PassFinals
Sexual Health

Pelvic inflammatory disease

Pelvic inflammatory disease is an ascending upper-genital-tract syndrome, often polymicrobial; early empirical treatment limits tubal inflammation and the later risks of chronic pelvic pain, infertility, ectopic pregnancy and tubo-ovarian abscess.

In a nutshell

PID is a clinical syndrome of ascending upper-genital-tract infection, often polymicrobial. Treat early on clinical suspicion after prompt pregnancy assessment and samples, because tubal inflammation and scarring cause chronic pelvic pain, infertility and ectopic pregnancy. Severe disease, pregnancy, abscess, peritonism or treatment failure needs hospital and gynaecology or sexual-health input.

Classic presentation

Recent lower-abdominal or pelvic pain with cervical motion, uterine or adnexal tenderness, often with discharge, deep dyspareunia or abnormal bleeding.

Key points

  • No single negative swab, normal inflammatory marker or normal ultrasound excludes early PID.
  • Perform a pregnancy test promptly: ectopic pregnancy is a critical differential and pregnancy changes the antibiotic and referral pathway.
  • Take chlamydia, gonorrhoea and M. genitalium tests where available, but start empirical broad-spectrum treatment without waiting when the clinical threshold is met.
  • Use the current BASHH and BNF regimen; quinolones are specialist or second-line options because of resistance and safety warnings.
  • Treat and notify partners, advise abstinence until treatment and follow-up are complete, and manage the IUD or IUS individually rather than removing it automatically.
  • Review moderate or severe disease at about 72 hours; no improvement suggests abscess, resistant infection, non-adherence or an alternative diagnosis.
  • Tubo-ovarian abscess, peritonitis, sepsis or pregnancy needs hospital assessment and possible drainage or surgery.
  • Right-upper-quadrant pain with PID may be Fitz-Hugh-Curtis perihepatitis, but dangerous abdominal and hepatobiliary differentials remain important.

First-line investigation

Prompt pregnancy test, bimanual and speculum examination, STI and HIV testing, with ultrasound and blood tests directed by severity and differential diagnosis.

Management

Exclude danger and treat early

  • Perform a pregnancy test, assess for ectopic pregnancy or acute abdomen, take STI samples where feasible and start empirical broad-spectrum antibiotics when the clinical threshold for PID is met.1,2,3,6

Classify severity and cause

  • Use pelvic examination, STI and HIV testing, inflammatory markers and ultrasound when severe disease, abscess, persistent symptoms or an alternative diagnosis is possible; do not let tests delay treatment.1,5,4

Support and prevent reinfection

  • Provide analgesia, rest and clear written advice, treat and notify recent partners, and advise abstinence until the patient and partners have completed treatment and follow-up.1,3,7

Admit complicated disease

  • Admit or urgently refer for severe illness, pregnancy, sepsis, peritonism, tubo-ovarian abscess, oral intolerance, suspected surgical emergency or failure to improve; discuss drainage or surgery when source control is needed.1,4,3,6

Confirm response and protect fertility

  • Review moderate or severe disease at about 72 hours, reassess adherence and partners, investigate non-response and explain the risks of recurrent PID, chronic pain, ectopic pregnancy and subfertility.1,4,3

Exam traps

  • Do not wait for positive chlamydia or gonorrhoea results before treating clinically suspected PID.
  • Do not use a negative NAAT or normal ultrasound to rule out mild PID.
  • Do not label pelvic pain as PID without considering ectopic pregnancy, torsion, appendicitis and other surgical emergencies.
  • Pregnancy is not a reason to withhold care: it is a reason for urgent specialist and parenteral treatment planning.
  • Do not remove an IUD automatically; balance infection response, patient preference and pregnancy risk.
  • No improvement by the review point needs renewed examination and investigation, not simply another outpatient antibiotic course.

Illustrations

Ascending route of pelvic infectionDiagram showing spread of infection from the cervix through the endometrium into the fallopian tubes and pelvic peritoneum.PassFinals · original
Tubal scarring and its consequencesIllustration of a fallopian tube damaged by inflammation, showing adhesions and narrowing linked to infertility and ectopic pregnancy.PassFinals · original
Fitz-Hugh-Curtis perihepatic adhesionsLaparoscopic image showing violin-string adhesions between the liver capsule and abdominal wall following pelvic infection.Hic et nunc, Wikimedia Commons · Public domain

Key sources

  1. BASHH: UK National Guideline for the Management of Pelvic Inflammatory Disease, 2019 interim update (Current BASHH clinical pathway for low-threshold diagnosis, empirical broad-spectrum treatment, partner management, pregnancy, IUD, admission, follow-up and PID sequelae.)
  2. NICE CKS: Pelvic inflammatory disease (NICE Clinical Knowledge Summary topic for symptom-based assessment, differential diagnosis, investigation and management of PID; use authenticated CKS access for the current detailed topic content.)
  3. NHS: Pelvic inflammatory disease (Current NHS information on symptoms, urgent red flags, pregnancy testing, antibiotics, partner treatment, abstinence and complications; page last reviewed December 2025.)
  4. RCOG: Pelvic inflammatory disease patient information, updated January 2026 (Current RCOG information on symptoms, pregnancy testing, ultrasound for severe disease or abscess, antibiotics, 48-to-72-hour reassessment and drainage when needed.)
  5. BASHH: Summary guidance on testing for sexually transmitted infections, 2023 (UK STI-testing guidance supporting risk-based chlamydia, gonorrhoea, HIV, syphilis and other sexual-health testing.)
  6. BNF online: current antibiotic prescribing for PID (Use current BNF and local sexual-health or obstetric protocols for antibiotic regimen, dosing, contraindications, allergy, pregnancy, renal or hepatic adjustment, interactions and monitoring; no fixed dose is reproduced in rapid-revision text.)
  7. BNF online: current analgesia prescribing information (Use the current BNF for analgesic choice, dosing, contraindications, pregnancy and renal or hepatic considerations.)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.