On this page
Referral and warning signs
When to refer
Refer to HC4/Hospital for: Suspected ectopic pregnancy (EMERGENCY). Severe PID (high fever, signs of peritonitis, suspected abscess). Pregnancy with PID. Inability to tolerate oral medication. No clinical improvement after 48-72 hours of outpatient treatment. Diagnostic uncertainty.
Red flags
- Signs of shock or peritonitis (suggests ruptured ectopic or abscess).
- High fever.
- Inability to tolerate oral intake.
- Positive pregnancy test with abdominal pain.
- Palpable adnexal mass.
Signs and symptoms
- Lower abdominal pain (usually <2 weeks duration) - KEY SYMPTOM
- Vaginal discharge (may be smelly, purulent)
- Painful sexual intercourse (dyspareunia)
- Abnormal uterine bleeding
- Dysuria
- Fever
- Cervical motion tenderness on vaginal examination
- Adnexal tenderness on bimanual examination
- Severe signs: Palpable pelvic mass (tubo-ovarian abscess), signs of peritonitis (rebound tenderness)
Risk factors
- Previous PID infection
- Presence of bacterial vaginosis
- Multiple or new sexual partners
- History of STIs (patient or partner)
- History of abortion
- Young age (<25 years)
- Postpartum endometritis
- Intrauterine device (IUD) use (risk primarily around insertion)
Diagnosis
Clinical assessment
Clinical diagnosis based on presence of lower abdominal pain PLUS one or more of: cervical motion tenderness, uterine tenderness, or adnexal tenderness. Supporting criteria include fever, abnormal discharge, positive STI test. High index of suspicion needed, especially in young, sexually active women.
Differential diagnosis
- Ectopic pregnancy
- Threatened abortion
- Ovulation pain (Mittelschmerz)
- Acute appendicitis
- Complicated or twisted ovarian cyst
- Endometriosis
- Urinary tract infection
- Cervical cancer
Investigations
- Pregnancy test (URGENTLY exclude ectopic pregnancy).
- Speculum examination (assess cervix, discharge).
- Bimanual examination (assess for cervical motion, uterine, adnexal tenderness).
- Endocervical swab for Gram stain, Culture & Sensitivity (C&S) (Neisseria gonorrhoea), Chlamydia testing (if available).
- High Vaginal Swab (HVS) for microscopy (BV, Trichomonas, Candida).
- Ultrasound scan (if available): Useful for detecting tubo-ovarian abscess, free fluid, ruling out other pathology.
- HIV testing should be offered.
Diagnostic criteria
Minimum criteria: Lower abdominal pain + Cervical motion tenderness OR Uterine tenderness OR Adnexal tenderness. Additional criteria support diagnosis (fever, discharge, elevated ESR/CRP, documented GC/Chlamydia).
Management
Non-pharmacological management
- Abstain from sex or use barrier methods (condoms) during treatment.
- Avoid alcohol while taking Metronidazole.
- Advise on safer sex practices.
- Partner notification and treatment is crucial to prevent reinfection.
- IUD management: Need not be removed initially. If no clinical improvement in 48-72h, consider removal and alternative contraception.
Pharmacological treatment
- Outpatient Treatment (Mild/Moderate PID): (LOC: HC3)
- - Ceftriaxone 250 mg IM single dose (or Cefixime 400 mg PO single dose if Ceftriaxone unavailable)
- - PLUS Doxycycline 100 mg PO BID for 14 days
- - PLUS Metronidazole 400 mg PO BID for 14 days
- Inpatient Treatment (Severe PID, tubo-ovarian abscess, pregnant, unable to tolerate oral meds, no improvement on outpatient): (LOC: HC4)
- - Ceftriaxone 1 g IV daily
- - PLUS Metronidazole 500 mg IV Q8H
- - Continue IV until clinical improvement (e.g., 24-48h after fever subsides), then switch to complete 14-day course with oral Doxycycline + Metronidazole (as per outpatient regimen).
- Pregnancy: Replace Doxycycline with Erythromycin 500 mg PO QID for 14 days.
- Partner Management: Treat sexual partner(s) syndromically for urethral discharge (see STI chapter/guidelines).
Monitoring
Clinical review within 72 hours for outpatient treatment. Monitor for improvement in pain, tenderness, fever. If severe or not improving after 7 days on outpatient regimen, refer for inpatient management/ultrasound.
Complications
- Infertility (due to tubal damage/blockage)
- Ectopic pregnancy (increased risk)
- Chronic pelvic pain
- Tubo-ovarian abscess
- Perihepatitis (Fitz-Hugh-Curtis syndrome)
Prevention
- Consistent condom use.
- Limiting number of sexual partners.
- Early diagnosis and treatment of STIs in patient and partners.
- Screening for STIs in high-risk populations.
- Avoiding unsafe abortion practices.
Patient education
- Explanation of PID as an infection of the reproductive organs.
- Importance of completing the full 14-day antibiotic course.
- Need for partner treatment to prevent reinfection.
- Abstinence or condom use during treatment.
- Avoid alcohol with Metronidazole.
- Symptoms that require immediate return (worsening pain, fever).
- Long-term risks (infertility, ectopic pregnancy, chronic pain).
- Importance of safer sex practices.
- Offer HIV testing.
Uganda-specific notes
PID is common, often associated with STIs like Gonorrhoea and Chlamydia. Syndromic management approach often used due to limited diagnostics. High rates of infertility and ectopic pregnancy linked to untreated/recurrent PID. HIV co-infection common. Ensure partner treatment.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 14, Section 14.1.2
- Uganda Clinical Guidelines (UCG) 2023
Chapter 3, Section 3.2 (STI Syndromic Management relevant sections)