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Referral and warning signs
When to refer
Referral for inpatient management if: Severe illness (high fever, nausea/vomiting), suspected tubo-ovarian abscess, pregnancy, unable to tolerate oral medications, failure to respond to outpatient therapy within 72 hours, diagnostic uncertainty (e.g., rule out appendicitis, ectopic).
Red flags
- High fever, signs of sepsis
- Suspected tubo-ovarian abscess (palpable mass, severe pain)
- Signs of peritonitis (rebound tenderness, guarding)
- Pregnancy with PID symptoms
- Failure to improve on outpatient treatment
Signs and symptoms
- Lower abdominal pain (bilateral)
- Abnormal vaginal discharge
- Deep dyspareunia (pain during intercourse)
- Abnormal vaginal bleeding (intermenstrual or post-coital)
- Fever, chills, malaise (less common)
- Cervical motion tenderness on bimanual examination
- Adnexal tenderness on bimanual examination
- Lower abdominal tenderness on palpation
Risk factors
- Untreated Gonorrhoea or Chlamydia
- Multiple sexual partners
- Young age at first intercourse
- History of PID or other STIs
- Recent IUD insertion
- Douching
Diagnosis
Clinical assessment
Clinical diagnosis based on presence of lower abdominal pain/tenderness, cervical motion tenderness, and adnexal tenderness in a sexually active woman, often with supporting symptoms like abnormal discharge. High index of suspicion needed.
Investigations
- Pregnancy test (rule out ectopic pregnancy)
- Vaginal/cervical swabs (Microscopy, Gram stain, Gonorrhoea/Chlamydia testing - NAAT preferred)
- Complete Blood Count (CBC)
- Erythrocyte Sedimentation Rate (ESR) / C-Reactive Protein (CRP)
- HIV testing, Syphilis testing
- Pelvic ultrasound (may show tubo-ovarian abscess, thickened tubes)
- Laparoscopy (definitive diagnosis, rarely needed)
Diagnostic criteria
Minimum criteria usually include uterine/adnexal tenderness or cervical motion tenderness. Additional criteria support diagnosis (fever, abnormal discharge, elevated ESR/CRP, documented GC/Chlamydia).
Management
Non-pharmacological management
- Refer to detailed PID management guidelines (e.g., UCG Section 14.1.2).
- Partner notification and treatment is crucial.
- Advise rest.
- Advise abstinence or condom use.
Pharmacological treatment
- Requires broad-spectrum antibiotic coverage for likely pathogens (Gonorrhoea, Chlamydia, anaerobes, Gram-negatives).
- Outpatient regimens often involve Ceftriaxone IM + Doxycycline PO +/- Metronidazole PO.
- Inpatient regimens used for severe cases, pregnancy, suspected abscess, or failure of outpatient therapy (e.g., IV Cefoxitin/Cefotetan + IV Doxycycline; or IV Clindamycin + IV Gentamicin).
- Specific regimens and durations detailed in Obs/Gynae guidelines (e.g., UCG 14.1.2).
Monitoring
Clinical improvement should be seen within 72 hours. Follow-up essential to ensure resolution and assess for complications.
Complications
- Tubo-ovarian abscess
- Chronic pelvic pain
- Infertility (due to tubal scarring)
- Ectopic pregnancy (increased risk)
- Fitz-Hugh-Curtis syndrome (perihepatitis)
Prevention
- Consistent and correct condom use
- Prompt diagnosis and treatment of STIs (especially Gonorrhoea/Chlamydia)
- Partner notification and treatment
- Regular screening for high-risk individuals
Patient education
- Explain PID and its potential long-term consequences (infertility, ectopic pregnancy).
- Stress importance of completing the full antibiotic course.
- Emphasize necessity of partner treatment.
- Advise abstinence until treatment complete for patient and partner(s).
- Discuss prevention strategies.
Uganda-specific notes
PID is a significant cause of morbidity. Treatment should adhere to national guidelines (UCG 14.1.2). Access to diagnostic tools like ultrasound or laparoscopy may be limited.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 3, Section 3.2.3 (Refers to Section 14.1.2)
- Uganda Clinical Guidelines (UCG) 2023
Chapter 14, Section 14.1.2 (Primary reference for detailed management)