DERMATOLOGY: Pelvic inflammatory disease

In the right clinical topic?

Age from 13 years onwards

This PRODIGY topic is based on guidelines on the management of acute pelvic inflammatory disease from the Royal College of Obstetricians and Gynaecologists [RCOG, 2009], the British Association for Sexual Health and HIV [BASHH, 2011a], and the European guideline for the management of pelvic inflammatory disease [Ross et al, 2008].

This PRODIGY topic covers the management of acute pelvic inflammatory disease (PID).

This PRODIGY topic does not cover chronic PID, chronic pelvic pain, postpartum endometritis, or PID following childbirth.

There are separate PRODIGY topics on Bacterial vaginosis, Candida - female genital, Chlamydia - uncomplicated genital, and Trichomoniasis.

The target audience for this PRODIGY topic is healthcare professionals working within the NHS in England, and providing first contact or primary health care. Patient information from NHS Choices is intended to be printed and given to people with this condition or their carers.

How up-to-date is this topic?

Changes

Version 1.4, revision planned in 2013.

Last revised in August 2009

October 2011 — minor update. The dose of intramuscular ceftriaxone has been increased from 250 mg to 500 mg to reflect the reduced sensitivity of Neisseria gonorrhoeae to cephalosporins and the current UK treatment guidelines for uncomplicated gonorrhoea [BASHH, 2011b]. Issued in November 2011.

May 2011 — minor update. Expanded on the advice and management of sexual partner nodes to include new recommendations from the British Association for Sexual Health and HIV [BASHH, 2011a]. Also included two new randomized controlled trials that suggest that moxifloxacin monotherapy is therapeutically equivalent to other regimens in the treatment of uncomplicated pelvic inflammatory disease [Heystek and Ross, 2009;Judlin et al, 2010]. The 2010/2011 QIPP options for local implementation have been added to this topic [NPC, 2011]. Issued in June 2011.

February 2011 — minor update. The Medicines and Healthcare products Regulatory Agency (MHRA) has advised that moxifloxacin should be restricted to second-line use for the management of pelvic inflammatory disease, because of the increased risk of liver reactions and QT prolongation [MHRA, 2011]. Issued in February 2011.

August 2010 — updated to include oral cefixime 400 mg as a single dose as an alternative to the intramuscular ceftriaxone component of the recommended antibiotic regimens [HPA and Association of Medical Microbiologists, 2010]. The lower age limit for quinolone prescriptions has also been raised from 16 to 18 years. Issued in September 2010.

March to August 2009 — converted from PRODIGY guidance to PRODIGY topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence.

There are no major changes to the recommendations.

Previous changes

September 2008 — minor correction to the Changes section. Issued September 2008.

January to March 2006 — reviewed. Validated in June 2006 and issued in July 2006.

October 2005 — minor technical update. Issued in November 2005.

December 2002 — reviewed. Validated in March 2003 and issued in April 2003.

December 1999 — written. Validated in March 2000 and issued in May 2000.

Knowledge update

New evidence

Evidence-based guidelines

Evidence-based guidelines published since the last revision of this topic:

BASHH (2011) UK national guideline for the management of pelvic inflammatory disease 2011. British Association for Sexual Health and HIV.www.bashh.org [Free Full-text]

HTAs (Health Technology Assessments)

No new HTAs since 1 January 2009.

Economic appraisals

No new economic appraisals relevant to England since 1 January 2009.

Systematic reviews and meta-analyses

No new systematic review or meta-analysis since 1 January 2009.

Primary evidence

Randomized controlled trials published since the last revision of this topic:

Oaskeshott, P., Kerry, S., Aghaizu, A., et al. (2010) Randomised controlled trial of screening for Chlamydia trachomatis to prevent pelvic inflammatory disease: the POPI (prevention of pelvic infection) trial. BMJ 340(Apr 8), c1642. [Abstract] [Free Full-text]

Observational studies published since the last revision of this topic:

Nicholson, A., Rait, G., Murray-Thomas, T., et al. (2010) Management of first-episode pelvic inflammatory disease in primary care: results from a large UK primary care database. British Journal of General Practice 60(579), e395-e406. [Abstract]

New policies

No new national policies or guidelines since 1 January 2009.

New safety alerts

No new safety alerts since 1 January 2009.

Changes in product availability

No changes in product availability since 1 January 2009.

Goals and outcome measures

Goals

To recognize the condition promptly
To make an accurate assessment (for example of the severity of the illness)
To begin appropriate treatment in the primary care setting
To refer to secondary care or other specialist service as required
To provide appropriate advice to the woman

QIPP - options for local implementation

Non-steroidal anti-inflammatory drugs (NSAIDs)

Review the appropriateness of NSAID prescribing widely and on a routine basis. Older patients are at higher risk of both gastrointestinal and cardiovascular morbidity and mortality.
Co-prescribing NSAIDs with angiotensin converting enzyme inhibitors (ACE inhibitors) may pose particular risks to renal function; this combination should be especially carefully considered and regularly monitored if continued.
If initiating an NSAID is obligatory, use ibuprofen (1200 mg per day or less) or naproxen (1000 mg per day).
Review patients currently prescribed NSAIDs. If continued use is necessary, consider changing to ibuprofen (1200 mg per day or less) or naproxen (1000 mg per day).
Review and, where appropriate, revise prescribing of etoricoxib to ensure it is in line with MHRA and NICE guidance.
Co-prescribe a proton pump inhibitor with NSAIDs in accordance with NICE [NICE, 2008; NICE, 2009] .

[NPC, 2011]

Background information

What is it?

Pelvic inflammatory disease (PID) is a general term for infection of the upper genital tract. Infection spreads upwards from the endocervix causing one or more of the following [CDC, 2006; RCOG, 2009; BASHH, 2011a]:

Endometritis.
Salpingitis.
Parametritis.
Oophoritis.
Tubo-ovarian abscess.
Pelvic peritonitis.

What causes it?

Pelvic inflammatory disease (PID) is almost always a sexually transmitted disease.

PID develops in 10–45% of women with endocervical Neisseria gonorrhoeae infection and in 10–30% of women with endocervical Chlamydia trachomatisinfection [Utah Department of Health, 2008].
Very rarely, PID follows instrumentation of the uterus.

The commonest sexually transmitted organisms detected in PID are C trachomatis and N gonorrhoeae.

Organisms in normal vaginal flora (such as anaerobes, Gardnerella vaginalis, Haemophilus influenzae, enteric Gram-negative rods, and Streptococcus agalactiae) have also been implicated.
Other organisms associated with PID include cytomegalovirus, Mycoplasma hominis, Ureaplasma urealyticum, and Mycoplasma genitalium [Barrett and Taylor, 2005; CDC, 2006; RCOG, 2009; BASHH, 2011a].

How common is it?

The incidence of PID is unknown because of the difficulty in making a clinical diagnosis, and because pelvic inflammatory disease (PID) is often unrecognized if it presents atypically or is asymptomatic [Simms et al, 1999].
An Office of Population Censuses Survey (1991–1992) of 60 general practices in England and Wales showed that PID was diagnosed in 1.7% of GP attendances by women 16–46 years of age [Simms et al, 1999].

What are the complications?

Tubal infertility, ectopic pregnancy, and chronic pelvic pain are the main complications of pelvic inflammatory disease [Drife and Magowan, 2004].

Management

Which scenario?

Scenario: Diagnosis: covers the diagnosis of pelvic inflammatory disease (PID).
Scenario: Management: covers the management of acute PID.

Scenario: Diagnosis of pelvic inflammatory disease

How should I diagnose pelvic inflammatory disease?

A diagnosis of pelvic inflammatory disease (PID) should be made on clinical grounds.

Negative swab results do not rule out a diagnosis of PID.
Do not delay making a diagnosis and initiating treatment whilst waiting for the results of laboratory tests.

Ectopic pregnancy should be ruled out.
Suspect PID if any of the following symptoms are present:

Pelvic or lower abdominal pain (usually bilateral).
Deep dyspareunia particularly of recent onset.
Abnormal vaginal bleeding (intermenstrual, postcoital, or 'breakthrough') which may be secondary to associated cervicitis and endometritis.
Abnormal vaginal or cervical discharge as a result of associated cervicitis, endometritis, or bacterial vaginosis. This is often very slight and may be transient, especially with chlamydial infection.
Right upper quadrant pain due to peri-hepatitis (Fitz–Hugh–Curtis syndrome).

Peri-hepatitis occurs in 10–20% of women with PID.
It is characterized by the development of adhesions between the liver and the peritoneum, causing right upper quadrant pain.

On examination look for:

Lower abdominal tenderness — usually bilateral.
Adnexal tenderness (with or without a palpable mass), cervical motion tenderness, uterine tenderness (on bimanual vaginal examination).
Abnormal cervical or vaginal mucopurulent discharge (on speculum examination).
A fever of greater than 38°C, although the temperature is often normal.

Take endocervical swabs for gonorrhoea and chlamydia and a high vaginal swab. Consider taking blood for a white cell count, erythrocyte sedimentation rate (ESR), and C-reactive protein.

For more information see Investigations.

Basis for recommendation

Making a diagnosis of PID on history and examination alone

These recommendation are based on expert opinion in guidelines on the management of acute pelvic inflammatory disease (PID) from the Royal College of Obstetricians and Gynaecologists [RCOG, 2009], the British Association for Sexual Health and HIV [BASHH, 2011a], and guidelines from the Department of Health and Human Services Centres for Disease Control and Prevention [CDC, 2006].
Making an accurate clinical diagnosis of PID from the symptoms and signs has been described as 'little better than tossing a coin' [Ross, 2002] and clinicians should have a low threshold for initiating treatment.

Symptoms and signs for suspected PID lack sensitivity and specificity [RCOG, 2009]. The positive predictive value of making a clinical diagnosis of PID compared with a laparoscopic diagnosis (using laparoscopic diagnosis as the gold standard) is 65–90% [RCOG, 2009]. However, although used as the gold standard, laparoscopy may have a low sensitivity, as 15–30% of women with suspected PID have no signs of acute infection on laparoscopy even when organisms have been found in their fallopian tubes [RCOG, 2009].
The positive predictive value of a clinical diagnosis of PID also depends on epidemiological factors, including [CDC, 2006]:

The age of the woman (PID is more common in adolescents).
Whether the woman is attending a genito-urinary medicine clinic.
Whether the woman is in a setting where the rates of chlamydia, gonorrhoea, and bacterial vaginosis are high [BASHH, 2011a].

There is evidence from a large cross-sectional analysis that:

Adnexal tenderness has a high sensitivity for PID.
The finding most strongly associated with endometritis was a positive test result for Chlamydia trachomatis or Neisseria gonorrhoeae.

Endocervical and high vaginal swabs

The recommendation that all women with suspected PID should be tested for C. trachomatis and N. gonorrhoeae (in general by taking endocervical swabs) is based on expert opinion in guidelines from the Royal College of Obstetricians and Gynaecologists [RCOG, 2009], the British Association for Sexual Health and HIV [BASHH, 2011a], the European guideline for the management of pelvic inflammatory disease[Ross et al, 2008], and guidelines from the Department of Health and Human Services Centres for Disease Control and Prevention [CDC, 2006]. These are the most common sexually transmitted organisms detected in PID.
PRODIGY recommends taking a high vaginal swab to look for other vaginal infections such as bacterial vaginosis and candidiasis.

Erythrocyte sedimentation rate (ESR), C-reactive protein, and leucocyte count

Increased ESR, C-reactive protein, and leucocyte count supports the diagnosis of PID and can provide useful measures of disease severity[RCOG, 2009].
However, the ESR or C-reactive protein and white cell count may be normal in mild or moderate PID [Ross et al, 2008].

Who is at risk of developing pelvic inflammatory disease?

Risk factors for developing pelvic inflammatory disease include:

Factors related to sexual behaviour:

Young age (less than 25 years).
Early age of first coitus.
Multiple sexual partners.
Recent new partner (within the previous 3 months).
History of sexually transmitted infection in the woman or her partner.

Recent instrumentation of the uterus or interruption of the cervical barrier:

Termination of pregnancy.
Insertion of an intrauterine device (within the past 6 weeks).
Hysterosalpingography.
In vitro fertilization and intrauterine insemination.

Basis for recommendation

These recommendations are based on expert opinion in guidelines from the Royal College of Obstetricians and Gynaecologists [RCOG, 2009], the British Association for Sexual Health and HIV [BASHH, 2011a], the European guideline for the management of pelvic inflammatory disease[Ross et al, 2008], and a non-systematic review [Barrett and Taylor, 2005].

What else might it be?

Lower abdominal pain in a young woman may also be due to:

An ectopic pregnancy.
Threatened abortion.
Ruptured corpus luteal cyst.
Acute appendicitis:

Nausea and vomiting occur in most women with appendicitis, but in only 50% of women with pelvic inflammatory disease.
Cervical motion pain occurs in about 25% of women with acute appendicitis.

Endometriosis.
Gastrointestinal disorders (most commonly irritable bowel syndrome).
Complications of an ovarian cyst, such as rupture, torsion, or haemorrhage.
Urinary tract infection.
Functional pain (that is of unknown physical origin). There may be longstanding symptoms.
Mittelschmerz pain.

Basis for recommendation

What investigations should I do?

Do a pregnancy test if pregnancy is a possibility.
Take endocervical swabs for Chlamydia trachomatis and Neisseria gonorrhoeae.

If uncertain, confirm with the local laboratory which testing methods are available, the samples required, and how soon these should reach the laboratory.
In general, chlamydia should be tested for by taking endocervical samples, using nucleic acid amplification tests (NAATs). First-catch urine samples or vulvovaginal swabs may be accepted for NAAT testing by some laboratories.
Endocervical swabs for N. gonorrhoeae should be sent in transport medium to arrive at the laboratory for culture within 24 hours. NAATs may be used, but a positive NAAT should be confirmed using a second NAAT test with a different primer sequence, or with culture.
Adequate sample collection is important. When taking an endocervical swab, the swab should be inserted inside the cervical os and firmly rotated against the endocervix. Swabbing a collection of discharge will result in an inadequate specimen, so it is generally recommended that excess cervical secretions are cleaned away prior to taking the swab.
There is no need to take a urethral swab unless local guidelines suggest this.

If possible, look for endocervical or vaginal pus cells under a microscope on a wet-mount vaginal smear:

If absent, a diagnosis of pelvic inflammatory disease (PID) is unlikely.
Excess leucocytes are associated with PID but they are also found in women with lower genital tract infection.

Consider performing the following tests. If elevated they support the diagnosis of PID but are non-specific:

Erythrocyte sedimentation rate (ESR).
C-reactive protein.
Leucocyte count.

Basis for recommendation

Taking swabs for Chlamydia trachomatis and Neisseria gonorrhoeae

The recommendation that all women with suspected PID should be tested for C. trachomatis and N. gonorrhoeae is based on expert opinion in guidelines from the Royal College of Obstetricians and Gynaecologists [RCOG, 2009], the British Association for Sexual Health and HIV[BASHH, 2011a], the European guideline for the management of pelvic inflammatory disease [Ross et al, 2008], and guidelines from the Department of Health and Human Services — Centres for Disease Control and Prevention [CDC, 2006].

A positive result supports a diagnosis of PID and reinforces the need to treat sexual partners.
However, a negative result does not exclude PID [BASHH, 2011a].

Interpreting the results of a wet-mount smear

The absence of endocervical or vaginal pus cells suggests that the diagnosis is not PID. The negative predictive value for a diagnosis of PID is 95% (that is, 19/20 people who have a negative test result will not have the disease) [BASHH, 2011a; RCOG, 2009].
The presence of pus cells is a non-specific finding. The positive predictive value is low (that is, the proportion of people who have a positive test result and who have PID is only 17%) [RCOG, 2009; BASHH, 2011a].

Erythrocyte sedimentation rate (ESR), C-reactive protein, and leucocyte count

Increased ESR or C-reactive protein, and leucocytosis, all support the diagnosis of PID and can provide a useful measure of disease severity[RCOG, 2009].
However, the ESR, C-reactive protein, or white cell count may be normal in mild or moderate PID [Ross et al, 2008].

Scenario: Management of pelvic inflammatory disease

How should I manage someone with suspected PID?

Women with suspected mild or moderate pelvic inflammatory disease (PID) may be treated in primary care if an ectopic pregnancy can be ruled out.
Test for other sexually transmitted infections and other genital infections.

Refer the woman and her sexual partner(s) to a genito-urinary medicine or sexual health clinic to facilitate screening for infections (and contact tracing). Ideally the woman should be screened for other sexually transmitted diseases before commencing antibiotics so that a diagnosis can be made and is not compromised. However starting antibiotics is a priority if PID is suspected and should not be delayed whilst awaiting an appointment.

Provide pain relief with ibuprofen or paracetamol. If the response to either drug is insufficient consider:

Combining/alternating paracetamol and ibuprofen, or
Adding codeine to paracetamol or ibuprofen.

