PELVIC INFLAMMATORY DISEASE (PID)

Sexually Transmitted Infections Non-certified Practice Decision Support Tools- Pelvic Inflammatory Disease (PID) 

PELVIC INFLAMMATORY DISEASE (PID) 

DEFINITION 

Pelvic inflammatory disease is an infection of the female upper genital tract that involves any 

combination of the uterus, endometrium, ovaries, fallopian tubes, pelvic peritoneum and adjacent 

tissues. PID consists of ascending infection from the lower to upper genital tract. 

RNs must consult or refer to a physician or NP to confirm diagnosis, treatment, and 

management. 

POTENTIAL CAUSES 

Most cases of PID can be categorized as sexually transmitted or endogenous and are associated 

with more than one organism. 

Bacterial: 

Neisseria gonorrhoeae 

Chlamydia trachomatis 

Trichomonas vaginalis 

Mycoplasma genitalium 

Mycoplasma hominis 

Ureaplasma urealyticum 

bacterial vaginosis (BV) 

PREDISPOSING RISK FACTORS 

 

 

 

 

sexual contact in which exchange of body fluid may occur 

history of STI 

multiple sexual partners 

upper female genital tract instrumentation: 

o dilatation & curettage (D&C) 

o recent intrauterine device (IUD) insertion 

o therapeutic abortion (T/A) 

BCCDC STI/HIV Division 

Reproductive Health Decision Support Tool – Non-certified Practice PID - April 1, 2010 

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TYPICAL FINDINGS 

Sexual Health History 

 

 

unprotected sexual contact with at least one partner 

recent IUD insertion or upper genital tract instrumentation 

PHYSICAL ASSESSMENT FINDINGS 

Cardinal Signs 

 

 

lower abdominal pain – usually bilateral 

abnormal bimanual pelvic exam that includes: 

o adenexal tenderness 

o fundal tenderness 

o cervical motion tenderness 

Additional Signs & Symptoms 

 

 

 

 

 

 

 

 

fever >38ºC 

dyspareunia 

abnormal vaginal bleeding or spotting 

abnormal vaginal discharge 

urinary frequency 

pelvic pain 

nausea or vomiting 

low back pain 

Differential Diagnosis: 

It is important to rule out other potential causes of lower abdominal pain including ectopic 

pregnancy, ovarian cysts, and gastrointestinal causes including appendicitis. 



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DIAGNOSTIC TESTS: 

cervical swab for NAAT (GC/CT) 

AND 

cervical swab for GC culture & sensitivity 

AND 

urine pregnancy test 

AND 

vaginal swabs 

vaginal slide smear for trichomonas, yeast, and bacterial vaginosis 

swab for KOH whiff test 

vaginal pH 

AND 

bimanual exam for tenderness 

CLINICAL EVALUATION 

Clients who present with suspected PID as defined by pelvic tenderness and lower abdominal 

pain during the bimanual exam require referral to physician/NP to confirm the diagnosis prior to 

receiving treatment. 

MANAGEMENT AND INTERVENTIONS 

Goals of Treatment: 

 

 

 

 

 

commence rapid treatment to preserve fertility 

treat infection 

alleviate symptoms 

prevent further complications 

prevent spread of infection 

NOTE: If an IUD is present, the device should NOT BE REMOVED until after antibiotic 

therapy has been initiated and at least 2 doses of antibiotics have been taken. 



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Criteria for Potential Hospitalization: 

The following criteria may indicate the need for hospitalization or parenteral therapy: 

 

 

 

surgical emergencies such as appendicitis or ectopic pregnancy that cannot be excluded 

client is pregnant 

client cannot tolerate oral treatments 

client is under the age of 19 

 

 

 

 

 

client has severe abdominal pain 

client has abdominal guarding, rigidity, or rebound tenderness 

client has severe nausea, vomiting, or a fever >38.5ºC 

client has underlying chronic illnesses such as diabetes, HIV or active Hepatitis infection 

concerns with the client’s ability to complete oral antibiotic therapy that may require 

parenteral treatment 

TREATMENT OF CHOICE - USE ONLY IN CONSULT WITH PHYSICIAN 

OR NP 

First Choice – PID Treatment without concurrent BV 

Cefixime 800mg po in a single dose AND doxycyline 100 mg PO BID for 10 days 

If BV is clinically diagnosed in the presence of PID then treatment for BV is added to the 

cefixime and doxycyline regime: 

First Choice – PID Treatment with concurrent BV 

Cefixime 800mg po in a single dose AND doxycyline 100 mg po bid for 10 days AND 

metronidazole 500 mg po bid for 10 days 

Note: 

1. Treatment for PID covers possibility of infection by chlamydia and gonorrhea; 

2. It is important for clients to abstain from sexual contact for 10 days after starting 

treatment until all partners have completed treatment; 

3. Do not use cefixime if allergic to cephalosporins or penicillin. 

4. Do not use doxyclycline if allergic to tetracycline 



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ALTERNATE TREATMENT - USE ONLY IN CONSULT WITH 

PHYSICIAN OR NP 

Second Choice - PID Treatment without concurrent BV 

Cefixime 800mg po in a single dose AND Azithromycin 1 gm po in a single dose 

If BV is clinically diagnosed in the presence of PID then treatment for BV is added to the 

cefixime and azithromycin regime: 

Second Choice - PID Treatment with concurrent BV 

Cefixime 800mg po in a single dose AND Azithromycin 1 gm po in a single dose 

AND metronidazole 500 mg po bid for 10 days 

NOTE: Clients who receive Azithromycin as alternate treatment may require repeat treatment 

(Azithromycin 1 gm po in a single dose) at the follow-up visit. This decision is made in 

consultation with the physician/NP. 

