Pelvic inflammatory disease

Disease Description (Causes and Symptoms)

• Definition summary: Pelvic inflammatory disease (PID) is a condition in which an ascending infection occurs through the vagina and cervix, causing inflammation in the endometrium, fallopian tubes, ovaries, and pelvic peritoneal cavity.
• Main causes: Sexually transmitted pathogens, including Neisseria gonorrhoeae and Chlamydia trachomatis, are common. Other possible causes include intestinal gram-negative bacilli, anaerobic bacteria, mixed infections, and postpartum or post-curettage infections.
• Pathophysiology summary: Ascending bacterial infection damages the fallopian tube mucosa, causing inflammation, swelling, and adhesions. In severe cases, it can progress to fallopian tube obstruction, abscess (tubo-ovarian abscess), and peritonitis.
• Main symptoms: Pelvic or lower abdominal pain, cervical tenderness and severe pain with cervical movement (difficulty conceiving or cervical motion tenderness), abnormal vaginal discharge (increased amount or foul odor), fever, dyspareunia, and dysuria. Symptoms may be unclear in some mild cases.
• Risk of complications: Infertility due to fallopian tube obstruction, increased risk of ectopic pregnancy, chronic pelvic pain, tubo-ovarian abscess, and peritonitis or sepsis caused by abscess rupture.

Treatment Methods

• General principles: Begin empiric treatment with broad-spectrum antibiotics as early as possible to cover major pathogens, including gonorrhea, chlamydia, and anaerobic bacteria. The treatment plan varies depending on severity, pregnancy status, and the presence of an abscess.
• Standard example for outpatient (oral) treatment:
  • Ceftriaxone 500 mg IM once (1 g if body weight ≥150 kg) + Doxycycline 100 mg PO twice daily for 14 days
  • If anaerobic coverage is considered necessary, consider adding Metronidazole 500 mg PO twice daily for 14 days
• Standard examples for inpatient (intravenous) treatment:
  • Cefotetan 2 g IV q12 + Doxycycline 100 mg IV/PO twice daily
  • Or Cefoxitin 2 g IV q6–8 + Doxycycline
  • For severe cases or when surgical treatment is necessary, Clindamycin + Gentamicin or other agents may be used
• Tubo-ovarian abscess (TOA):
  • Small abscesses may resolve with antibiotic treatment.
  • If the abscess is large (usually >3–6 cm), the patient’s condition worsens clinically, or there is a risk of rupture, percutaneous drainage (aspiration) or surgery (laparoscopy/laparotomy) may be considered.
• Concurrent management:
  • Treatment of sexual contacts (simultaneous treatment of sexual contacts within the past 60 days is recommended)
  • Confirmation of pregnancy status (the recommended treatment and precautions differ during pregnancy)
  • Pain control (analgesics); hospitalization and fluid replacement if necessary
• Follow-up:
  • Check for symptom improvement within 48–72 hours. If symptoms worsen or do not respond, hospitalization and a change in treatment are necessary.
  • For chlamydia infection, a test-of-cure is recommended for pregnant women after treatment (3–4 weeks); retesting is recommended for nonpregnant women after 3 months.
• Lifestyle management and precautions:
  • Avoid sexual intercourse during treatment and until the partner has completed treatment
  • Take all prescribed antibiotics for the full prescribed duration
  • Seek medical attention immediately in case of fever, severe pain, vomiting, or sudden worsening of symptoms

Pre-Outpatient Visit Checkpoints (What to Bring and Example Questions)

• Items/materials to bring:
  • A list of current medications (including prescription and nonprescription drugs, herbal medicines, and supplements)
  • Information about medication allergies (especially to penicillins, cephalosporins, tetracyclines, etc.)
  • Recent sexual activity and number of partners, condom use, and possible exposure to sexually transmitted infections
  • Menstrual history (the first day of the last menstrual period) and whether pregnancy is possible
  • The timing and changes in symptoms (location and severity of pain, changes in discharge, fever, etc.)
  • Previous STI test results or imaging and blood test results, if available
• Checklist before an outpatient visit:
  • A urine pregnancy test may be performed (in the outpatient clinic) — pregnancy status needs to be confirmed
  • Confirm whether antibiotics have been taken recently
  • If possible, record notes or take pictures of the discharge (color, amount, and odor)
• Potential emergency signs (immediate ER visit required):
  • High fever (>38.5℃), persistent and severe abdominal pain, vomiting or dehydration, dizziness or fainting, or signs of peritoneal irritation (marked tenderness or rebound tenderness)

Examples of General Questions to Ask the Doctor

• "What are the major side effects of the antibiotics you prescribed?"
• "Once treatment begins, how quickly do symptoms usually improve?"
• "What additional tests should I undergo to prevent recurrence?"
• "How should my sexual partner be tested and treated? Until when should we avoid sexual intercourse?"
• "How do treatment options differ if pregnancy is possible?"

Examples of Disease-Specific Questions

• "What additional tests, such as hysterosalpingography, do you recommend to reduce the risk of infertility, and when would be the appropriate time to undergo them?"
• "Could my IUD (intrauterine device) be the cause? Can I keep the IUD in place during treatment?"