Start empirical antibiotics as soon as a presumptive diagnosis of PID is made clinically. Do not wait for swab results.

If the risk of gonococcal infection is low prescribe any of the following:

Ofloxacin 400 mg orally twice daily plus oral metronidazole 400 mg twice daily, both for 14 days. (Levofloxacin may be used as a more convenient alternative to ofloxacin).
Ceftriaxone 500 mg as a single intramuscular dose, followed by oral doxycycline 100 mg twice daily plus oral metronidazole 400 mg twice daily, both for 14 days.
Ceftriaxone 500 mg as a single intramuscular dose, followed by oral azithromycin 1 g per week for 2 weeks (there is less evidence to support this regimen).
Oral cefixime 400 mg as a single dose (off-label use) can be used as an alternative to ceftriaxone 500 mg in the above regimens.

If the risk of gonococcal infection is high (the woman's partner has gonorrhoea, her symptoms and signs are clinically severe, or she has had sexual contact whilst abroad) prescribe either of the following:

Ceftriaxone 500 mg as a single intramuscular dose, followed by oral doxycycline 100 mg twice daily plus oral metronidazole 400 mg twice daily, both for 14 days.
Cefixime 400 mg as a single oral dose (off-label use), plus oral doxycycline 100 mg twice daily and oral metronidazole 400 mg twice daily, both for 14 days.
Regimens containing ofloxacin or azithromycin are not recommended in people at high risk of gonococcal PID.
A regimen of metronidazole and doxycycline (without intramuscular ceftriaxone) is not recommended.

See Prescribing information for more information on the recommended antibiotics.

If there is a risk of a very early pregnancy (too early for a pregnancy test to be positive):

Offer paracetamol first line for analgesia. Ibuprofen is an alternative if paracetamol is ineffective but should only be used before 30 weeks gestation.
The risk of giving any of the recommended antibiotic regimens at this stage of pregnancy is low. If drug toxicity did occur at this stage of pregnancy, it would result in failed implantation. For a more detailed discussion of potential risks, see Basis for recommendation.
Admit women with a positive pregnancy test urgently.

Treat women who are infected with HIV the same treatment as women who are not infected. PID should be managed in conjunction with their HIV physician.

Basis for recommendation

Women with mild or moderate PID can be treated in primary care

There is evidence from a large randomized trial that women with mild-to-moderate PID can be safely treated at home. Outpatient and inpatient treatments are equally effective for women with clinically mild-to-moderate PID, and there is evidence that long-term reproductive outcomes are also similar.

Importance of excluding pregnancy

National guidance from the Royal College of Obstetrics and Gynaecology stresses the importance of excluding an ectopic pregnancy in all women suspected of having PID [RCOG, 2009].

Referral for contact tracing and screening

These recommendations are based on guidance from the Royal College of Obstetricians and Gynaecologists [RCOG, 2009] and the British Association for Sexual Health and HIV [BASHH, 2011a].

Analgesia

This recommendation is based on expert advice in the European guideline for the management of pelvic inflammatory disease [Ross et al, 2008]and the British Association for Sexual Health and HIV [BASHH, 2011a].

Importance of prompt treatment

It is likely that delaying treatment increases the risk of the PID becoming worse, and increases the risk of complications such as ectopic pregnancy, subfertility, or chronic pelvic pain occurring in the future [CDC, 2006; Ross, 2008; RCOG, 2009; BASHH, 2011a].

A low threshold for commencing an empirical antibiotic (that is, before the results of tests are available) is recommended because of the risk of serious complications if treatment is delayed. This is particularly important in women younger than 25 years of age because there is a higher incidence of PID in this age group.
Negative swabs do not exclude PID and should not necessarily influence the decision to treat.
There is limited evidence from a case-controlled study that fertility may be impaired and ectopic pregnancy may be more likely if treatment for acute pelvic inflammatory disease is delayed for 3 days or more after the onset of symptoms.

Recommended antibiotic regimens

The antibiotic regimens included are those which are practical for use in primary care (that is, they do not require intravenous antibiotics) and are recommended in guidelines produced by the Royal College of Obstetricians and Gynaecologists (RCOG) and the British Association for Sexual Health and HIV (BASHH) [RCOG, 2009; BASHH, 2011a].

These guidelines recognize that there is uncertainty about the optimum treatment regimen [RCOG, 2009] due to limited evidence from clinical trials. However, the recommended regimens are likely to be effective against the most likely pathogens involved (Chlamydia trachomatis, Neisseria gonorrhoeae,anaerobes).

There is a better evidence base for the use of cefoxitin than ceftriaxone but, as it is not easily available in the UK, intramuscular ceftriaxone is recommended in its place [RCOG, 2009; BASHH, 2011a]. The dose of ceftriaxone has been increased to 500 mg to reflect the reduced sensitivity of N gonorrhoeae to cephalosporins and the current UK treatment guidelines for uncomplicated gonorrhoea [BASHH, 2011b].
Metronidazole is included in the intramuscular ceftriaxone plus oral doxycycline regimen to improve coverage for anaerobic bacteria. However, anaerobic bacteria are of more importance in women with severe PID so metronidazole may be stopped in women with mild or moderate PID who cannot tolerate it [BASHH, 2011a].
Ofloxacin, moxifloxacin and azithromycin should be avoided in women at high risk of gonorrhoea because of increasing resistance in the UK [BASHH, 2005; BASHH, 2011a].
Levofloxacin is the L isomer of ofloxacin and may be used as a more convenient alternative to ofloxacin (500 mg once daily for 14 days) [BASHH, 2011a].

Although PID presenting in primary care may be less severe than in other settings, there is no published evidence to support the use of less intensive regimens.

Recent guidance from the RCOG and BASHH recommends the combination of intramuscular ceftriaxone and oral azithromycin but states that since clinical trial evidence for this regimen is limited, it should be reserved for when other regimens are not appropriate [RCOG, 2009; BASHH, 2011a]. There is limited evidence from two randomized controlled trials that azithromycin used alone or in combination with ceftriaxone is effective in the treatment of PID.

Oral cefixime as alternative to intramuscular ceftriaxone

Ceftriaxone is included in the regimen primarily to cover gonorrhoea but it is not always practical to administer ceftriaxone in primary care. A single dose of oral cefixime 400 mg (off-label use) is recommended by the Health Protection Agency, as an alternative to the intramuscular ceftriaxone component of the regimens for practical issues of administration in primary care [HPA and Association of Medical Microbiologists, 2010].
However, BASHH does not recommend replacing intramuscular ceftriaxone with an oral cephalosporin (such as cefixime) due to the lack of clinical trial evidence to support their use. There are reports of increased resistance of Neisseria gonorrhoeae to cephalosporins and a parenteral based regimen (when gonococcal PID is suspected) is thought to maximize tissue levels of the cephalosporin and overcome low level resistance [BASHH, 2011a].

Antibiotic regimens not recommended

A combination of metronidazole and doxycyline (without intramuscular ceftriaxone). Although this regimen has been recommended in the past and is still used in primary care it is not recommended in the guidelines produced by the British Association for Sexual Health and HIV or the Royal College of Obstetricians and Gynaecologists [RCOG, 2009; BASHH, 2011a]. Guidelines from the Royal College of Obstetricians and Gynaecologists state that there are no clinical trials adequately assessing the effectiveness of this regimen, and its use in isolation (that is, without intramuscular ceftriaxone) is not recommended [RCOG, 2009]. There is evidence from a retrospective study and a systematic review that metronidazole combined with doxycycline is not suitable for the treatment of acute PID in the UK. The addition of intramuscular ceftriaxone as an initial dose significantly improved the clinical cure rate in the one retrospective study [Piyadigamage and Wilson, 2005].
Azithromycin used alone (that is, without intramuscular ceftriaxone). Data supporting its use alone are limited and it is not recommended [RCOG, 2009].
BASHH recommend that oral moxifloxacin can be used alone in the treatment of PID as there is evidence from three randomized controlled trials that it has similar efficacy to a combination of ofloxacin and metronidazole. However, due to the increased risk of liver reactions and other serious adverse effects with moxifloxacin, it should only be used when other appropriate regimens are unsuitable or have failed [BASHH, 2011a].

PRODIGY does not recommend the use of oral moxifloxacin as it is a black triangle drug (under intensive surveillance by the Medicines and Healthcare products Regulatory Agency [MHRA]), and there are concerns that it may have similar issues with gonococcal resistance to ofloxacin. In addition, although moxifloxacin is now licensed for the treatment of PID, the MHRA has restricted its indications to second-line use when other medicines cannot be prescribed or have failed. This is because of an increased risk of life-threatening liver reactions and other serious risks associated with its use (such as prolongation of QT interval) [MHRA, 2008; MHRA, 2011 ].

Drug choice during very early pregnancy (before a positive pregnancy test)

Experience suggests that paracetamol can be used at any time during pregnancy or breastfeeding [NTIS, 2004; Schaefer et al, 2007].
The UK Teratology Information Service (UKTIS, formerly the National Teratology Information Service [NTIS]), reviewed safety data of NSAIDs from published research and postmarketing surveillance systems. They concluded that 'the available data do not indicate that exposure to ibuprofen before 30 weeks of pregnancy is associated with an increased risk of congenital defects or spontaneous abortions' [NTIS, 2004].
The Royal College of Obstetricians and Gynaecologists recommends that the risk of giving any of their recommended antibiotic regimens in very early pregnancy (before a positive pregnancy test) is low, since significant drug toxicity results in failed implantation [RCOG, 2009].

Ceftriaxone has not specifically been studied during pregnancy. However, the risk associated with use of cephalosporins during pregnancy is thought to be low and, although data are limited for individual agents such as ceftriaxone, the cephalosporins as a class are considered to be an appropriate choice during pregnancy [NTIS, 2008b]. Although ceftriaxone crosses the placental barrier, it has not been associated with adverse events on fetal development in laboratory animals [ABPI Medicines Compendium, 2009].
Doxycycline is contraindicated beyond the 15th week of gestation because, from the 16th week of pregnancy it causes tooth and bone discolouration and inhibits bone growth. However, it can be used in the first trimester. Inadvertent first-trimester use of tetracyclines occurs frequently and has not been associated with an increased risk of congenital malformations [Schaefer et al, 2007].
Metronidazole has been in clinical use for a long time, and experience suggests that it is not teratogenic in humans [Schaefer et al, 2007]. A recent prospective controlled study in 228 women exposed to metronidazole in pregnancy, 86% of whom had first trimester exposure, confirms these findings[Schaefer et al, 2007].
Ofloxacin has only limited pregnancy-exposure data. Quinolones have caused arthropathy in animal studies. However, a recent study (most of the data are on ciprofloxacin and norfloxacin, but some are on ofloxacin) did not find that quinolone use in the first trimester of pregnancy was associated with an increased risk of malformations or other adverse effects on pregnancy outcome [Schaefer et al, 2007].
There are fewer published data on the use of azithromycin rather than erythromycin during pregnancy and breastfeeding. The limited published data and follow-up data collected by the UK Teratology Information Service (UKTIS, formerly the National Teratology Information Service [NTIS]), do not demonstrate an increased risk of congenital malformations following exposure to azithromycin in human pregnancy [NTIS, 2008a].

Management of women with HIV

Women with HIV may experience more severe symptoms of PID, but will usually respond to the standard antibiotic regimens. No change in treatment from that recommended for women without HIV infection is required [BASHH, 2011a]. There is no evidence to suggest that HIV-positive women benefit from hospitalization or parenteral treatment [Sweet, 2009].

When should I seek specialist advice or admit urgently?

Admit urgently if:

Ectopic pregnancy cannot be ruled out.
Symptoms and signs are severe (such as nausea, vomiting, and a fever greater than 38°C).
There are signs of pelvic peritonitis.
A surgical emergency such as acute appendicitis cannot be ruled out.
The woman is pregnant.
A tubo-ovarian abscess is suspected.
The woman is unwell and there is diagnostic doubt.
The woman is unable to follow or tolerate an outpatient regimen.

Consider seeking specialist advice:

If the woman is immunocompromised (such as HIV, taking immunosuppressants).

Admission is required for women who have HIV only if they have clinically severe pelvic inflammatory disease (PID).
Discussion with a genito-urinary specialist or gynaecologist is advised if there is doubt regarding whether admission is necessary.

If peri-hepatitis (Fitz–Hugh–Curtis syndrome) is suspected.

Basis for recommendation

Urgent admission

These recommendations are based on expert opinion in guidelines from the Royal College of Obstetricians and Gynaecologists [RCOG, 2009], the British Association for Sexual Health and HIV [BASHH, 2011a], the European guideline for the management of pelvic inflammatory disease [Ross et al, 2008], and guidelines from the Department of Health and Human Services Centres for Disease Control and Prevention [CDC, 2006].

Pregnant women

If the pregnancy is intrauterine, then pelvic inflammatory disease (PID) is rare except in the case of septic abortion [RCOG, 2009].
The recommendation that pregnant women with PID should be admitted to hospital under the care of an obstetrician is based on expert opinion, as intravenous antibiotics are required because of the increased risk of maternal and fetal morbidity and pre-term delivery [CDC, 2006; Ross et al, 2008; RCOG, 2009; BASHH, 2011a].
Neonatal complications can occur as a result of perinatal transmission of infection, such as ophthalmia neonatorum (due to Chlamydia trachomatisor Neisseria gonorrhoeae infection) and chlamydial pneumonitis [Brocklehurst and Rooney, 1998].

Women with HIV

Women with HIV may experience more severe symptoms of PID. Expert opinion in guidelines from the Royal College of Obstetricians and Gynaecologists and the British Association for Sexual Health and HIV [RCOG, 2009; BASHH, 2011a] recommend that only women with severe disease should be admitted.

Suspected peri-hepatitis

Guidelines from the Royal College of Obstetricians and Gynaecologists and the British Association for Sexual Health and HIV [RCOG, 2009; BASHH, 2011a] state that although laparoscopic division of adhesions is sometimes performed, there is insufficient trial evidence to make any recommendations other than giving the usual treatment for PID. PRODIGY therefore recommends seeking specialist advice if peri-hepatitis is suspected.

What advice should I give?

Explain:

The importance of completing the course of antibiotics (even if swabs are negative) in order to reduce the risk of long-term complications such as infertility, ectopic pregnancy, and chronic pelvic pain.

The exception to this is if the woman has mild or moderate pelvic inflammatory disease (PID) and is unable to tolerate metronidazole. She may stop taking the metronidazole but must continue with the other antibiotics in the regimen.

That after treatment fertility is usually maintained but there is still a risk of future long-term complications such as infertility, ectopic pregnancy, and chronic pelvic pain. Severe cases of PID are associated with a greater risk of these complications.
The importance of screening for sexually transmitted infections.
The need for contact tracing, and screening and treatment of sexual partners to prevent reinfection.
The need to use a barrier method of contraception (such as a condom) until both the woman and her partner(s) have completed treatment.
That future use of a barrier method of contraception will greatly reduce the risk of reinfection.
That repeated episodes of PID are associated with an exponential increase in the risk of infertility.

Basis for recommendation

These recommendations are based on expert advice in guidelines from the Royal College of Obstetricians and Gynaecologists, the British Association for Sexual Health and HIV [BASHH, 2011a], and the European guideline for the management of pelvic inflammatory disease [Ross et al, 2008].

Complications of pelvic inflammatory disease (PID)

Tubal infertility:

There is evidence from prospective cohort studies that the risk of infertility is related to the number of episodes of pelvic inflammatory disease (PID) and their severity: 0.6% of women had tubal-factor infertility after an episode of mild PID, and 21.4% of women had tubal-factor infertility after an episode of severe PID.

The risk of ectopic pregnancy is increased ten-fold after one episode of PID [Oakeshott, 2003].
Estimates vary but chronic pelvic or abdominal pain (lasting for more than 6 months) develops in 18% of women who have had PID [Drife and Magowan, 2004]. There is evidence from a large randomized trial of 831 women who have had an episode of mild-to-moderate PID that chronic pelvic pain may be present in 34% of women at a mean follow up of 35 months [Ness et al, 2002].
About a third of women have repeated infections [Drife and Magowan, 2004].

Discontinuation of metronidazole if it is not tolerated

Although anaerobes may have a role in the pathogenesis of PID, they are probably of more importance in women who have severe PID. Expert opinion in guidelines from the Royal College of Obstetricians and Gynaecologists [RCOG, 2009], the British Association for Sexual Health and HIV[BASHH, 2011a], and the European guideline for the management of pelvic inflammatory disease [Ross et al, 2008], based on studies which have not included metronidazole but have had good outcomes, is that if the PID is not severe and metronidazole is not tolerated then it may be stopped.

Referral for contact tracing and screening

These recommendations are based on expert opinion in guidelines from the Royal College of Obstetricians and Gynaecologists [RCOG, 2009] and the British Association for Sexual Health and HIV [BASHH, 2011a].

