OG27.3 | Pelvic Inflammatory Disease — Summary & Reflection

KEY TAKEAWAYS

Pelvic Inflammatory Disease — Summary

Aetiology: Polymicrobial ascending infection — STI pathogens (N. gonorrhoeae, C. trachomatis) initiate cervical breach; endogenous anaerobes and facultative flora amplify. ~30-40% cases: no STI pathogen isolated in upper tract.

Anatomical progression: Endocervicitis → endometritis → salpingitis → oophoritis → peritonitis → Fitz-Hugh-Curtis perihepatitis (4-14%).

Fitz-Hugh-Curtis syndrome: RUQ pain in context of PID — 'violin-string' perihepatic adhesions; always examine the pelvis in a young woman with RUQ pain.

Diagnosis (CDC 2021):
- Minimum criteria (start treatment): uterine tenderness OR adnexal tenderness OR CMT in at-risk woman — no lab confirmation needed
- Additional: fever, mucopurulent discharge, elevated WBC/CRP/ESR, positive NAAT
- Always exclude ectopic pregnancy (β-hCG mandatory)

Management:
- Outpatient: ceftriaxone 500 mg IM + doxycycline 100 mg BD × 14d + metronidazole 500 mg BD × 14d
- Inpatient A: cefoxitin IV + doxycycline; Inpatient B: clindamycin IV + gentamicin
- TOA: IV antibiotics; surgery if no improvement at 72 hours
- Partner treatment: mandatory within 60-day exposure window

Long-term consequences:
- Tubal infertility: 1 episode = 15-20%; 3+ episodes = >50%
- Ectopic pregnancy: 7-fold increased risk
- Chronic pelvic pain: ~18% after PID

REFLECT

The woman in the hook scenario had both PID and Fitz-Hugh-Curtis syndrome — her right upper quadrant pain was the clue that the infection had spread beyond the pelvis. Consider how you would communicate this diagnosis to a 24-year-old woman: you need to explain that she has a pelvic infection that was likely sexually transmitted, that her partner needs treatment, that she must use condoms in future, and that repeated episodes could affect her ability to have children. This conversation requires clinical accuracy, sensitivity about stigma, and clarity about the urgency of partner treatment. In a busy outpatient or emergency setting, how do you ensure this counselling actually happens and is not shortchanged for time? What systems (printed information, STI nurse counsellor, digital follow-up) could support this? Reflect on how your clinical communication can break the recurrence cycle.