelvic pain
  • Perihepatitis and perihepatiske adhesions (Fitz-Hugh-Curtis syndrome) develops in 5-15% of pelvic inflammatory disease in particular by Chlamydia infection. Pain under right curvatur may be the dominant symptom
  • Women with HIV may have more pronounced symptoms, but respond well to antibiotics
  • It is rare that pregnant women get pelvic inflammatory disease, but if infection is both the maternal and fetal morbidity increased
  • By pelvic inflammatory disease of the spiral coil users should remove 5


  • Depends on the severity of the infection
    • By moderately severe to severe infection developed sterility in 6
      • 15% after 1 infection
      • 30% after 2 infections
      • 60% after 3 infections
    • After a light pelvic infection, 10% will be sterile
    • After an average 20% infection
    • After a serious infection up to 40%

patient Information

What you should inform the patient

  • How to prevent recurrence
  • Condom, possibly. use of double contraception
  • Avoid “casual sex”
  • Chlamydia Screening by changing partners

What are the written patient information

  • Information about pelvic inflammatory disease
  • About antibiotics
  • chlamydia


  • pelvic inflammatory disease



  • The patient should be monitored for 2-3 weeks
  • Severe cases should be assessed after 1-3 days

What should be checked

  • Gynecological examination – feel for whether there still is soreness
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