Avoiding unprotected sexual intercourse

These recommendations are based on expert opinion in guidelines from the Royal College of Obstetricians and Gynaecologists [RCOG, 2009] and the British Association for Sexual Health and HIV [BASHH, 2011a].

How should I manage sexual partners?

Ideally, current partners and recent partners (within the last 6 months) should be seen in a genito-urinary medicine (GUM) clinic, or primary care facility with equivalent expertise, for screening, treatment, and contact tracing.

Partners may need to be managed in primary care if they refuse or are unable to attend a GUM clinic, or if there is likely to be an unacceptable delay in accessing specialist services.

Screen for chlamydia and gonorrhoea. Whilst awaiting the results, offer the woman and her partner(s) empirical treatment with a broad spectrum antibiotic such azithromycin (1 gram, single dose).

If chlamydia or gonorrhoea is diagnosed in the partner(s), treat both the partner(s) and the woman appropriately.
If it is not possible to adequately screen the partner(s) for gonorrhoea, additional treatment with a specific antibiotic effective against Neisseria gonorrhoeae (such as a single intramuscular dose of ceftriaxone 250 mg) should be given.
For more information, see the PRODIGY topics on Chlamydia - uncomplicated genital and Gonorrhoea.

Advise sexual abstinence until both the woman with pelvic inflammatory disease and her partner(s) have completed the course of treatment. A barrier method is recommended if sexual intercourse cannot be avoided.

Basis for recommendation

These recommendations are based on expert opinion in guidelines from the Royal College of Obstetricians and Gynaecologists [RCOG, 2009] and the British Association for Sexual Health and HIV (BASHH)[BASHH, 2011a].

Broad spectrum empirical treatment whilst awaiting results for gonorrhoea and chlamydia testing.

BASHH recommend that broad spectrum empirical treatment should also be offered to male partners because many cases of pelvic inflammatory disease (PID) are not associated with gonorrhoea or chlamydia.

What follow up should I arrange?

Review within 72 hours.

There should be demonstrable clinical improvement (such as a reduction in abdominal tenderness, and a reduction in uterine, adnexal, and cervical motion tenderness).
If there has been little or no improvement, consider admitting to hospital or review the diagnosis.
Check the antibiotic sensitivities from swab results. Even if swabs are negative, treatment should be continued.
If metronidazole is not tolerated it may be discontinued in women with mild or moderate pelvic inflammatory disease (PID) as it has uncertain efficacy in this group.

Consider further review at about 4 weeks in order to:

Check compliance with, and response to, treatment.
Confirm that sexual contacts have been screened and treated.
Discuss the potential sequelae of PID.

Tests of cure are only necessary if:

Symptoms persist after treatment.
Antibiotic resistance is likely (particularly in cases of gonorrhoea).
Poor compliance with treatment is suspected, or the treatment has not been tolerated.
There is a possibility of reinfection (that is, further contact with untreated partners).
Sensitivity testing has not been undertaken or has indicated resistance.

Basis for recommendation

Admission, if the woman is failing to improve

Failure to improve substantially after 72 hours suggests a need for further investigation, intravenous therapy, or surgical intervention [BASHH, 2011a].

Discontinuation of metronidazole if it is not tolerated

Although anaerobes may have a role in the pathogenesis of pelvic inflammatory disease (PID), they are probably of more importance in women who have severe PID. Expert opinion in guidelines from the Royal College of Obstetricians and Gynaecologists [RCOG, 2009], the British Association for Sexual Health and HIV [BASHH, 2011a], and the European guideline for the management of pelvic inflammatory disease [Ross et al, 2008], based on studies which have not included metronidazole but have had good outcomes, suggests that if the PID is not severe and metronidazole is not tolerated then it may be stopped.

How should I manage a woman who has an intrauterine device in situ?

Consider removing any contraceptive intrauterine device (IUD) in women presenting with pelvic inflammatory disease (PID), after discussion with the woman.

Experts agree that the device should be removed if the woman wishes removal or if symptoms have not resolved within 72 hours.
Evidence is limited and expert opinion is divided over whether it is necessary to remove the IUD at the initial presentation.

If a decision is made to remove the IUD, ask if the woman has had sexual intercourse within the last 7 days and consider offering emergency hormonal contraception. For more information see the PRODIGY topic on Contraception - emergency.
If the woman develops pelvic pain and has had actinomyces-like organisms (ALOs) identified on a smear in the past:

Take endocervical swabs, and
Urgently seek specialist advice regarding treatment.
Consider removal of the IUD.

Basis for recommendation

Removal of an intrauterine device (IUD)

Evidence on whether or not to remove an intrauterine device in a woman who has pelvic inflammatory disease is limited and conflicting. There are no long term data on the effects on fertility.
Expert opinion differs regarding women with pelvic inflammatory disease (PID) who have an IUD:

Expert advice in the Faculty of Sexual and Reproductive Healthcare clinical guideline on intrauterine contraception does not routinely recommend the removal of an IUD. The Faculty's Clinical Effectiveness Unit supports the continued use of intrauterine contraception and appropriate antibiotic treatment if PID is suspected; there is no need to remove the IUD unless symptoms fail to resolve within 72 hours or the woman wants it removed [FFPRHC, 2006;FSRH, 2007].
Expert opinion in guidelines on the management of acute PID from the Royal College of Obstetricians and Gynaecologists [RCOG, 2009] advises that consideration be given to removing the IUD especially if symptoms have not resolved within 72 hours.
The British Association for Sexual Health and HIV recommend considering removing the IUD if the woman develops PID. They advise balancing the decision to remove the IUD against the risk of pregnancy if the woman has had sexual intercourse in the preceding 7 days [BASHH, 2011a].
Selected practice recommendations for contraceptive use from the World Health Organization state that [WHO, 2004]:

There is no need for removal of the IUD if the woman wishes to continue its use.
If the woman wishes removal, remove it after antibiotic treatment has been started.
If the infection does not improve then generally the course would be to remove the IUD and continue antibiotics. If the IUD is not removed then the antibiotic should be continued and the woman should be monitored closely.

Presence of actinomyces-like organisms (ALOs)

Expert opinion in guidelines from the Faculty of Sexual and Reproductive Healthcare is that [FSRH, 2007]:

The role of ALOs in infection in women using intrauterine contraception is unclear. Actinomyces israelii is a commensal organism in the female genital tract and although these organisms may be found on cervical smears or swabs, their presence is not diagnostic or predictive of disease. Therefore, there is no need to remove an IUD if the woman does not have symptoms.
If PID is suspected in a woman who has a history of ALOs on a cervical smear, it is important to consider that the infection may be due to other organisms.
It may be appropriate to remove the IUD.

What contraceptive advice should I give?

Women who have a history of, or currently have, pelvic inflammatory disease (PID) may use the following contraceptive methods (UK Medical Eligibility Criteria [UKMEC] category 1, that is, a condition for which there is no restriction for the use of the contraceptive method):

Combined oral contraceptive (COC) pill.
Progestogen-only pill.
Depot progestogen injection.
Progesterone-only contraceptive implant.

For women with a history of PID who wish to have an intrauterine device (IUD) fitted:

Explain that the relative risk of PID is increased six-fold in the 20 days following insertion, but that the absolute risk remains low (approximately 1%). After this time, the risk is the same as the population without an IUD and remains low unless there is exposure to sexually transmitted infection (STI).
If the woman has had a subsequent pregnancy, there are no restrictions on the use of both the copper IUD and the levonorgestrel intrauterine system (LNG-IUS) (UKMEC category 1).
If the woman has not had a subsequent pregnancy, the benefit of using either the copper IUD or the LNG-IUS generally outweighs the theoretical or proven risks (UKMEC category 2, that is, a condition where the advantages of using the method generally outweigh the theoretical or proven risks).
Test for the following infections a few days before IUD insertion to allow infection to be treated before or at the time of insertion:

Chlamydia trachomatis in women at risk of STIs.
Neisseria gonorrhoeae in women at risk or STIs from areas where gonorrhoea is prevalent.
All STIs, if this is requested by the woman.
Consider taking a high vaginal swab to test for other vaginal infections.

Give prophylactic antibiotics before IUD insertion if testing for STIs is not possible or has not been completed.

There is no consensus about which antibiotic regimen to use. Choose a regimen (seeking specialist advice where appropriate) that will treat chlamydia infection and that will also treat gonorrhoea if local prevalence is high.

If the woman currently has PID, an IUD should not be inserted as there is an unacceptable health risk (UKMEC category 4, that is, a condition which represents an unacceptable health risk if the contraceptive method is used).
If the woman requires sterilization:

A pelvic examination should be done to rule out recurrent or persistent PID and to determine the mobility of the uterus.
Provided there is no current PID, and if the woman has had a subsequent pregnancy, there are no medical reasons to deny sterilization.
If the woman has not had a subsequent pregnancy or has current PID, provide an alternative form of contraception until she can be fully assessed. At operation, it may be difficult to localize the tubes due to pelvic adhesions.

Women should be advised to use a barrier method of contraception to protect against STIs.

Basis for recommendation

Choice of contraception

These recommendations are based on the UK Medical Eligibility Criteria (UKMEC) for contraceptive use [FFPRHC, 2006] and a guideline from the Faculty of Sexual and Reproductive Healthcare [FSRH, 2007].

Intrauterine device (IUD)

A review of the World Health Organization's experience of pelvic inflammatory disease (PID) associated with IUD use from around the world included 12 randomized studies and one non-randomized study, and found that [FSRH, 2007]:

Amongst 22,908 IUD insertions and during 51,399 woman-years of follow up, the overall rate of PID was 1.6 cases per 1000 years of use.
The risk of PID was six-fold higher during the 20 days after IUD insertion than during later times.

Testing for bacterial vaginosis

PRODIGY recommends taking a high vaginal swab to look for other vaginal infections such as bacterial vaginosis.

Recommendation on antibiotic prophylaxis

The recommendation to test for sexually transmitted infections (STIs), or prescribe prophylactic antibiotics if testing for STIs is not possible or has not been completed, before IUD insertion is based on expert opinion in guidelines from the National Institute for Health and Clinical Excellence[NICE, 2005] and the Faculty of Sexual and Reproductive Healthcare [FSRH, 2007] as the risk of PID following insertion of an IUD where infection is present is unknown.

Both guidelines recommend testing for STIs and prescribing prophylactic antibiotics if testing for STIs is not possible or has not been completed before an IUD is inserted in women at increased risk of STIs. Woman who have a history of PID are at increased risk of STIs.

However, there is good evidence from a Cochrane systematic review that the use of doxycycline or azithromycin orally before IUD confers little benefit even in populations with a high prevalence of STIs.

Sterilization

These recommendations are based on the UKMEC for contraceptive use [FFPRHC, 2006].

Protection against STIs

Evidence supports the use of male or female condoms to reduce the risk of several sexually transmitted infections (STIs). For more information see the PRODIGY topics on Contraception - assessment and Contraception - barrier methods and spermicides. However, even with consistent and correct use, infections may still (rarely) be transmitted [FFPRHC, 2007].

What investigations and treatments are available in secondary care?

In secondary care, investigations that might be considered to help make a diagnosis of pelvic inflammatory disease (PID) include:

Transvaginal ultrasound scanning supported by power Doppler. This can identify inflamed and dilated tubes and tubo-ovarian masses, especially when there is diagnostic difficulty. However, similar changes may occur in endometriosis or early ectopic pregnancy.
Magnetic resonance imaging and computerized tomography.
Laparoscopy with direct visualization of the fallopian tubes. This is an invasive procedure and is not routinely used in clinical practice.
Endometrial biopsy.

Surgical management may include:

Laparoscopy: division of adhesions and drainage of pelvic abscesses may help early resolution.
Ultrasound-guided aspiration of pelvic fluid collections.
Adhesiolysis if there is peri-hepatitis.

Basis for recommendation

Other investigations in secondary care

Transvaginal ultrasound is most useful in detecting large tubal swellings or fluid collections which only occur in women with severe pelvic inflammatory disease (PID) in whom irreversible tubal damage may already have occurred [Ross, 2003]. Power Doppler ultrasound is able to detect changes in blood flow associated with the hyperaemia that occurs with tubal inflammation [Ross, 2003].
The recommendation that transvaginal ultrasound scanning supported by power Doppler may be helpful is based on expert opinion in a guideline from the Royal College of Obstetricians and Gynaecologists who also commented that there is limited evidence that magnetic resonance imaging and computerized tomography can assist in making a diagnosis [RCOG, 2009].
Laparoscopy may provide information on the severity of the condition. However there is potential difficulty in identifying mild intra-tubal inflammation or endometritis and there is diagnostic variability between clinicians [Ross, 2003; RCOG, 2009; BASHH, 2011a].
Endometrial biopsy may be helpful, but there is insufficient evidence to support its routine use [Ross et al, 2008].

Surgical treatment

These recommendations are based on expert opinion in guidelines from the Royal College of Obstetricians and Gynaecologists and the British Association for Sexual Health and HIV [RCOG, 2009; BASHH, 2011a].
The British Association for Sexual Health and HIV [BASHH, 2011a] comment that although it is possible to perform adhesiolysis in women with peri-hepatitis there is no evidence that this is superior to antibiotic treatment alone.

Prescriptions

For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).

Antibiotics

Age from 13 years onwards

Multi-therapy: Ceftriaxone injection + doxycycline + metronidazole

Ceftriaxone injection: 500mg single dose

Ceftriaxone 250mg powder for solution for injection vials

Reconstitute the contents of two vials and give a single dose of 500mg by intramuscular injection.

Supply 2 250mg vial.

Age: from 13 years onwards

NHS cost: £4.80

Licensed use: no - off-label dose

Doxycycline capsules: 100mg twice a day for 14 days

Doxycycline 100mg capsules

Take one capsule twice a day for 14 days.

Supply 28 capsules.

Age: from 13 years onwards

NHS cost: £1.94

Licensed use: off-label duration

Metronidazole tablets: 400mg twice a day for 14 days

Metronidazole 400mg tablets

Take one tablet twice a day for 14 days.

Supply 28 tablets.

Age: from 13 years onwards

NHS cost: £1.63

Licensed use: yes

Multi-therapy: Ceftriaxone injection + azithromycin

Ceftriaxone injection: 500mg single dose

Ceftriaxone 250mg powder for solution for injection vials

Reconstitute the contents of two vials and give a single dose of 500mg by intramuscular injection.

Supply 2 250mg vial.

Age: from 13 years onwards

NHS cost: £4.80

Licensed use: no - off-label dose

Azithromycin capsules: 1 gram single dose

Azithromycin 250mg capsules

Take four capsules as a single dose.

Supply 4 capsules.

Age: from 13 years onwards

NHS cost: £9.64

Licensed use: no - off-label indication

Multi-therapy: Cefixime + doxycycline + metronidazole

Cefixime tablets: 400mg single dose

Cefixime 200mg tablets

Take two tablets as a single dose.

Supply 2 tablets.

Age: from 13 years onwards

NHS cost: £3.78

Licensed use: no - off-label indication

Doxycycline capsules: 100mg twice a day for 14 days

Doxycycline 100mg capsules

Take one capsule twice a day for 14 days.

Supply 28 capsules.

Age: from 13 years onwards

NHS cost: £1.94

Licensed use: off-label duration

Metronidazole tablets: 400mg twice a day for 14 days

Metronidazole 400mg tablets

Take one tablet twice a day for 14 days.

Supply 28 tablets.

Age: from 13 years onwards

NHS cost: £1.63

Licensed use: yes

Multi-therapy: Cefixime + azithromycin

Cefixime tablets: 400mg single dose

Cefixime 200mg tablets

Take two tablets as a single dose.

Supply 2 tablets.

Age: from 13 years onwards

NHS cost: £3.78

Licensed use: no - off-label indication

Azithromycin tablets: 1g once a week for 2 weeks

Azithromycin 500mg tablets

Take two tablets as a single dose once a week for 2 weeks.

Supply 4 tablets.

Age: from 13 years onwards

NHS cost: £9.86

Licensed use: no - off-label dose

Age from 18 years onwards

Multi-therapy: Ofloxacin + metronidazole

Ofloxacin tablets: 400mg twice a day for 14 days

Ofloxacin 400mg tablets

Take one tablet twice a day for 14 days.

Supply 28 tablets.

Age: from 18 years onwards

NHS cost: £15.46

Licensed use: no - off-label dose

Metronidazole tablets: 400mg twice a day for 14 days

Metronidazole 400mg tablets

Take one tablet twice a day for 14 days.

Supply 28 tablets.

Age: from 18 years onwards

NHS cost: £1.63

Licensed use: yes

Analgesia: use when required

Age from 13 years onwards

Ibuprofen tablets: 200mg to 400mg three to four times a day

Ibuprofen 200mg tablets

Take one or two tablets 3 to 4 times a day when required for pain relief. Do not exceed the stated dose.

Supply 56 tablets.

