All sexually active women presenting with lower abdominal pain should be carefully evaluated for the presence of salpingitis and/or endometritis - pelvic inflammatory disease (PID). In addition, routine bimanual and abdominal examinations should be carried out on all women with a presumptive STI since some women with PID or endometritis will not complain of lower abdominal pain. Women with endometritis may present with complaints of vaginal discharge and/or bleeding and/or uterine tenderness on pelvic examination. Symptoms suggestive of PID include abdominal pain, dyspareunia, vaginal discharge, menometrorrhagia, dysuria, pain associated with menses, fever, and sometimes nausea and vomiting.

PID is difficult to diagnose because clinical manifestations are varied. PID becomes highly probable when one or more of the above symptoms are seen in a woman with adnexal tenderness, evidence of lower genital tract infection, and cervical motion tenderness. Enlargement or induration of one or both fallopian tubes, a tender pelvic mass, and direct or rebound tenderness may also be present. The patient's temperature may be elevated but is normal in many cases. In general, clinicians should err on the side of over-diagnosing and treating suspected cases.

Hospitalisation of patients with acute pelvic inflammatory disease should be seriously considered when:

• the diagnosis is uncertain;

• surgical emergencies such as appendicitis and ectopic pregnancy can not be excluded;

• a pelvic abscess is suspected;

• severe illness precludes management on an outpatient basis;

• the patient is pregnant;

• the patient is unable to follow or tolerate an outpatient regimen; or

• the patient has failed to respond to outpatient therapy. Many experts recommend that all patients with PID should be admitted to hospital for treatment.

Etiological agents include N. gonorrhoeae, C. trachomatis, anaerobic bacteria (Bacteroides spp. and Gram-positive cocci). Facultative Gram-negative rods and Mycoplasma hominis have also been implicated. As it is impossible to differentiate between these clinically, and a precise microbiological diagnosis is difficult, the treatment regimens must be effective against this broad range of pathogens. The regimens recommended below are based on this principle.

OUTPATIENT THERAPY

Recommended syndromic treatment

• single-dose therapy for uncomplicated gonorrhoea (see section 3.1- single-dose ceftriaxone has been shown to be effective; other single dose regimens have not been formally evaluated as treatments for PID)

PLUS

• doxycycline, 100mg orally twice daily, or tetracycline, 500mg orally, 4 times daily for 14 days

PLUS

• metronidazole, 400-500mg orally, twice daily for 14 days.

Note

• Patients taking metronidazole should be cautioned to avoid alcohol.

• Tetracyclines are contraindicated in pregnancy.

Alternative syndromic treatment where single dose therapy for gonorrhoea is not available

• trimethoprim (80mg)/sulfamethoxazole (400mg), 10 tablets orally once daily for 3 days, and then 2 tablets orally, twice daily for 10 days

PLUS

• doxycycline, 100mg orally, twice daily, or tetracycline, 500mg orally, 4 times daily for 14 days

PLUS

• metronidazole, 400-500mg orally, twice daily for 14 days.

Note

This regimen should only be used in areas where trimethoprim/sulfamethoxazole has been shown to be effective in the treatment of uncomplicated gonorrhoea. Patients taking metronidazole should be cautioned to avoid alcohol.

Adjuncts to therapy: removal of intrauterine device (IUD)

The IUD is a risk factor for the development of PID. Although the exact effect of removing an IUD on the response of acute salpingitis to antimicrobial therapy and on the risk of recurrent salpingitis is unknown, removal of the IUD is recommended soon after antimicrobial therapy has been initiated. When an IUD is removed, contraceptive counselling is necessary.

Follow-up

Outpatients with PID should be followed up after 72 hours and admitted if their condition has not improved.

INPATIENT THERAPY

Recommended syndromic treatment

1. ceftriaxone, 250mg by intramuscular injection, once daily

PLUS

• doxycycline, 100mg orally or by intravenous injection, twice daily, or tetracycline, 500mg orally 4 times daily

PLUS

• metronidazole, 400-500mg orally or by intravenous injection, twice daily, or chloramphenicol, 500mg orally or by intravenous injection, 4 times daily.

2. clindamycin, 900mg by intravenous injection, every 8 hours

PLUS

• gentamicin, 1.5 mg/kg by intravenous injection every 8 hours.

3. ciprofloxacin, 500mg orally, twice daily, or spectinomycin 1g by intramuscular injection, 4 times daily

PLUS

• doxycycline, 100mg orally or by intravenous injection, twice daily, or tetracycline, 500mg orally, 4 times daily

PLUS

• metronidazole 400-500mg orally or by intravenous injection, twice daily, or chloramphenicol, 500mg orally or by intravenous injection, 4 times daily.

Note

• For all three regimens, therapy should be continued until at least 2 days after the patient has improved and should then be followed by either doxycycline, 100mg orally, twice daily for 14 days, or tetracycline, 500mg orally, 4 times daily, for 14 days. Patients taking metronidazole should be cautioned to avoid alcohol. Tetracyclines are contraindicated in pregnancy.

FIGURE 9. LOWER ABDOMINAL PAIN