TREATMENT OF CONTACT(S) TO PID 

Treat and offer screening to all sexual contacts within the past 60 days. See treatment of contacts 

DST for treatment regime. 

PREGNANT OR BREASTFEEDING WOMEN 

Refer all pregnant or breastfeeding women to a physician or NP. 

PARTNER COUNSELLING AND REFERRAL 

Counsel clients to notify sexual contacts within the previous 60 days that they require testing and 

treatment to cover uncomplicated chlamydia and gonorrhea. 

Commence formal follow-up and partner notification processes if any reportable infections are 

diagnosed from the laboratory submitted specimens. 

MONITORING AND FOLLOW-UP 

Clients treated for PID should return to clinic for repeat assessment (bimanual exam) to ensure 

pelvic tenderness is resolving 2–3 days after the onset of treatment and again 4–7 days after 

treatment is completed. 



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POTENTIAL COMPLICATIONS 

 

 

 

 

 

 

Fitz-Hugh-Curtis syndrome 

tubo-ovarian abcess 

ectopic pregnancy 

chronic pelvic pain 

tubal factor infertility 

recurrent PID 

CLIENT EDUCATION /DISCHARGE INFORMATION 

Counsel client: 

 

 

 

 

 

 

 

 

 

to return for follow up assessment for pelvic tenderness in 48 to 72 hours after first visit 

and 4 to 7 days after treatment is finished 

regarding the importance of revisiting health care provider if symptoms worsen or persist 

regarding the appropriate use of medications (dosage, side effects, and need for retreatment 

if dosage not completed) 

to avoid sexual contact with current partners until they and partners have completed 

screening and treatment 

to inform last sexual contact and all sexual contacts within the last 60 days that they 

require testing and treatment 

regarding harm reduction measures (condom use) 

regarding the complications from untreated PID 

regarding the risk of co infection risk for HIV when another STI is present 

the asymptomatic nature of STI and HIV 

CONSULTATION OR REFERRAL 

 

 

Refer/consult for all clients who present clinically with suspected PID to physician/NP 

Refer to physician/NP for clients who are experiencing persistent and/or worsening 

symptoms after treatment has been initiated 



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DOCUMENTATION 

 

 

 

PID is not reportable 

institute reporting and partner notification processes if lab reportable infections are 

confirmed from diagnostic tests 

Document as per agency guidelines 

REFERENCES 

Altunyurt, S., Demir, N., Posaci, C. (2003). A randomized controlled trial of coil removal prior 

to treatment of pelvic inflammatory disease. European Journal of Obsterics & Gynecology and 

Reproductive Biology 107(2003) p. 81-84. 

BCCDC (2007) British Columbia Treatment Guidelines. Sexually Transmitted Infections in 

Adolescent and Adults. STI/HIV Prevention and Control Division, BC Centre for Disease Control. 

Haggerty, C., Hillier, S., Bass, D., Ness, R. (2004). Bacterial vaginosis and anaerobic bacteria 

are associated with endometritis. Clinical Infectious Disease 39 p. 990-995. 

Hillis, S., Joesoef, R., Marchbanks, P., Wasserheit, J., Cates, W., Westrom, L. (1993). Delayed 

care of pelvic inflammatory disease as a risk facto for impaired fertility. American Journal of Obstetrics 

and Gynecology 168(5) p. 1503-1509. 

Holmes, K., Sparling, P., Stamm, W., Piot, P., Wasserheit, J., Corey, L., Cohen, M., Watts, H. 

(2008). Sexually transmitted disease (4 th ed). Toronto, ON: McGraw Hill Medical. 

Ness, R., Trautmann, G., Richter, H., Randall, H., Peipert, J., Nelson, D., Schubeck, D., 

McNeeley, S., Trout, W., Bass, D., Soper, D. (2005). Effectiveness of treatment strategies of some 

women with pelvic inflammatory disease: A randomized trial. Obstetrics & Geynecology 106(3) p. 573- 

580. 

Public Health Agency of Canada. (2006). Canadian Guidelines on Sexually Transmitted 

Infections. (updated January 2008). Retrieved from http://www.phac-aspc.gc.ca/std-mts/sti-its/indexeng.php 

Public Health Agency of Canada. (2008) Pelvic inflammatory disease. Canadian Guidelines on 

Sexually Transmitted Infections. Retrieved from 

www.phac-aspc.gc.ca/std-mts/sti_2006/pdf/pid06_e.pdf 

Ross, J., Judlin, P., Nilas, L. (2008 update). European guideline for the management of pelvic 

inflammatory disease. PID Treatment Guidelines. Retrieved from 

www.iusti.org/regions/europe/PID_v5.pdf 

Short, V., Totten, P., Ness, R., Astete, S., Kelsey, S., Haggerty, C. (2009). Clinical presentation 

of Mycoplasma genitalium infection versus Nesisseria gonorrhoeae infection among women with pelvic 

inflammatory disease. Clinical Infectious Disease 48 p. 41-47. 

Simms, I., Eastick, K., Mallinson, H., Thomas, K., Gokhale, R., Hay, P., Herring, A., Rogers, P. 

(2003). Associations between Mycoplasma genitalium, Chamydia trachomatis, and pelvic inflammatory 

disease. Sexually Transmitted Infections 79 p. 154-156. 

Trautmann, G., Kip, K., Richter, H., Soper, Dl, Peipert, J., Nelson, D., Trout, W., Schubeck, D., 

Bass, D., Ness, R. (2008). Do short-term markers of treatment efficacy predict long-term sequelae of 

pelvic inflammatory disease? American Journal of Obstetrics & Gynecology. 30e1-e7. 



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PELVIC INFLAMMATORY DISEASE (PID)

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