Age: from 13 years onwards

NHS cost: £1.38

OTC cost: £2.38

Licensed use: yes

Paracetamol tablets: 500mg to 1g up to four times a day

Paracetamol 500mg tablets

Take one or two tablets every 4 to 6 hours when required for pain relief. Maximum of 8 tablets in 24 hours.

Supply 50 tablets.

Age: from 13 years onwards

NHS cost: £0.79

Licensed use: yes

Age from 18 years onwards

Codeine 30mg tablets: add on to paracetamol or NSAID if required

Codeine 30mg tablets

Take one or two tablets every 4 to 6 hours when required for pain relief. Maximum of 8 tablets in 24 hours.

Supply 28 tablets.

Age: from 18 years onwards

NHS cost: £1.22

Licensed use: yes

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this PRODIGY topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).

Antibiotics and oral hormonal contraception

Additional contraceptive precautions are not required during or after courses of doxycycline [FSRH, 2011].
However, women should be advised about the importance of correct contraceptive practice if they experience vomiting or diarrhoea. For further information, see the section on Antibiotics in the PRODIGY topic on Contraception - assessment.

Metronidazole and alcohol

Women should be warned that they might experience a reaction if they also take alcohol (such as flushing, nausea, headache, and dizziness). However, this disulfiram-like reaction is unpredictable, and some dispute its existence; the incidence of this reaction has been reported to be between 0% and 100% [Baxter, 2008].

Ofloxacin

Ofloxacin should be avoided where possible in young women when bone development is still occurring (although this recommendation is based on animal studies and no problems have been reported in humans) [RCOG, 2009].
Avoid giving ibuprofen to women with epilepsy taking the ofloxacin regimen. The combination of quinolones with nonsteroidal anti-inflammatory drugs (NSAIDs) can lower the seizure threshold.

Doxycycline

Advise women taking doxycycline to avoid exposure to direct sunlight or to sunlamps, because of the risk of photosensitivity reactions.

Evidence

Supporting evidence

Evidence on clinical findings associated with pelvic inflammatory disease

There is evidence from a large cross-sectional analysis that adnexal tenderness has a high sensitivity for pelvic inflammatory disease (PID) and that the finding most strongly associated with endometritis is a positive test result for Chlamydia trachomatis or Neisseria gonorrhoeae.

A cross-sectional analysis of 651 women enrolled in the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) study considered the clinical predictors of endometritis in women with PID [Peipert et al, 2001]:

Adnexal tenderness was found to have a high sensitivity (95%) but a low specificity (4%). This means that if this symptom was used alone then many women would be over-treated although it is unlikely many women with PID would be missed.
Combining symptoms (lower abdominal tenderness, adnexal tenderness, and cervical motion tenderness) lowers the sensitivity to 83% but improves the specificity (22%).
The finding most strongly associated with endometritis was a positive test result for Chlamydia trachomatis or Neisseria gonorrhoeae (adjusted odds ratio 4.3, 95% CI 2.89 to 2.63).
Women who had a high temperature as well as a high white cell count were at a significantly increased risk of endometritis (p < 0.001) but women with an elevated temperature alone at presentation were at significantly less risk of having endometritis, possibly because the elevated temperature was due to another cause (such as viral gastroenteritis) that did not increase the white cell count [Ross, 2002].

Evidence on prompt treatment of pelvic inflammatory disease

There is limited evidence from a case-control study that fertility may be impaired and ectopic pregnancy more likely if treatment for acute pelvic inflammatory disease (PID) is delayed for 3 days or more after the onset of symptoms.

A case-control study [Hillis et al, 1993] analysed data from a cohort of women who had one known episode of clinically recognizable PID. The study included women with either ectopic pregnancy or infertility (n = 76). The control group were women with intrauterine pregnancy (n = 367).

After adjustment for confounding factors, women who had sought care 3 days or more after developing lower abdominal pain were three times more likely to experience infertility or ectopic pregnancy than women who had sought care within 2 days of onset (odds ratio 2.6, 95% CI 1.2 to 5.9).

Evidence on treating women with mild or moderate pelvic inflammatory disease in primary care

There is very good evidence from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) randomized controlled trial that outpatient treatment of women with mild or moderate pelvic inflammatory disease (PID) is as effective as inpatient treatment. Short-term clinical outcomes were similar (such as symptom severity, adverse reactions) after 30 days. There was no significant difference in pregnancy rates, time to pregnancy, ectopic pregnancies, chronic pelvic pain, and recurrent pelvic inflammatory disease between the outpatient and inpatient groups at 35 months of follow up.

One randomized controlled trial (the PEACH study) [Ness et al, 2002] included 831 women with mild-to-moderate PID (excluding those with a tubo-ovarian abscess). Women were randomized to receive either one intramuscular dose of cefoxitin plus oral probenecid, followed by oral doxycycline as outpatients, or to receive inpatient treatment with parenteral antibiotics (intravenous cefoxitin and doxycycline).

At 30 days' follow up, outpatient and inpatient treatment regimens were not found to be significantly different with regard to:

Uterine or adnexal tenderness on bimanual pelvic examination (20.6% for outpatient treatment compared with 18.4% with inpatient treatment, p = 0.5).
Gonorrhoeal or chlamydial infection (gonorrhoeal infection 3.9% for outpatient treatment compared with 2.4% with inpatient treatment, p = 0.44; chlamydial infection 2.7% for outpatient treatment compared with 3.6% with inpatient treatment, p = 0.52).
Endometritis (45.9% with outpatient treatment compared with 37.6% with inpatient treatment, p = 0.09).
Adverse drug reactions (1.7% for outpatient treatment compared with 1.5% with inpatient treatment, p = 0.85).

At 35 months' follow up (n = 808), there was no significant difference between outpatient and inpatient treatment in terms of:

Pregnancy rates (42% compared with 41.7%, p = 1.0).
PID recurrence (12.4% compared with 16.6%, p = 0.11).
Chronic pelvic pain (33.7% compared with 29.8%, p = 0.27).
Infertility (18.4% compared with 17.9%, p = 0.85).
Ectopic pregnancy (1% compared with 0.3%, p = 0.37).

Evidence on antibiotic treatment of pelvic inflammatory disease

Only trials for antibiotic regimens that are practical for use in primary care and, at the time of writing, are likely to be effective against Chlamydia trachomatis, Neisseria gonorrhoeae, and anaerobes have been reviewed.

No randomized controlled trials comparing antibiotics with placebo or no treatment were found, probably because there is agreement that antibiotics are effective in women with pelvic inflammatory disease, and that studies would therefore be unethical.

Evidence on oral ofloxacin and metronidazole for pelvic inflammatory disease

There is good evidence from two systematic reviews that antibiotics are effective in the treatment of acute pelvic inflammatory disease (PID). It is not possible to determine the most effective regimen from the evidence but ofloxacin used alone and with metronidazole appears to be effective and has high clinical and microbiological cure rates.

A systematic review (search date: 2004, 34 RCTs, n = 3548) investigated the clinical effectiveness and cost effectiveness of antibiotic treatments for PID. Many of the trials in this review were small, open-label, and of poor methodological quality, and some included women with pelvic infections rather than PID. The review studied, in particular, the seven treatment regimens that were recommended (at the time the review was carried out) in the guideline for the management of PID from the Royal College of Obstetricians and Gynaecologists and by the British National Formulary [Meads et al, 2004].

One of the regimens relevant to primary care was oral ofloxacin combined with oral metronidazole. One small trial was found, and the review commented that the report on this trial was brief.

This trial compared intravenous and then oral ofloxacin and metronidazole with clindamycin plus gentamicin.
The cure rate was 15/15 for ofloxacin and 17/18 for clindamycin plus gentamicin.

A systematic review [Walker et al, 1993] included 34 trials on the treatment of women with PID. An update of this review (search date: 1997) [Walker et al, 1999] included an additional five studies (total 39 studies, 1925 women). Some of the trials were case-studies and the data were aggregated making it impossible to know how many of the trials were randomized and controlled.

Three trials were included on ofloxacin alone.

One inpatient trial (n = 36): clinical cure rate 100% and microbiological cure rate 97%.
Two outpatient trials (n = 165): clinical cure rate 95% and microbiological cure rate 100%.

Evidence on intramuscular ceftriaxone and oral doxycycline with or without metronidazole for pelvic inflammatory disease

There is evidence from two systematic reviews that intramuscular ceftriaxone or intramuscular cefoxitin (with or without probenecid) followed by oral doxycycline is effective in treating pelvic inflammatory disease (PID).

A systematic review (search date: 2004, 34 RCTs, n = 3548) investigated the clinical effectiveness and cost effectiveness of antibiotic treatments for PID. Many of the trials in this review were small, open-label, and of poor methodological quality and some included women with pelvic infections rather than just PID. The review studied in particular the seven treatment regimens that were recommended (at the time the review was carried out) in the guideline for the management of PID from the Royal College of Obstetricians and Gynaecologists and by the British National formulary [Meads et al, 2004]. Three of these regimens are suitable for use in primary care; the other four regimens involved intravenous antibiotics. The review looked for trials using:

Intramuscular ceftriaxone (or intramuscular cefoxitin with oral probenecid) or a third generation cephalosporin plus oral doxycycline.

Six trials (n = 641) undertaken between 1985 and 1997 were reported. No trials were found that included metronidazole (except for one of the trials in which some women received metronidazole). Intramuscular ceftriaxone (or intramuscular cefoxitin with oral probenecid) or a third generation cephalosporin plus oral doxycycline were compared with non-standard regimens: ciprofloxacin plus clindamycin (one trial); clindamycin plus tobramycin (two trials); clindamycin plus amikacin (one trial), and ofloxacin (two trials).
All showed no significant difference between cefoxitin, probenecid, and doxycycline compared with the comparative non-standard treatments.

Cefoxitin plus doxycycline.

Three trials (n = 216) took place in the 1980s and compared intravenous cefoxitin plus doxycycline (intravenous or oral) followed by oral doxycycline with clindamycin plus gentamicin. Clinical cure rates varied from 46–75% in the cefoxitin plus doxycycline group, and 52–87% in the clindamycin plus gentamicin group, but there was no significant difference between the groups.

A systematic review [Walker et al, 1993] included 34 trials on the treatment of women with PID. An update of this review (search date: 1997) [Walker et al, 1999] included an additional five studies (total 39 studies, 1925 women). Some of the trials were case studies and the data were aggregated making it impossible to know how many of the trials were randomized controlled trials. Trials that included doxycycline with either cefoxitin or ceftriaxone were categorized as either inpatient or outpatient trials:

Inpatient trials:

Cefoxitin plus doxycycline: eight trials (n = 427); clinical cure rate 91% and microbiological cure rate 98%.

Outpatient trials:

Cefoxitin, probenecid and doxycycline: three trials (n = 219); clinical cure rate 89% and microbiological cure rate 93%.
Ceftriaxone plus doxycycline: one trial (n = 64); clinical cure rate 95% and microbiological cure rate 100%.

Evidence on oral azithromycin and intramuscular ceftriaxone for pelvic inflammatory disease

There is limited evidence from two randomized controlled trials (RCTs) that azithromycin used alone or in combination with ceftriaxone is effective in the treatment of pelvic inflammatory disease (PID).

Two open-label, comparative, multicentre and multinational trials of women with PID confirmed by laparoscopy (n = 310) and requiring hospitalization for treatment, compared azithromycin alone, or azithromycin plus metronidazole, with either cefoxitin (plus probenecid, doxycycline and metronidazole), or co-amoxiclav plus doxycycline [Bevan et al, 2003].

The intention-to-treat analysis included 300 women and included data from all women who were recruited and who had undergone one pre-dosing, and at least one post-dosing, efficacy test. However the majority of the participants in the trial did not attend the two planned follow-up assessments.
All regimens had clinical cure rates of over 94%.
The eradication rate for the key pathogens at the end of treatment (day 13–18) was over 95% and at final follow up (day 35–44) was over 90% for all of the regimens.
The azithromycin regimens were well tolerated.
As data from two studies were combined it was not possible to determine the optimum dose of azithromycin.
These results should be interpreted with caution as the majority of those recruited did not attend all of the planned follow-up appointments, PID was confirmed laparoscopically in only 74.8% of participants, and there was a lack of clear outcome criteria.

An RCT included women with mild PID (n = 133) who were all given an intramuscular injection of ceftriaxone and then randomized to receive either doxycycline 200 mg daily for 2 weeks or azithromycin 1 g per week for 2 weeks as outpatients [Savaris et al, 2007].

Clinical cure was assessed on day 14.
Twenty-seven women were excluded from the analysis (13 were found not to have PID, 11 were lost to follow up, and 3 were intolerant of the antibiotic treatment).
Clinical cure rates in a modified intention-to-treat analysis were:

90.3% for azithromycin (56/62; 95% CI 0.80 to 0.96).
72.4% for doxycycline (42/58; 95% CI 0.58 to 0.82, p = 0.01).

Number needed to treat (NNT): six women had to be treated with azithromycin for one woman to benefit.
Combined with ceftriaxone, 1 g of azithromycin weekly for 2 weeks is an effective treatment for mild PID.

Evidence on oral metronidazole and doxycycline for pelvic inflammatory disease

There is evidence from a systematic review and a retrospective study that metronidazole combined with doxycycline is not suitable for the treatment of acute pelvic inflammatory disease (PID) in the UK. The addition of intramuscular ceftriaxone as an initial dose significantly improves the clinical cure rate.

A retrospective review of the case notes of 135 women with PID treated with oral doxycycline and metronidazole in Leeds in 2000 showed that the clinical cure rate was only 55% [Piyadigamage and Wilson, 2005].

Therefore, all women diagnosed with PID during a 6-month period in 2002 were treated with intramuscular ceftriaxone followed by a 2-week course of doxycycline and metronidazole.
Using intention-to-treat analysis, there was a significant improvement in cure rate in the group who had received intramuscular ceftriaxone compared with the group who had not (odds ratio 2.03, 95% CI 1.18 to 3.5, p = 0.009).

A systematic review [Walker et al, 1993] included 34 trials on the treatment of women with PID. An update of this review (search date: 1997) [Walker et al, 1999] included an additional five studies (total 39 studies, 1925 women). Some of the trials were case-studies and the data were aggregated making it impossible to know how many of trials were randomized and controlled.

Two trials were included on metronidazole and doxycycline.

Both were inpatient trials (n = 36). The clinical cure rate was 75% and the microbiological cure rate was 71%.

This review evaluated 10 inpatient and six outpatient treatment regimens. Only the doxycycline plus metronidazole regimen did not perform well. The clinical cure rate for the all of the other regimens was at least 88% and the microbiological cure rate was at least 95%.

Evidence on moxifloxacin for pelvic inflammatory disease

The British Association for Sexual health and HIV (BASHH) identified three randomized controlled trial which suggest that oral moxifloxacin has similar efficacy to other regimens in the treatment of uncomplicated pelvic inflammatory disease (that is, absence of pelvic or tubo-ovarian abscesses).

One study, a multinational, multicentre, prospective, randomized, double-blinded, parallel group, non-inferiority study, compared moxifloxacin alone with a combination of ofloxacin and metronidazole [Ross et al, 2006]. The women were randomized to receive a 14-day course of either moxifloxacin 400 mg daily (n = 384), or ofloxacin 400 mg twice daily combined with metronidazole 500 mg twice daily (n = 365).

Clinical resolution rates were similar in both groups for the per protocol population:

90.2% (248/275) for moxifloxacin and 90.7% (262/289) for ofloxacin plus metronidazole (95% CI –5.7 to +4.0) at 5–24 days post-therapy.
85.8% (236/275) for moxifloxacin and 87.9% (254/289) for ofloxacin plus metronidazole (95% CI –8.0 to +3.1) at 28–42 days post therapy.

Intention-to-treat analysis (n = 741) found clinical resolution rates:

At 5–24 days post-therapy of 75.7% (286/378) in the moxifloxacin group and 82.6% (300/363) in the ofloxacin and metronidazole group.
At 28–42 days post-therapy of 75.1% (284/378) in the moxifloxacin group and 81% (294/363) in the ofloxacin and metronidazole group.

Moxifloxacin was effective against:

Neisseria gonorrhoeae (100%, 13/13) compared with ofloxacin and metronidazole (81.2%, 18/22).
Chlamydia trachomatis (88.5%, 23/26) compared with ofloxacin and metronidazole (85.7%, 18/21).

Most adverse effects were mild and there were significantly fewer (p = 0.035) in the moxifloxacin group (179/378, 47.4%) compared with the ofloxacin and metronidazole group (200/363, 55.1%).
Moxifloxacin had similar efficacy to a combination of ofloxacin and metronidazole and had fewer adverse effects.

The second study, a multicentre, prospective, randomized, double-blinded study, compared moxifloxacin alone with a combination of doxycycline, metronidazole and ciprofloxacin [Heystek and Ross, 2009]. The women were randomized to receive a 14-day course of either moxifloxacin 400 mg daily (n = 343), or doxycyline 100 mg twice daily plus metronidazole 400 mg three times daily plus one single 500 mg ciprofloxacin dose (n = 326).

The overall clinical success rates (clinical cure and improvement combined) were similar for both the moxifloxacin and the doxycyline, metronidazole, and ciprofloxacin group in the per protocol population:

96.6% (224/232) for moxifloxacin and 98.0% (198/202) for doxycyline, metronidazole, and ciprofloxacin (95% CI –4.5 to +1.6) at 2-14 days post therapy.
93.8% (166/177) for moxifloxacin and 91.3% (147/161) for doxycyline, metronidazole, and ciprofloxacin (95% CI –3.8 to +7.4) at 21-35 days post therapy.

Intention-to treat analysis (n=686) found clinical success rates:

At 2–14 days post-therapy in 77.0% (264/343) of the moxifloxacin group and 76.7% (250/326) of the doxycyline, metronidazole, and ciprofloxacin group.
At 21–35 days post-therapy in 60.1% (206/343) of the moxifloxacin group and 58.6% (191/326) of the doxycyline, metronidazole, and ciprofloxacin group.

Moxifloxacin was effective against:

Neisseria gonorrhoeae (91.7%, 22/24) compared with doxycyline, metronidazole, and ciprofloxacin (90.0%, 18/20).
Chlamydia trachomatis (95.5%, 21/22) compared with doxycyline, metronidazole, and ciprofloxacin (89.5%, 17/19).

The adverse effects profile for both groups was very similar (p = 0.14 for any adverse effect). Of the moxifloxacin group, 44.0% (151/343) experienced an adverse effect, compared with 49.7% (162/326) of the doxycyline, metronidazole and ciprofloxacin group.
Moxifloxacin had similar efficacy to a combination of doxycyline, metronidazole and ciprofloxacin. The once-daily dosing regimen may also enhance patient compliance.

The final study (a multinational, multicentre, prospective, randomized, double-blinded, parallel group study) compared moxifloxacin alone with a combination of oral levofloxacin and metronidazole [Judlin et al, 2010]. The women were randomized to receive a 14-day course of either moxifloxacin 400 mg daily (n = 228), or levofloxacin 500 mg once daily combined with metronidazole 500 mg twice daily (n = 232). Women who tested positive for Neisseria gonorrhoeae (moxifloxacin group, n=5; levofloxacin and metronidazole group, n=2) were also given a single 250 mg dose of ceftriaxone.

Clinical cure rates in the levofloxacin plus metronidazole group were no better than those for moxifloxacin alone for the per protocol population (95% confidence interval [CI] -10.7 to +4.9; p = 0.460):

78.4% (152/194) for moxifloxacin and 81.6% (155/190) for levofloxacin plus metronidazole at 7–14 days post-therapy.

Intention-to-treat analysis (n = 460) had similar results:

71.5% (163/228) for moxifloxacin and 73.7% (171/232) for levofloxacin plus metronidazole at 7–14 days post-therapy.

Moxifloxacin was also non-inferior to levofloxacin plus metronidazole during treatment (day 4-7) and at follow up (28-42 days post-therapy), for both the per protocol and the intention-to-treat population.
Moxifloxacin was effective against:

Neisseria gonorrhoeae (100%, 4/4) compared with levofloxacin and metronidazole (50%, 1/2).
Chlamydia trachomatis (100%, 8/8) compared with levofloxacin and metronidazole (83.3%, 10/12).

Most adverse effects were of mild to moderate intensity, the two most common being nausea and dizziness. One serious drug-related adverse effect (Stevens-Johnson syndrome) was reported in the moxifloxacin group but this improved with treatment.

56.6% (129/228) of women in the moxifloxacin group experienced overall adverse effects compared with 56.9% (132/232) in the levofloxacin and metronidazole group.
46.5% (106/228) of women in the moxifloxacin group experienced drug-related adverse effects compared with 48.7% (113/232) in the levofloxacin and metronidazole group.

Moxifloxacin had similar efficacy to a combination of levofloxacin and metronidazole and had slightly fewer adverse effects.

Evidence on removal of an intrauterine device in a woman who has pelvic inflammatory disease

Evidence on whether or not to remove an intrauterine device in a woman who has pelvic inflammatory disease (PID) is limited and conflicting. There are no long term data on the effect on fertility.

A prospective study of 53 hospitalised women with an intrauterine device (IUD) and acute salpingitis investigated whether the IUD should be removed or left in position [Soderberg and Lindgren, 1981]. The diagnosis of acute salpingitis was based on acute pelvic pain, adnexal tenderness, and an increased erythrocyte sedimentation rate (ESR) of at least 40 mm/hour.

Forty six women completed the study by staying in hospital until their ESR had halved.
In 23 women the device was removed before treatment with pivampicillin and doxycycline and in the other 23 women the device was left in place and the same treatment was given.
Early removal of the IUD did not influence the course of the disease, which was monitored by the course of the ESR.
This study is limited by its small size, and by choosing to use only one outcome measure, the ESR, to monitor progress. It also did not take place in a primary care setting.

A randomized controlled trial of 126 women with mild-to-moderate PID during IUD usage evaluated the effects of removing the IUD [Altunyurt et al, 2003]. The diagnosis was made by using a variety of clinical symptoms (recent onset of pelvic pain and vaginal discharge, dysuria and frequency, nausea and vomiting, intermenstrual bleeding, and recent onset of dyspareunia); clinical signs (abdominal tenderness, purulent cervical discharge, and cervical tenderness); and ESR and white cell counts.

All of the participants were given ciprofloxacin, metronidazole, and doxycycline and in 60 women the IUD was removed. Twelve women defaulted from the follow up assessment at 15 days.
Women in whom the IUD had been removed had significantly less pelvic pain (p = 0.0001), vaginal discharge (p = 0.007), dysuria and frequency (p = 0.0003), dyspareunia (p = 0.0001), cervical tenderness (p = 0.0001), and a lower white cell count (p = 0.001) and ESR (p = 0.001) than the group in whom the device was not removed.
However this study is limited by its short follow up interval and therefore long term outcomes such as whether the risk of tubal infertility is reduced are unknown.

A retrospective study of 186 women with acute PID investigated the effect of removing the IUD on the resolution of the disease. The diagnosis of PID was based on a history of acute pelvic pain, uterine and adnexal tenderness, and an increased ESR of above 15 mm/hour [Teisala, 1989].

The IUD was removed on admission in 81 women and left in place in 105 women. All women received penicillin with or without metronidazole and 17 women received penicillin before admission.
There was no significant difference between the two groups in the outcome measures: duration of fever, highest ESR during hospitalisation, ESR on discharge, and the mean time in hospital.
This study is limited by its lack of long term data and that it did not take place in primary care.

A randomized trial of 928 women with PID who were hospitalised investigated the effect of a copper IUD on the resolution and recurrence of PID. The diagnosis of PID was based on palpable, tender adnexal masses, and/or an ESR above 15 mm/hour in addition to lower abdominal pain and sometimes a fever of over 38°C [Larsson and Wennergren, 1977]. There were three groups of women: 632 with no IUD in situ, 236 women whose IUD was not removed during treatment, and 60 women selected at random on admission who had their IUD removed.

A significantly higher proportion of women in whom the IUD had been removed spent more than 3 weeks in hospital but there was no difference between the other two groups.
184 women (17 women in whom the device had been removed before treatment, 46 women in whom the device had been left in situ and 121 women who did not have an IUD) were followed up for approximately 18 months. Recurrence rates were 15% in the group who had had the IUD removed and 9% in the other two groups. This difference was not statistically significant.
The authors concluded that there was no evidence that the copper IUD had an unfavourable effect on either the recurrence or the resolution of PID.
This study is limited by its lack of detail regarding randomization, the choice of a non-specific outcome measure of a hospital stay of over 3 weeks and the small number of women who were followed up.

Evidence on antibiotic prophylaxis for intrauterine contraceptive device (IUD) insertion

There is good evidence from a Cochrane systematic review that the use of doxycycline or azithromycin orally before intrauterine device (IUD) insertion confers little benefit.

A Cochrane systematic review [Grimes and Schulz, 1999] investigated whether antibiotic prophylaxis at the time of insertion of an IUD reduces the risk of upper genital tract infection.

Randomized trials that compared an antibiotic with placebo were included. Four trials were found and two also had pilot study data available (n = 5797). Trials were from Kenya, Nigeria, the USA, and Turkey.
Use of prophylactic antibiotics (doxycycline 200 mg or azithromycin 500 mg by mouth) before IUD insertion reduced the likelihood of an unplanned visit to the provider by 18%, which was marginally significant (odds ratio [OR] 0.82, 95% CI 0.70 to 0.98).
There was no significant difference in the number of upper genital tract infections (OR 0.89, 95% CI 0.53 to 1.51) or in IUD continuation rates (OR 1.05, 95% CI 0.68 to 1.63).
The authors concluded that IUD insertion has a good safety profile with or without the use of prophylactic antibiotics, even in populations with a high prevalence of sexually transmitted disease.

Evidence on the risk of infertility with pelvic inflammatory disease

There is evidence from prospective cohort studies that the risk of infertility is related to the number of episodes of pelvic inflammatory disease (PID) and their severity.

A prospective cohort study enrolled 2501 women who had undergone laparoscopy for suspected pelvic inflammatory disease. At laparoscopy 1844 had abnormal findings and 657 had normal findings. The time of follow up was related to the time of the index laparoscopy; 136.6 months in those enrolled between 1960–1964 and 45.7 months in those enrolled between 1980–1984. Of the 1309 women with a history of laparoscopically-confirmed PID, and the 451 women who had had a normal laparoscopy (control group) who were attempting to conceive [Westrom et al, 1992]:

16% of women with a history of PID were not pregnant within 1 year, compared with 2.7% of controls.
10.8% of women with a history of PID had confirmed tubal-factor infertility, compared with none in the control group.
0.6% of women had tubal-factor infertility after an episode of mild PID and 21.4% of women had tubal-factor infertility after an episode of severe PID.
Each repeated episode of PID roughly doubled the rate of tubal-factor infertility: after one episode the rate was 8%, after two episodes the rate was 19.5%, and after three or more episodes the rate was 40%.

A prospective cohort study followed up 1288 women who had experienced clinical symptoms of PID and who wanted to get pregnant [Lepine et al, 1998]. The cumulative probability of a live birth after 12 years was, for women who had:

Mild salpingitis (371 women): 90%.
Moderate salpingitis (580 women): 82%.
Severe salpingitis (337 women): 57%.

References

All references with links to [Free Full-text] are freely available online to users in the UK. Links to PubMed abstracts are also provided where available. Clarity is not responsible for the content of external sites.

Free Full-text links are to dynamic documents that may have been updated since they were originally cited in the PRODIGY topic. All links are checked regularly by Information Specialists and updated to the latest version. Changes in the content of updated documents will not be reflected in the PRODIGY topic text until the next revision.

The following references were cited in August 2009. References dated after this reflect new evidence incorporated since original publication of this topic.

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Search strategy

Further information on the PRODIGY literature searching policy is available in the 'About' section of the PRODIGY website.

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of Pelvic inflammatory disease.

Search dates

July 2006 – January 2009

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request.

pelvic inflammatory disease/, pelvic inflammatory disease.tw. PID.tw.

Table 1. Key to search terms.

Search commands	Explanation
/	indicates a MeSH subject heading with all subheadings selected
.tw	indicates a search for a term in the title or abstract
exp	indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree
$	indicates that the search term was truncated (e.g. wart$ searches for wart and warts)

Sources of guidelines

Sources of systematic reviews and meta-analyses

The Cochrane Library:

Systematic reviews
Protocols
Database of Abstracts of Reviews of Effects

Medline (with systematic review filter)
EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

NIHR Health Technology Assessment programme
The Cochrane Library:

NHS Economic Evaluations
Health Technology Assessments

Canadian Agency for Drugs and Technologies in Health
International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

The Cochrane Library:

Central Register of Controlled Trials

Medline (with randomized controlled trial filter)
EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Department of Health
Health Management Information Consortium (HMIC)

Drugs in this topic

Scenario: Management

Azithromycin 500mg tablets

Age from 13 years onwards

Azithromycin 500mg tablets: Take two tablets as a single dose once a week for 2 weeks.

Azithromycin 500mg tablets

Take two tablets as a single dose once a week for 2 weeks.

Supply 4 tablets.

Age: from 13 years onwards

NHS cost: £9.86

Licensed use: no - off-label dose

Azithromycin 500mg tablets: Take two tablets as a single dose once a week for 2 weeks.

Azithromycin 500mg tablets

Take two tablets as a single dose once a week for 2 weeks.

Supply 4 tablets.

Age: from 13 years onwards

NHS cost: £9.86

Licensed use: no - off-label dose

Age from 13 years onwards

Azithromycin 500mg tablets: Take two tablets as a single dose once a week for 2 weeks.

Azithromycin 500mg tablets

Take two tablets as a single dose once a week for 2 weeks.

Supply 4 tablets.

Age: from 13 years onwards

NHS cost: £9.86

Licensed use: no - off-label dose

Azithromycin 500mg tablets: Take two tablets as a single dose once a week for 2 weeks.

Azithromycin 500mg tablets

Take two tablets as a single dose once a week for 2 weeks.

Supply 4 tablets.

Age: from 13 years onwards

NHS cost: £9.86

Licensed use: no - off-label dose

Cefixime 200mg tablets

Age from 13 years onwards

Cefixime 200mg tablets: Take two tablets as a single dose.

Cefixime 200mg tablets

Take two tablets as a single dose.

Supply 2 tablets.

Age: from 13 years onwards

NHS cost: £3.78

Licensed use: no - off-label indication

Cefixime 200mg tablets: Take two tablets as a single dose.

Cefixime 200mg tablets

Take two tablets as a single dose.

Supply 2 tablets.

Age: from 13 years onwards

NHS cost: £3.78

Licensed use: no - off-label indication

Age from 13 years onwards

Cefixime 200mg tablets: Take two tablets as a single dose.

Cefixime 200mg tablets

Take two tablets as a single dose.

Supply 2 tablets.

Age: from 13 years onwards

NHS cost: £3.78

Licensed use: no - off-label indication

Cefixime 200mg tablets: Take two tablets as a single dose.

Cefixime 200mg tablets

Take two tablets as a single dose.

Supply 2 tablets.

Age: from 13 years onwards

NHS cost: £3.78

Licensed use: no - off-label indication

Ceftriaxone 250mg powder for solution for injection vials

Age from 13 years onwards

Ceftriaxone 250mg powder for solution for injection vials: Reconstitute and give a single dose of 250mg by intramuscular injection.

Ceftriaxone 250mg powder for solution for injection vials

Reconstitute and give a single dose of 250mg by intramuscular injection.

Supply 1 250mg vial.

Age: from 13 years onwards

NHS cost: £2.45

Licensed use: yes

Ceftriaxone 250mg powder for solution for injection vials: Reconstitute and give a single dose of 250mg by intramuscular injection.

Ceftriaxone 250mg powder for solution for injection vials

Reconstitute and give a single dose of 250mg by intramuscular injection.

Supply 1 250mg vial.

Age: from 13 years onwards

NHS cost: £2.45

Licensed use: yes

Age from 13 years onwards

Ceftriaxone 250mg powder for solution for injection vials: Reconstitute and give a single dose of 250mg by intramuscular injection.

Ceftriaxone 250mg powder for solution for injection vials

Reconstitute and give a single dose of 250mg by intramuscular injection.

Supply 1 250mg vial.

Age: from 13 years onwards

NHS cost: £2.45

Licensed use: yes

Ceftriaxone 250mg powder for solution for injection vials: Reconstitute and give a single dose of 250mg by intramuscular injection.

Ceftriaxone 250mg powder for solution for injection vials

Reconstitute and give a single dose of 250mg by intramuscular injection.

Supply 1 250mg vial.

Age: from 13 years onwards

NHS cost: £2.45

Licensed use: yes

Codeine 30mg tablets

Age from 18 years onwards

Codeine 30mg tablets: Take one or two tablets every 4 to 6 hours when required for pain relief. Maximum of 8 tablets in 24 hours.

Codeine 30mg tablets

Take one or two tablets every 4 to 6 hours when required for pain relief. Maximum of 8 tablets in 24 hours.

Supply 28 tablets.

Age: from 18 years onwards

NHS cost: £1.22

Licensed use: yes

Doxycycline 100mg capsules

Age from 13 years onwards

Doxycycline 100mg capsules: Take one capsule twice a day for 14 days.

Doxycycline 100mg capsules

Take one capsule twice a day for 14 days.

Supply 28 capsules.

Age: from 13 years onwards

NHS cost: £1.94

Licensed use: off-label duration

Doxycycline 100mg capsules: Take one capsule twice a day for 14 days.

Doxycycline 100mg capsules

Take one capsule twice a day for 14 days.

Supply 28 capsules.

Age: from 13 years onwards

NHS cost: £1.94

Licensed use: off-label duration

Age from 13 years onwards

Doxycycline 100mg capsules: Take one capsule twice a day for 14 days.

Doxycycline 100mg capsules

Take one capsule twice a day for 14 days.

Supply 28 capsules.

Age: from 13 years onwards

NHS cost: £1.94

Licensed use: off-label duration

Doxycycline 100mg capsules: Take one capsule twice a day for 14 days.

Doxycycline 100mg capsules

Take one capsule twice a day for 14 days.

Supply 28 capsules.

Age: from 13 years onwards

NHS cost: £1.94

Licensed use: off-label duration

Ibuprofen 200mg tablets

Age from 13 years onwards

Ibuprofen 200mg tablets: Take one or two tablets 3 to 4 times a day when required for pain relief. Do not exceed the stated dose. (a)

Ibuprofen 200mg tablets

Take one or two tablets 3 to 4 times a day when required for pain relief. Do not exceed the stated dose.

Supply 56 tablets.

Age: from 13 years onwards

NHS cost: £1.38

OTC cost: £2.38

Licensed use: yes

Metronidazole 400mg tablets

Age from 13 years onwards

Metronidazole 400mg tablets: Take one tablet twice a day for 14 days.

Metronidazole 400mg tablets

Take one tablet twice a day for 14 days.

Supply 28 tablets.

Age: from 13 years onwards

NHS cost: £1.63

Licensed use: yes

Metronidazole 400mg tablets: Take one tablet twice a day for 14 days.

Metronidazole 400mg tablets

Take one tablet twice a day for 14 days.

Supply 28 tablets.

Age: from 13 years onwards

NHS cost: £1.63

Licensed use: yes

Age from 18 years onwards

Metronidazole 400mg tablets: Take one tablet twice a day for 14 days.

Metronidazole 400mg tablets

Take one tablet twice a day for 14 days.

Supply 28 tablets.

Age: from 18 years onwards

NHS cost: £1.63

Licensed use: yes

Age from 13 years onwards

Metronidazole 400mg tablets: Take one tablet twice a day for 14 days.

Metronidazole 400mg tablets

Take one tablet twice a day for 14 days.

Supply 28 tablets.

Age: from 13 years onwards

NHS cost: £1.63

Licensed use: yes

Metronidazole 400mg tablets: Take one tablet twice a day for 14 days.

Metronidazole 400mg tablets

Take one tablet twice a day for 14 days.

Supply 28 tablets.

Age: from 13 years onwards

NHS cost: £1.63

Licensed use: yes

Ofloxacin 400mg tablets

Age from 18 years onwards

Ofloxacin 400mg tablets: Take one tablet twice a day for 14 days.

Ofloxacin 400mg tablets

Take one tablet twice a day for 14 days.

Supply 28 tablets.

Age: from 18 years onwards

NHS cost: £15.46

Licensed use: no - off-label dose

Paracetamol 500mg tablets

Age from 13 years onwards

Paracetamol 500mg tablets: Take one or two tablets every 4 to 6 hours when required for pain relief. Maximum of 8 tablets in 24 hours.

Paracetamol 500mg tablets

Take one or two tablets every 4 to 6 hours when required for pain relief. Maximum of 8 tablets in 24 hours.

Supply 50 tablets.

Age: from 13 years onwards

NHS cost: £0.79

Licensed use: yes

Leaflets for patients

Chlamydia

Introduction

Chlamydia is a sexually transmitted infection (STI) caused by the bacterium chlamydia trachomatis. In the UK, the number of new diagnoses has been steadily increasing each year since the mid-1990s, and it has now become the most commonly diagnosed STI.

Chlamydia is called the 'silent' disease because most people who get it do not experience any noticeable symptoms. Around 50% of men and 70-80% of women who get the chlamydia infection will have no symptoms and many cases of chlamydia remain undiagnosed.

How common is it?

Between 2007 and 2008, the number of confirmed cases of chlamydia rose from 121,791 to 123,018. Young people under 25 are most likely to be infected, 65% (80,258) of all new chlamydia diagnoses made in 2008 were in people between the ages of 16 and 24.

Outlook

The chlamydia infection can be easily diagnosed through a simple swab or urine test, once diagnosed it can be treated with antibiotics. Undiagnosed chlamydia can lead to more serious long term health problems and infertility.

Under 25s can get a free, confidential chlamydia test through the National Chlamydia Screening Programme. People over 25 can visit their GP or a local GUM (genitourinary medicine) or sexual health clinic to arrange a test.

Symptoms

Chlamydia often goes unnoticed due to the lack of noticeable symptoms. Because of this, many cases of chlamydia remain undiagnosed.

Women

In women, genital chlamydia does not always cause symptoms. Signs and symptoms can appear 1-3 weeks after coming in contact with chlamydia, many months later or not until the infection has spread to other parts of your body.

Some women may notice:

Cystitis (pain when passing urine),
a change in their vaginal discharge,
lower abdominal pain,
pain and/or bleeding during sexual intercourse,
bleeding after sex, or
bleeding between periods or heavier periods.

If left untreated the chlamydial infection can spread to the womb, and cause Pelvic Inflammatory Disease (PID). PID is a major cause of infertility,ectopic pregnancy and miscarriage.

Men

Symptoms of genital chlamydia are more common in men than in women. Signs and symptoms can appear 1-3 weeks after coming in contact with chlamydia, many months later or not until the infection has spread to other parts of your body.

Some men may notice:

a white, cloudy or watery discharge from the tip of the penis,
pain when passing urine, or
pain in the tesiticles.

Some men experience mild symptoms that disappear after two or three days. However, after the discomfort disappears, you may still have the chlamydia infection. This means that you can pass it on to a sexual partner and you are at risk of complications such as inflamed and swollen testicles, reactive arthritis and infertility.

Men and women

Very rarely the chlamydia infection may affect areas other than the genitals in both men and women, such as the rectum, eyes or throat.

If the infection is in the rectum it can cause some discomfort and discharge. In the eyes it can cause pain, swelling, irritation and discharge (conjunctivitis). Infection in the throat is very rare and does not usually cause any symptoms.

Causes

As chlamydia is a sexually transmitted infection (STI), it is transmitted (passed on) from one person to another during intimate sexual contact. You can catch chlamydia through having:

unprotected vaginal sex,
unprotected anal sex,
unprotected oral sex,
genital contact with an infected partner, or
sharing sex toys if they are not washed or covered with a condom each time they are used.

If infected semen or vaginal fluid comes into contact with the eye, it can cause conjunctivitis.

It is not clear whether chlamydia infection can be spread by transferring infected semen or vaginal fluid on the fingers or by rubbing female genitals (vulvas) together.

As it is common for someone with the chlamydia infection not to have symptoms, it is possible for him or her to infect a partner without knowing.

Chlamydia can be passed from a mother to her baby during childbirth. Although no obvious symptoms are immediately apparent, the infection will often develop after birth, and can result in complications such as inflammation and discharge in the baby's eyes (conjunctivitis) and pneumonia.

Diagnosis

The only way to be certain that you have chlamydia is to be tested. If you suspect you could have chlamydia, it is important not to put off having a test done.

Early diagnosis and treatment of chlamydia will reduce the risk of any complications developing. Complications that arise from long-term chlamydial infection are much more difficult to treat.

The accuracy of chlamydia testing depends on what kind of test is used. Recommended tests are over 90% accurate in picking up the infection, shop bought tests may be less reliable.

There are different ways to test for chlamydia:

Women

Women can be tested for chlamydia by taking a swab from the cervix (neck of the womb) or using a urine sample.

In recent years tests have been developed that allow women to carry them out at home, by using a urine sample, or by taking a swab themselves from the lower vagina. The sample is put into a container and sent to a laboratory to be tested.

Routine cervical screening tests do not detect chlamydia. Ask your doctor or nurse if you also wish to be tested for chlamydia.

Men

In the past, the chlamydia test for men involved putting a swab into the opening of the urethra at the tip of the penis to collect a sample of cells. A urine test is now commonly used. This method is slightly less reliable than using a swab, but it is a much easier and less uncomfortable.

Testing for non-genital chlamydia

If you have had anal or oral sex, a swab of calls may be collected from your rectum or throat, but this is not done routinely.

If you have symptoms of conjunctivitis, such as discharge from the eyes, a swab may be taken to collect cells from your eye.

When to get tested

Statistics from the National Chlamydia Screening Programme (NCSP) in England show that you are more at risk of becoming infected with chlamydia if you are under 25, have a new sexual partner, or have had more than one sexual partner in the past year and have not used condoms.

It is recommended that you consider getting tested for chlamydia if:

you or your partner think you have symptoms,
you have had unprotected sex with a new partner,
you or your partner have unprotected sex with other people,
you have an STI,
a sexual partner tells you that they have an STI,
during a vaginal examination your nurse or doctor tells you that the cells of your cervix are inflamed or there is discharge, or
you are pregnant or planning a pregnancy.

Where to get tested

There are a number of different places you can go to for a chlamydia test, you can chose the place most comfortable and convenient for you:

a genitourinary medicine (GUM) or sexual health clinic,
your GP surgery,
a contraceptive and young people's clinic, or
pharmacists where you can buy a chlamydia test to do at home - some tests may be more reliable than others so it is best to ask your pharmacist for advice.

The National Chlamydia Screening Programme (NCSP) offers free tests to men and women under 25 who have been sexually active. The programme runs across the UK and can help you access local chlamydia screening services. The screening takes place in a variety of community settings, including GP surgeries, military bases, contraceptive clinics, sexual health and GUM clinics, pharmacies, gynaecology departments and youth centres. To find out more, visit the NCSP website or call the sexual health helpline on 0800 567 123.

You can find details of your nearest sexual health or GUM clinic in the phone book, or by using the local health service search. You can attend these clinics at any age, even if you are less than 16 years of age (the age of consent for sex), and all results are treated confidentially.

Treatment

The common treatment for chlamydia is a course of antibiotics. If taken correctly it is more than 95% effective. The course of antibiotics can be either a single dose, or a longer course of up to two weeks.

If there is a high chance that you have been infected with chlamydia, treatment may be started before you receive your test results. You will always be given treatment if your partner is found to have chlamydia.

The two most commonly prescribed antibiotics to treat chlamydia are:

Azithromycin (single dose)
Doxycycline (usually two capsules a day for a week)

Other less commonly prescribed antibiotics include Ofloxacin, Amoxicillin and Erythromycin.

It is important that you finish all the capsules prescribed to you. If you do not, the treatment may not be effective at getting rid of the infection.

You can discuss with your GP which antibiotic is the most suitable for you. If you are pregnant, for example, some antibiotics may not be suitable, but alternatives are available. Azithromycin, Amoxicillin and Erythromycin are all suitable for pregnant women..

Antibiotics used to treat chlamydia may interact with the combined contraceptive pill and the contraceptive patch. If you use these methods of contraception, you can discuss with your GP or nurse which additional contraception is suitable for this time.

Side effects

The side effects of antibiotics are usually mild, the most common side effects include:

stomach pain,
diarrhoea, and
feeling sick.

Occasionally, Doxycycline can cause a skin rash if you are exposed to too much sunlight (photosensitivity).

Sexual partners

Chlamydia is easily passed on through intimate sexual contact. If you are diagnosed with the infection, anyone you have recently had sex with in the last six months may also have it. It is important that your current partner and any other recent sexual partners are tested and treated.

Your local genitourinary medicine (GUM) or sexual health clinic may be able to help by notifying any of your previous partners on your behalf. A contact slip can be sent to them explaining that they may have been exposed to a sexually transmitted infection (STI) and suggesting that they go for a check up. The slip sometimes notes what the infection is but will not have your name on it, so your confidentiality is protected.

If you or your current partner is diagnosed with chlamydia, you should not have sex until you have both finished your course of treatment.

Complications

If chlamydia is not treated it can spread to other parts of the body and cause long-term problems.

Women

In women, if chlamydia is not treated it can spread to other reproductive organs causing pelvic inflammatory disease (PID) and inflammation of the cervix (cervicitis), fallopian tubes (salpingitis) and Bartholin's glands (Bartholinitis).

Infection with chlamydia during pregnancy may also be linked to early miscarriage or premature birth of the baby.

Pelvic Inflammatory Disease (PID)

Chlamydial infection is one of the main causes of pelvic inflammatory disease (PID) in women. PID is an infection of the uterus, ovaries and fallopian tubes that can cause infertility, persistent pelvic pain and an increased risk of ectopic pregnancy. The condition can be treated using antibiotics, and early treatment will reduce the risk of infertility. You should avoid having sexual intercourse while receiving treatment for PID.

Cervicitis

Cervicitis is an inflammation of the neck of the womb, the cervix. It often causes no symptoms but you may experience some discomfort, have a vaginal discharge containing pus or irregular bleeding. Some people also experience pain during intercourse and urinary symptoms, such as the need to urinate more often, and a burning pain when they urinate. When left untreated cervicitis causes the cervix to become enlarged and cervical cysts to develop, which may become infected. Chronic (long term) cervicitis can cause backache, deep pelvic pain, and a persistent vaginal discharge.

Salpingitis

Infection with chlamydia can cause a blockage of the fallopian tubes. This may prevent eggs from passing along, or entering the tubes. Even a partial blockage of the fallopian tubes will increase the risk of ectopic pregnancy occurring. This is when a fertilised egg is implanted outside of the womb, usually in a fallopian tube..Microsurgery can sometimes be used to effectively treat a blockage.

Bartholinitis

The glands that produce the lubricating mucus to make sexual intercourse easier are known as the Bartholin's glands. They are situated on either side of the vaginal opening. Infection with chlamydia can cause the glands to become blocked and infected and lead to a Bartholin's cyst. A cyst is usually painless but if it becomes infected it can lead to a pus-filled Bartholin's abscess. An abscess is usually red, very tender and painful to touch, and can cause a fever. An infected abscess will need to be treated with antibiotics.

Men

Urethritis

Urethritis in men is inflammation of the urethra (the urine tube) that runs along the underside of the penis. Symptoms include a white or cloudy discharge from the tip of the penis, a burning or painful sensation when you urinate, the urge to urinate often and irritation and soreness around the tip of the penis. If left untreated a urethral stricture can occur, this can seriously interfere with the flow of urine and lead to back pressure which can damage the kidneys. Urethritis can be treated with antibiotics.

Epididymitis

Epididymitis is the inflammation of the epididymis, a long tube that connects the testes (where sperm are produced) to the vas deferens (a pair of ducts where sperm collect ready for ejaculation through the urethra). An infected epididymis can become inflamed, causing swelling and tenderness in the affected area of the scrotum. Infection can lead to an accumulation of fluid in the area or even an abscess. If left untreated epididymitis can lead to you becoming infertile.

Reactive arthritis

Reactive arthritis develops as a reaction to an infection, such as chlamydia. Symptoms include inflammation of the joints (arthritis), the urethra (urethritis) and the eyes (conjunctivitis). Although chlamydia can sometimes cause inflammation of the joints in women, reactive arthritis is more likely to occur in men. There is no cure for arthritis and although symptoms usually get better in three to 12 months, they can recur after this. Symptoms can be controlled by non-steroidal anti-inflammatory drugs (NSAIDs), such as ibruprofen.

Prevention

Chlamydia can be successfully prevented by:

using condoms (male or female) every time you have vaginal or anal sex,
using a condom to cover the penis or latex or plastic square (dam) to cover the female genitals if you have oral sex, and
not sharing sex toys. If you do share them wash them or cover them with a new condom before anyone else uses them.

These measures can also protect you from other sexually transmitted infections (STIs), such as genital herpes and gonorrhoea.

If you are worried you may be at risk of having an STI or have any of the symptoms mentioned in the symptoms section, you should visit your local sexual health or GUM clinic to have them checked out. Find your local sexual health service here.

For information on all sexual health services, the fpa run a helpline called sexual health direct, on 0845 122 8690.

Gonorrhoea

Introduction

Gonorrhoea is a sexually transmitted infection (STI) caused by bacteria called Neisseria gonorrhoeae or gonococcus. It used to be known as "the clap".

The bacteria are found mainly in discharge from the penis and vaginal fluid from infected men and women. Gonorrhoea is easily passed between people through:

unprotected vaginal, oral or anal sex, and
sharing vibrators or other sex aids, that have not been washed or covered with a new condom each time they are used.

It can also be passed from a pregnant woman to her baby.

Typical symptoms are an unusual discharge from the vagina or penis and pain when urinating.

How common is it?

Gonorrhoea is a less common STI in the UK than chlamydia, genital warts or genital herpes, but over 16,500 new cases of gonorrhoea were reported in 2008. Young men and women aged 16-24 are the most affected: in 2008, they accounted for 47% of new gonorrhoea diagnoses.

Who is at risk?

Anyone who is sexually active can contract gonorrhoea, especially people who change partners frequently or do not use a barrier method of contraception, such as a condom, when having sexual intercourse.

Previous successful treatment for gonorrhoea does not make you immune from catching the infection again.

Outlook

Gonorrhoea can be easily diagnosed through a simple swab test and treated with antibiotics. If left untreated, it can lead to more serious long-term health problems and infertility.

Symptoms

Symptoms of gonorrhoea usually show up within two weeks of being infected. But sometimes symptoms may not appear until many months later, or until the infection has spread to other parts of your body.

About one in 10 infected men and half of infected women will not experience any obvious symptoms after contracting gonorrhoea, which means it can go untreated for some time.

Women

In women, symptoms of gonorrhoea can include:

an unusual discharge from the vagina, which may be thick, and green or yellow in colour
pain when passing urine
pain or tenderness in the lower abdominal area (this is less common)
bleeding between periods or heavier periods (this is less common)

Men

Nine out of 10 men who contract gonorrhoea experience symptoms after they are infected, which can include:

an unusual discharge from the tip of the penis, which may be white, yellow or green
pain or a burning sensation when urinating
inflammation (swelling) of the foreskin
pain or tenderness in the testicles or prostate gland (this is rare)

Men and women

Both men and women can also catch gonorrhoea at other sites of the body. These include:

infection in the rectum, which may cause pain, discomfort or discharge
infection in the throat, which does not usually have any symptoms
infection in the eyes, which can cause pain, swelling, irritation and discharge (conjunctivitis)

Babies

Gonorrhoea can be passed from a mother to her baby during childbirth. Newborn babies normally show symptoms in their eyes during the first two weeks. The eyes become red and swollen, and have a thick pus-like discharge (conjunctivitis).

Gonorrhoea can be treated with antibiotics when you are pregnant or when you are breastfeeding. The antibiotics will not harm your baby.

Causes

Gonorrhoea is a sexually transmitted infection (STI) caused by the Neisseria gonorrhoeae bacteria. The bacteria are usually found in discharge from the penis and vaginal fluid of infected men and women, and are easily passed from one person to another through sexual contact.

The gonorrhoea bacteria can infect the vagina or penis and other places that come into contact with infected semen or vaginal fluid during sex. It can live inside the cells of the cervix (entrance to the womb), the urethra (tube where urine comes out), the rectum, the throat and, very occasionally, the eyes.

The infection is most commonly spread through:

unprotected vaginal, anal or oral sex
sharing sex toys if you do not wash them or cover them with a new condom each time

If you are a woman, it is possible for gonorrhoea to spread from your vaginal secretions to your anus. You do not need to have had anal sex for this to happen.

If you are pregnant, gonorrhoea can be passed from you to your baby during birth. This can lead to your newborn baby having an infection of the eyes (conjunctivitis), which can lead to blindness if not treated.

It is not clear if gonorrhoea can be spread by transferring the bacteria to another person on the fingers, or by female-to-female genital contact.

Diagnosis

The only way to find out if you have gonorrhoea is to be tested. If you suspect that you have it or any other sexually transmitted infection (STI), it is important not to delay getting tested.

It is possible to be tested within a few days of having sex, but you may be advised to wait up to two weeks. You can be tested even if you do not have any symptoms.

Early diagnosis and treatment of gonorrhoea will reduce the risk of any complications developing, such as pelvic inflammatory disease or infection in the testicles. Complications that arise from long-term infection are much more difficult to treat.

How you are tested

There are different ways to test for gonorrhoea.

Women

A doctor or nurse may take a swab to collect a sample from the cervix or vagina during an internal examination.
You may be asked to use a swab or tampon yourself to collect a sample from inside your vagina.

Cervical smear tests and routine blood tests do not check for gonorrhoea. If you are not sure if you have been tested for the presence of gonorrhoea, ask your nurse or doctor.

Men

You may be asked to provide a urine sample and will usually be asked not to pass urine for one to two hours beforehand.

Men and women

A doctor or nurse may take a swab to collect a sample from the entrance of the urethra (where urine is passed out).

If you have had anal or oral sex the doctor or nurse may need to take a swab from the rectum or throat.
If you have symptoms of conjunctivitis, such as red inflamed eyes with discharge, a sample of the discharge may be collected from your eye.

A swab looks a bit like a cotton bud but is smaller and rounded. It is wiped over parts of the body that may be infected, to pick up samples of discharge. This only takes a few seconds and is not painful, although it may be a little uncomfortable.

Some clinics may be able to carry out rapid diagnostic tests, when the doctor can view the sample through a microscope and give you your test results straight away. Otherwise, you will have to wait up to two weeks to get the results.

Who should get tested

You can only be certain you have gonorrhoea if you have a test. It is recommended you get tested if:

you or your partner think you have symptoms of gonorrhoea
you have had unprotected sex with a new partner
you or your partner have had unprotected sex with other people
you have another STI
a sexual partner tells you that they have an STI
during a vaginal examination your nurse or doctor tells you that the cells of your cervix are inflamed or there is discharge
you are pregnant or planning a pregnancy

Where to get tested

There are a number of different places you can go to be tested for gonorrhoea:

a genitourinary medicine (GUM) or sexual health clinic
your GP surgery
a contraceptive and young people's clinic
a private clinic

It is possible to buy a gonorrhoea test from a pharmacy to do yourself at home. However, these tests vary in accuracy. It is recommended that you go to your local sexual health service.

You can find details of your nearest sexual health or GUM clinic in the phone book, or by using the local health service search. You can attend these clinics at any age, even if you are under 16 (the age of consent for sex). All results are treated confidentially.

All tests are free through the NHS, but you will have to pay if you go to a private clinic. If you go to your GP practice, you may have to pay a prescription charge for any treatment.

Treatment

It is important to receive treatment for gonorrhoea as quickly as possible. It is unlikely the infection will go away without treatment and, if you delay treatment, you risk the infection causing complications and more serious health problems. You may also pass the infection onto someone else.

Gonorrhoea is treated with a single dose of antibiotics, usually one of the following:

ceftriaxone
cefiximine
spectinomycin

The antibiotics are either given orally (as a pill) or as an injection.

Recently, it has become apparent that some strains of gonorrhoea are becoming resistant to some antibiotics, particularly antibiotics that have been used heavily in the past, like penicillin, so these tend not to be used.

If there is a high chance that you have gonorrhoea, you may be given treatment before you get your results back. You will always be offered treatment if your partner is found to have gonorrhoea.

You should avoid sexual intercourse and intimate contact with other partners until you (and your partner) have both finished the course of treatment. This is to prevent reinfection or passing the infection onto anyone else.

Babies who display signs of a gonorrhoea infection at birth (such as inflammation of the eyes), or who are at increased risk of infection because the mother has gonorrhoea, will usually be given antibiotics immediately after birth. This is to prevent blindness and other complications developing and does not harm the baby.

Follow up

Treatment is at least 95% effective and you should only have to go back for a follow-up test if:

the signs and symptoms do not go away
you had unprotected sex with your partner in the week following treatment
you think you have come into contact with gonorrhoea again
you had gonorrhoea of the throat
your test was negative but you develop symptoms of gonorrhoea

In these situations, you may need a repeat test.

Recovery

If the antibiotics have been effective, you should soon notice an improvement in your symptoms.

Pain and discharge when you urinate should improve within two to three days.
Pain and discharge in your rectum should improve within two to three days.
Bleeding between periods, or extra heavy periods, should improve by the time of your next period.
Pain in your pelvis or testicles should start to improve quickly but could take up to two weeks to go away.

If you have pelvic pain or experience pain during sex that does not go away after treatment, you should see your doctor or nurse. You may need further treatment, or it may be necessary to investigate other causes of pain.

Sexual partners

Gonorrhoea is easily passed on through intimate sexual contact. If you are diagnosed with it, anyone you have recently had sex with may have it too. It is important that your current partner and any other recent sexual partners are tested and treated.

Your local genitourinary medicine (GUM) or sexual health clinic may be able to help by notifying any of your previous partners on your behalf. A contact slip can be sent to them explaining that they may have been exposed to a sexually transmitted infection (STI) and suggesting that they go for a check-up. The slip sometimes notes what the infection is but will not have your name on it, so your confidentiality is protected.

If you or your current partner is diagnosed with gonorrhoea, you should not have sex until you have both finished your treatment course.

Complications

If treated early, gonorrhoea is unlikely to lead to any complications or long-term problems. However, without treatment it can spread to other parts of your body and cause serious problems. The more times that you have gonorrhoea, the more likely you are to get complications.

In women, gonorrhoea can spread to the reproductive organs and cause pelvic inflammatory disease (PID). PID can lead to long-term pelvic pain,ectopic pregnancy and infertility.
In men, gonorrhoea can cause painful infection in the testicles and prostate gland, which can lead to reduced fertility.

In rare cases, when gonorrhoea has been left untreated, it can spread through the bloodstream to cause infections in other parts of your body. In both men and women, this can cause:

inflammation (swelling) of the joints and tendons
skin lesions (rash)
inflammation around the brain and spinal cord (meningitis), and the heart, which can be fatal.

Prevention

Gonorrhoea can be successfully prevented by:

using condoms (male or female) every time you have vaginal or anal sex
using a condom to cover the penis, or latex or plastic square (dam) to cover the female genitals if you have oral sex
not sharing sex toys. If you do share them, wash them and cover them with a new condom before anyone else uses them.

Taking these precautions can also help to protect you from getting other sexually transmitted infections (STIs), such as genital herpes and chlamydia.

If you are worried that you may be at risk of having an STI or have any of the symptoms mentioned in the symptoms section, you should visit your local sexual health or genitourinary medicine (GUM) clinic to have them checked out. Find your local sexual health service here.

For information on all sexual health services, the FPA runs a sexual health direct helpline, on 0845 122 8690.

Pelvic inflammatory disease

Introduction

Pelvic inflammatory disease (PID) is a bacterial infection of the female upper genital tract, including the womb, fallopian tubes and ovaries.

Most cases of PID are caused by an infection in the vagina or the neck of the womb (cervix) that has spread to the reproductive organs higher up.

Many different types of bacteria can cause PID, but most cases are the result of a chlamydia or gonorrhoea infection (see Causes for more information).

What happens?

When infection spreads upwards from the cervix (entrance to the womb), it causes one or more of the following:

endometritis: inflammation and infection of the endometrium (womb lining),
salpingitis: inflammation and infection of the fallopian tubes,
parametritis: inflammation and infection of the tissue around the womb,
oophoritis: inflammation and infection of the ovaries,
an abscess: a pocket of infected fluid in the ovary and fallopian tube, and
pelvic peritonitis: inflammation and infection of the peritoneum (lining of the inside of the abdomen).

If you develop salpingitis, the lining of the fallopian tubes swells and the already narrow canals become even narrower. This means that fertilised eggs may not be able to move along them normally, increasing the risk of ectopic pregnancy (a pregnancy that occurs outside of the womb) and infertility. See Complications for more information.

Who is affected?

PID most commonly develops in sexually active women between the ages of 15 and 24.

The disease is fairly common and is the reason for 1 in 60 visits to GPs by women under 45. Many more women with PID experience few or no symptoms.

Outlook

If diagnosed at an early stage, PID can be treated quickly and efficiently with antibiotics. However, if left untreated, it can lead to more serious long-term complications such as an ectopic pregnancy.

Further infection is common. After a first episode of PID, one in five women has more episodes, mostly within two years. Repeated episodes of PID are associated with an increased risk of infertility.

Symptoms

The symptoms of pelvic inflammatory disease (PID) are fairly general, which means the condition can be difficult to diagnose.

The warning signs include:

pain around the pelvis or lower abdomen,
discomfort or pain during sexual intercourse that is felt deep inside the pelvis,
bleeding between periods and after sex,
unusual vaginal discharge, especially if it is yellow or green,
fever and vomiting, and
pain in the rectum (back passage).

You may have PID without being aware of it. Sometimes, there are no symptoms at all or symptoms may not be obvious. For example, you may only experience mild discomfort.

Causes

Pelvic inflammatory disease (PID) is an infection. If a woman develops an infection in her vagina, the bacteria causing the infection can move upwards through the cervix (the entrance to the womb) into the womb and spread to the fallopian tubes and ovaries.

PID is often caused by more than one type of bacterium and it can sometimes be difficult for doctors to pinpoint which bacteria are responsible. Therefore, a combination of antibiotics may be prescribed so that a variety of bacteria can be treated.

Chlamydia and gonorrhoea

Many different types of bacteria can cause PID. However, the most frequent causes are two common sexually transmitted infections: chlamydia and gonorrhoea.

In the UK, the bacteria that cause chlamydia (Chlamydia trachomatis) are responsible for 50-65% of cases of PID. The bacteria that cause gonorrhoea (Neisseria gonorrhoeae) are responsible for about 14% of cases. About 8% of women with PID are infected with both chlamydia and gonorrhoea.

Other causes

Sometimes, the infection that leads to PID may start as a result of bacteria introduced into the vagina or upper genital tract during childbirth, an abortion or miscarriage, or a procedure to take a sample of tissue from the inside of the womb (endometrial biopsy).

In rare cases, PID can develop as a result of appendicitis, treatment following an abnormal cervical smear or after the fitting of an IUD (intrauterine device or coil).

In some cases, the cause of the infection that leads to PID is unknown. Such cases may be the result of normally harmless bacteria found in the vagina. These bacteria can sometimes get past the cervix and into the reproductive organs. Although harmless to the vagina, these types of bacteria can cause infection in other parts of the body. Infection in this way is most likely to happen when there has been damage to the cervix, or if you have had PID before.

Diagnosis

There is no single test for diagnosing pelvic inflammatory disease (PID).

Your doctor will diagnose PID based on your symptoms and on a gynaecological examination. When your doctor examines you, they will look for tenderness in your pelvic region and an abnormal vaginal discharge.

The doctor will usually take swabs from inside your vagina and cervix, which will be sent to a laboratory to try to identify the type of bacteria causing the infection. However, a swab test cannot be relied on to diagnose PID as some women with PID have a negative swab result.

Because PID is difficult to diagnose by the symptoms alone, you may have a blood test or an ultrasound scan. Scans can identify severe PID but will not show up mild disease. It is, therefore, possible to have a normal scan and still have PID.

In some cases, a laparoscopy (keyhole surgery) may be used to diagnose PID. A laparoscopy is a minor surgical procedure where two small cuts are made in the abdomen. A thin microscope is inserted so that the doctor can look at your internal organs and, if necessary, take tissue samples. This is usually only done in more severe cases where there may be other possible causes of the symptoms, such as appendicitis.

Admission to hospital

You may be urgently admitted to hospital if:

you are pregnant, especially if there is a chance you may have an ectopic pregnancy,
your symptoms are severe (such as nausea, vomiting and a high fever),
you have signs of pelvic peritonitis (inflammation of the inside lining of the abdomen),
an abscess is suspected, or
you may need emergency surgery, for example for appendicitis.

Treatment

If it is diagnosed at an early stage, pelvic inflammatory disease (PID) can be treated quickly and efficiently. However, if it is left untreated, it can lead to more serious, long-term complications (see Complications for more information).

If you have mild or moderate PID, your GP or sexual health clinic will usually manage your treatment.

Antibiotics

A combination of at least two antibiotics is usually prescribed to treat PID. This is because PID often involves several different types of bacteria.

Without running tests, it can be hard for doctors to identify the exact bacteria responsible, and so a combination of antibiotics may be initially prescribed so that a variety of bacteria can be treated. Quick and efficient treatment of PID is essential for minimising the risk of infertility.

If your doctor is able to identify the bacteria, your antibiotics may be changed accordingly. Antibiotics that are commonly prescribed to treat PID include ofloxacin, metronidazole, ceftriaxone and doxycycline.

You will usually have to take the antibiotics for 14 days. It is very important that you complete the entire course of antibiotics, otherwise the treatment may not be effective.

In particularly severe cases of PID, you may have to be admitted to hospital where you will receive antibiotics intravenously (through a drip in your arm).

Surgery

The bacteria that cause PID can leave scar tissue and collections of infected fluid (abscesses) on the lining of your fallopian tubes. This makes it very hard for an egg to pass along it.

The longer PID is left untreated, the more likely scarring will occur. Prompt treatment is essential for minimising the risk of damage to the fallopian tubes and other reproductive organs.

Studies suggest that delaying treatment by even a few days can increase the risk of impaired fertility. However, most women get pregnant without problems after a single episode of PID.

Laparoscopy

Sometimes, blocked or damaged tubes can be repaired during a laparoscopy (keyhole surgery), where the abnormal tissue on the lining of the tubes is removed. However, this can sometimes cause further scarring and may not always restore fertility.

Salpingectomy

A more extreme form of surgery is a salpingectomy. This involves the removal of one or both of the fallopian tubes to stop the spread of further infection.

This is only to be considered as a last resort, as the removal of both fallopian tubes will mean you will no longer be able to get pregnant naturally.

The longer treatment for PID is delayed, the more likely it is that the fallopian tubes and other reproductive organs will be permanently damaged.

If the tubes are so damaged that it is impossible to get pregnant naturally, some people will be helped by IVF (in-vitro fertilisation).

Complications

The main complications that can occur from pelvic inflammatory disease (PID) are outlined below.

Recurrent pelvic inflammatory disease

Recurrent pelvic inflammatory disease is where a woman develops repeated episodes of PID. The more often a woman gets PID, the more likely she is to get it in the future.

The condition can return if the initial infection is not entirely cured or because a sexual partner has not been tested and treated.

If an initial episode of PID damages the cervix, it can become easier for bacteria to move into the reproductive organs in the future, making you more susceptible to developing the condition again. Repeated episodes of PID are associated with an increased risk of infertility.

Abscesses

Sometimes, PID can cause abscesses on the lips to the entrance of the vagina (Bartholin's cysts) and in the fallopian tubes and ovaries. An abscess is a collection of infected fluid. It can usually be treated with antibiotics. If an abscess does not respond to antibiotics, you may require surgery.

It is important that abscesses inside the pelvis are either treated or removed, as an abscess that bursts can be potentially life threatening.

Ectopic pregnancy

The word ectopic means in the wrong place. In a normal pregnancy, the fertilised egg implants in the womb lining. An ectopic pregnancy is one that occurs outside the womb.

Over 95% of ectopic pregnancies occur in a fallopian tube. If PID develops in the fallopian tubes, it can scar the lining of the tubes, making it more difficult for eggs to pass through. If a fertilised egg gets stuck and begins to grow inside the tube, it can cause the tube to burst, which can sometimes lead to severe internal bleeding. Ectopic pregnancy is a potentially fatal condition.

Infertility

It is estimated that one in five women become infertile as a result of PID. This means they will be unable to get pregnant naturally. PID can make a woman infertile by scarring the fallopian tubes so severely that it makes it virtually impossible for the egg to travel down into the womb. Delaying treatment for PID can increase your chances of becoming infertile.

If you want to get pregnant after becoming infertile from PID, you could consider an assisted conception technique such as in-vitro fertilisation (IVF). With IVF treatment, eggs are surgically removed from a woman's ovaries and then fertilised with sperm in a laboratory, before being planted into the woman's womb. IVF does not have a very high success rate. For more information, see Health A-Z: IVF.

Prevention

The most effective way to prevent pelvic inflammatory disease (PID) is to protect yourself from sexually transmitted infections. This means using a barrier contraceptive, such as a condom, Femidom or cervical cap. Barrier contraceptive methods, used consistently and carefully, reduce (but do not remove altogether) the risk of getting a sexually transmitted infection.

It is also important to get regular sexual health check-ups at your local sexual health clinic. Get a check-up if you change your partner or have unprotected sex with a casual partner, or if you think your partner has been having sex with someone else. Find your local sexual health clinic.

Have a sexual health check if you have had sexual contact with someone you think may have been infected with either a sexually transmitted infection or PID.

Sexual health clinics

Introduction

Sexual health clinics are sometimes known as genito-urinary medicine (GUM) clinics. They are usually located at a hospital or as part of another health centre, and provide a range of sexual health services including:

contraception and contraception advice,
emergency contraception and emergency contraception advice,
testing and treatment for sexually transmitted infections (STIs), such as chlamydia, syphilis, gonorrhoea and genital warts, and
testing and counselling for HIV and AIDS.

What is genito-urinary medicine?

Genito-urinary medicine (GUM) deals with the male and female sexual organs, and the urinary system (which produces, stores and removes urine from your body).

As well as testing for and treating STIs, GUM also investigates and treats urinary tract infections (UTIs). These include cystitis, which is a bladder infection, and urethritis, which is an infection of the urethra (the tube used to urinate). Other infections of the genitals, such as thrush (candida), are also treated under GUM.

How it works

If you need advice and support with a sexual health matter or you have a problem with your urinary system, you can either see your GP or make an appointment to visit your local sexual health clinic.

Referral from your GP

If your GP thinks that you have a genito-urinary infection, they may refer you to a genito-urinary specialist at a sexual health clinic for testing.

Non-referrals

As well as being referred by your GP, you can also make an appointment to visit a sexual health clinic without a referral. At certain times, some genito-urinary medicine (GUM) clinics also operate as drop-in centres, where you can turn up without needing to make a prior appointment.

It is important to remember that many sexually transmitted infections (STIs) do not have any noticeable symptoms. Therefore, it is a good idea for you and your partner to be tested for STIs before you start a new sexual relationship.

Most GUM clinics carry out general health check-ups, which include tests for a range of STIs. You may also want to have a check-up before trying for a baby.

All information regarding your visit to the sexual health clinic will be treated confidentially, and your GP will not be contacted without your permission.

Sexual health services

Sexual health services are free and available to everyone regardless of sex, age, ethnic origin and sexual orientation.

If you have a disability and you have special requirements, or if English is not your first language, contact the sexual health clinic to discuss your requirements and make appropriate arrangements. If you are unable to get to the clinic it may be possible for someone to visit you at home.

What happens

When you visit a sexual health clinic for the first time you will usually be asked to fill in a form with your name and contact details. You do not have to give your real name or tell staff who your GP is if you do not want to.

The type of health professional that you see will depend on the reason you are visiting the clinic. If you need to be tested for sexually transmitted infections (STIs), you may need to provide a urine or blood sample.

Contraception

If you are seeking advice about contraception you will be asked about your medical and sexual history.

There are several different types of contraception, and each type works in a different way. Barrier methods of contraception, such as condoms, create a physical barrier against sperm.

Women can use hormonal methods of contraception, such as the contraceptive pill. They can also use mechanical contraceptive devices, such as an intra-uterine device (IUD), which is placed in the womb (uterus). For more information about IUDs, see below.

If you decide to use a mechanical method of contraception, such as an IUD, you may need to have an internal examination and be tested for STIs.

See Useful links for more about contraception.

Emergency contraception

Most sexual health clinics will be able to provide you with advice about emergency contraception. If you have had unprotected sex (sex without using contraception), or if the contraception that you were using failed, emergency contraception can be used to prevent pregnancy.

There are two types of emergency contraception: the emergency contraceptive pill and the IUD.

The emergency contraceptive pill can be taken up to three days (72 hours) after sex. If it is taken within 24 hours, it is 95% effective.
An IUD is a small, rigid T-shaped contraceptive device that is fitted inside the womb (uterus) by a nurse or doctor within five days of having unprotected sex. It works by stopping sperm reaching an egg and is almost 100% effective.

See Useful links for further information about emergency contraception.

Sexually transmitted infections

If you are visiting a sexual health clinic to be tested for STIs, you will be asked a number of questions about your sex life. This might be embarrassing for you at first, but you need to answer honestly in order to ensure that you receive the most appropriate advice and treatment.

If you are diagnosed with an STI it is very important that your current sexual partner, and some, or all, of your previous sexual partners, is informed as soon as possible. The number of sexual partners that need to be contacted will depend on the type of STI you have.

If you have an STI, your partner (and previous partners) will need to be tested and, if necessary, treated in order to prevent the infection being passed on to anyone else.

Staff at the sexual health clinic will be able to advise you about the sexual partners who will need to be contacted, and may be able to contact them on your behalf. If you wish, your anonymity will be protected when contacting your previous sexual partners.

See Useful links to find out more about STIs and for further information about testing.

HIV and AIDS

The Human Immunodeficiency Virus (HIV) is a sexually transmitted virus that attacks the body's immune system. A healthy immune system provides the body with a natural defence against disease and infection.

Over time, HIV destroys the cells that are responsible for fighting infection, leaving you with a high risk of developing other diseases or infections, such as cancer.

If you are visiting a sexual health clinic to be tested for HIV, you will be asked a series of questions about your symptoms and medical history. The HIV test looks for antibodies to HIV.

It is usually recommended that you wait 12 weeks after having unprotected sex before having the HIV test. This is because the body can take a while to develop antibodies to HIV. Waiting will ensure that the test results are reliable.

See Useful links for more about HIV and AIDS.

Results

If you have had a test for a sexually transmitted infection (STI), you may be informed of the result straight away. However, you may have to wait several weeks for the results of some tests.

Getting your test results

Staff at the sexual health clinic will ask for your permission before phoning you with your results, or they may send them to you in an unmarked envelope. Alternatively, you may be asked to come into the clinic to get your test results and to talk to an adviser. This will be the case if you are diagnosed with HIV.

Treatment and advice

If your test results show that you have an STI, a healthcare professional at the clinic will be able to discuss your results with you and advise you about possible treatment options.

Many STIs can be treated using antibiotics. Others, such as HIV, are not curable. If you have HIV, staff at the clinic will arrange an appointment for you with a counsellor, as well as advising you about treatments to control the condition and slow its progression.

Preventing sexually transmitted infections

The best way to protect yourself from getting an STI, including HIV, is to practise safe sex. When having sex, including oral and anal sex, always use a condom.

If you are diagnosed with an STI, make sure you follow the advice of the healthcare professional at the clinic with regards to having sex while you are being treated.

It is a crime knowingly to infect someone with HIV.

See Useful links for further information about a wide range of sexual health matters and to find your nearest sexual health or genito-urinary medicine(GUM) clinic.

Sexually transmitted infections (STIs)

Introduction

Sexually transmitted infections (STIs) are diseases passed on through intimate sexual contact. They can be passed on during vaginal, anal and oral sex, as well as through genital contact with an infected partner. Common STIs in the UK include chlamydia, genital warts and gonorrhoea.

How common are they?

In the UK, the incidence of STI has been rising since the 1990s. Between 2007 and 2008, the Health Protection Agency (HPA) reported a 0.5% increase in the number of diagnosed STIs, with a total of 399,738 new cases reported in 2008.

The biggest increase was in the number of confirmed diagnoses of genital herpes, which rose by 10% to a total of 28,957 cases. There were also increases in diagnoses of genital warts and chlamydia.

Numbers of diagnosed cases of STIs are still going up and the greatest affected age group continues to be 16-24 year olds. Even though they account for just 12% of the population, young people account for more than half of all STIs diagnosed in the UK. This includes 65% of new chlamydia cases and 55% of new genital warts cases.

More information on STIs

For more information on the most common STIs, see:

Getting tested

There are a number of places where you can get screened for sexually transmitted infections (STIs) including GUM (genitourinary medicine) clinics, some GP surgeries, sexual health and contraception clinics.

The National Chlamydia Screening Programme offers free chlamydia testing to men and women under 25 who have been sexually active and do-it-yourself chlamydia tests are available in many places, including colleges and pharmacies.

All advice, information and STI tests are free, but if you go to your GP you may have to pay a prescription charge for any treatment.

Most STIs are initially diagnosed when you experience symptoms. Other STIs are difficult to diagnose initially because they don’t show any symptoms, such as chlamydia, gonorrheoa and genital herpes. Because of this it is a good idea to get tested for STIs if:

you have had unprotected sex with a new partner recently,
you or your sexual partner have had unprotected sex with other people without using a condom,
your sexual partner has symptoms, or,
you are planning a pregnancy and have been at risk of infection.

Testing

Tests for both men and women may include:

an examination of your genitals, mouth, anus, rectum and skin to look for signs of infection,
a urine sample,
a blood test,
taking swabs from the urethra (tube where you urinate) and any sores or blisters, or,
taking swabs from the throat and the rectum, although this is less common.

For women the tests might also include:

taking swabs from the vagina and cervix (entrance to the womb),
having an examination of your vagina.

Confidentiality

All sexual health services are confidential. This means that your personal information, any information about your visit and the tests and treatments that you have will not be shared with anyone outside that service without your permission.

If you are under 16 you still have the same right to confidentiality.

Informing your partner

As STIs are easily passed on through sexual contact, if you have a positive diagnosis for an STI it is important that your current and past sexual partners are notified so that they can be tested and treated, to reduce the risk of spreading and re-infection.

If you do not want to contact your previous partners yourself your local GUM clinic will be able to notify them on your behalf by sending out a contact slip that asks the person to go for a check up at their GP or local sexual health clinic. This will not give your details and will not necessarily say what the infection is that they may be at risk of having.

Preventing STIs

The best prevention against sexually transmitted infections (STIs) is to not have sexual intercourse or to be in a long term relationship with one person where you have both had a sexual health check up and know that you are not infected.

Other ways to prevent STIs include:

Using a condom - using a male condom is the most effective form of protection against STIs when having sexual intercourse. Female condoms are also available but these are not quite as effective. Make sure any condom you use is within its use-by date printed on the packet and that it is put on the penis properly. If you are not in a long term relationship be prepared, have condoms to hand and ready to use when you need them. See our A-Z information on condoms.

Limit your number of partners - the less sexual partners you have the more you reduce your risk of contracting an STI. Remember that if your partner has sex with other people this will also increase your risk of contracting an STI.

Be sensible - drinking alcohol or take other drugs it can cloud your judgement. You may make decisions that you regret the next day, that puts you at risk of contracting an STI.

Leave out the intercourse - have fun in other ways with your partner. You can touch, cuddle, give each other massages and share your sexual fantasies all without having intercourse and being at risk of contracting an STI. Any kind of genital rubbing or oral sex still comes with a risk and some sort of barrier protection, such as a condom, should be used.

Get tested - you can never be 100% sure that a prospective sexual partner does not have an STI, and the more sexual partners that you or they have had, the higher the risk of contracting an STI. If you have a new partner, it is always a good idea for you both to be tested for STIs before having sexual intercourse.

Be aware - if you think that you may have contracted an STI, you should visit your local sexual health or genitourinary (GUM) clinic to have a check up.

Help and advice

There are lots of organisations that can give you advice and information about sexual health, such as:

your local GP,
contraception (family planning) clinics,
genitourinary (GUM) clinics and sexual health clinics,
pharmacists - some pharmacists are able to provide a range of sexual health services including some tests,
NHS walk-in centres - some areas of England have walk-in centres that can supply emergency contraception for free, and,
the sexual health information line (0800 567 123) - for information on HIV, AIDS, sexual health, sexually transmitted infections, local services, clinics and support services.

All advice, information and tests are free, but if you go to your GP you may have to pay a prescription charge for treatment.

Finding a service

You can find your local sexual health service here.

For information on all sexual health services, the fpa run sexual health direct, on 0845 122 8690.

DERMATOLOGY

http://ckdl.blogspot.com; FACEBOOK: VN Dermatology

Friday, November 04, 2011

Pelvic inflammatory disease

In the right clinical topic?

How up-to-date is this topic?

Changes

Previous changes

Knowledge update

New evidence

New policies

New safety alerts

Changes in product availability

Goals and outcome measures

Goals

QIPP - options for local implementation

Background information

What is it?

What causes it?

How common is it?

What are the complications?

Management

Which scenario?

Scenario: Diagnosis of pelvic inflammatory disease

How should I diagnose pelvic inflammatory disease?

Basis for recommendation

Who is at risk of developing pelvic inflammatory disease?

Basis for recommendation

What else might it be?

Basis for recommendation

What investigations should I do?

Basis for recommendation

Scenario: Management of pelvic inflammatory disease

How should I manage someone with suspected PID?

When should I seek specialist advice or admit urgently?

What advice should I give?

How should I manage sexual partners?

What follow up should I arrange?

How should I manage a woman who has an intrauterine device in situ?

What contraceptive advice should I give?

What investigations and treatments are available in secondary care?

Prescriptions

Antibiotics

Analgesia: use when required

Prescribing information

Prescribing information

Antibiotics and oral hormonal contraception

Metronidazole and alcohol

Ofloxacin

Doxycycline

Evidence

Supporting evidence

Evidence on clinical findings associated with pelvic inflammatory disease

Evidence on prompt treatment of pelvic inflammatory disease

Evidence on treating women with mild or moderate pelvic inflammatory disease in primary care

Evidence on antibiotic treatment of pelvic inflammatory disease

Evidence on oral ofloxacin and metronidazole for pelvic inflammatory disease

Evidence on intramuscular ceftriaxone and oral doxycycline with or without metronidazole for pelvic inflammatory disease

Evidence on oral azithromycin and intramuscular ceftriaxone for pelvic inflammatory disease

Evidence on oral metronidazole and doxycycline for pelvic inflammatory disease

Evidence on moxifloxacin for pelvic inflammatory disease

Evidence on removal of an intrauterine device in a woman who has pelvic inflammatory disease

Evidence on antibiotic prophylaxis for intrauterine contraceptive device (IUD) insertion

Evidence on the risk of infertility with pelvic inflammatory disease

References

Search strategy

Drugs in this topic

Scenario: Management

Azithromycin 500mg tablets

Cefixime 200mg tablets

Ceftriaxone 250mg powder for solution for injection vials

Codeine 30mg tablets

Doxycycline 100mg capsules

Ibuprofen 200mg tablets

Metronidazole 400mg tablets

Ofloxacin 400mg tablets

Paracetamol 500mg tablets

Leaflets for patients

Chlamydia

Introduction