About This Page
This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Ascending infection: endometritis → salpingitis → oophoritis → peritonitis. Chlamydia (most common), gonorrhoea, and mixed anaerobes
- Presentation: bilateral lower abdominal pain, deep dyspareunia, abnormal vaginal discharge, IMB/PCB, pyrexia
- Cervical excitation (cervical motion tenderness) is the classic examination finding
- Diagnosis is clinical — low threshold to treat. Endocervical swabs for chlamydia (NAAT) and gonorrhoea (NAAT + culture)
- Treatment (BASHH): IM ceftriaxone 1 g STAT + doxycycline 100 mg BD 14 days + metronidazole 400 mg BD 14 days
- Complications: tubo-ovarian abscess, tubal damage → subfertility (15–20% after single episode), ectopic pregnancy, chronic pelvic pain, Fitz-Hugh-Curtis syndrome
Overview
Pelvic inflammatory disease (PID) is infection and inflammation of the upper female genital tract, including the endometrium (endometritis), fallopian tubes (salpingitis), ovaries (oophoritis), and pelvic peritoneum (peritonitis). It results from ascending infection from the cervix and vagina. Chlamydia trachomatis is the most commonly identified organism, followed by Neisseria gonorrhoeae and mixed anaerobic bacteria. However, in many cases no organism is identified. PID is a major cause of tubal factor subfertility and ectopic pregnancy, making early diagnosis and treatment essential.
Epidemiology
PID is common in sexually active young women, with the highest incidence in the 15–24 age group. Exact incidence is difficult to determine due to subclinical cases. Risk factors include age <25, multiple sexual partners, recent partner change, previous PID, STI history, non-barrier contraception, recent instrumentation (IUD insertion, ERPC, hysteroscopy), and BV. The LNG-IUS and COCP appear to offer some protection against PID. Barrier contraception reduces risk.
Clinical Features
Symptoms
Bilateral lower abdominal pain — usually gradual onset, dull
Abnormal vaginal or cervical discharge — mucopurulent
Deep dyspareunia
Intermenstrual or postcoital bleeding
Fever, malaise, nausea
Right upper quadrant pain (Fitz-Hugh-Curtis syndrome — perihepatitis)
Severe unilateral pain with high fever (tubo-ovarian abscess)
Signs
Cervical excitation (cervical motion tenderness) on bimanual examination — classic finding
Bilateral adnexal tenderness
Uterine tenderness
Pyrexia (>38°C)
Mucopurulent cervical or vaginal discharge
Adnexal mass (tubo-ovarian abscess)
Peritonism (if pelvic peritonitis or ruptured abscess)
Investigations
First-line
Endocervical swabsNAAT for chlamydia and gonorrhoea (most sensitive). Also culture gonorrhoea swab (for sensitivity testing)
High vaginal swabMicroscopy and culture — identify BV, other organisms
Pregnancy testExclude ectopic pregnancy — essential in any woman with pelvic pain
FBC, CRPRaised WCC and CRP support diagnosis but may be normal in mild PID
Second-line
Pelvic USS (TVUSS)If tubo-ovarian abscess suspected — fluid-filled dilated tubes, complex adnexal mass
Urine dipstick/MSUExclude UTI as differential
Specialist
LaparoscopyGold standard for diagnosis but rarely performed. Reserved for diagnostic uncertainty, failure to respond to treatment, or drainage of tubo-ovarian abscess
Management
BASHH PID Guidelines, 20191
Outpatient management (mild-moderate PID)
- Empirical antibiotics — do NOT wait for swab results:
- IM ceftriaxone 1 g STAT (covers gonorrhoea)
- + Doxycycline 100 mg PO BD for 14 days (covers chlamydia)
- + Metronidazole 400 mg PO BD for 14 days (covers anaerobes)
- Alternative if ceftriaxone unavailable: ofloxacin 400 mg PO BD + metronidazole 400 mg PO BD for 14 days
- Review at 48–72 hours — should be improving. If not, consider admission
2
Inpatient management (severe PID)
- Admit if: tubo-ovarian abscess, severe systemic symptoms, failed outpatient treatment, surgical emergency not excluded, pregnant
- IV ceftriaxone 2 g OD + IV metronidazole 500 mg TDS + oral doxycycline 100 mg BD
- Switch to oral when improving (usually 24–48 hours). Complete 14-day course
3
Partner notification and STI management
- Contact tracing: all sexual contacts in the preceding 6 months should be tested and treated
- Advise abstinence from sexual intercourse until both patient and partner(s) have completed treatment
- Offer comprehensive STI screen including HIV
4
Follow-up
- Review at 2–4 weeks to confirm resolution of symptoms
- If IUD in situ: generally leave in place unless clinical deterioration. Removal associated with poorer fertility outcomes
- Advise on barrier contraception to prevent future episodes
Complications
- Tubo-ovarian abscess: Collection of pus involving tube and ovary — may require surgical drainage if antibiotics fail
- Tubal damage and subfertility: 15–20% after single episode, rising to 50–75% after 3+ episodes
- Ectopic pregnancy: 6–10 fold increased risk from tubal damage
- Chronic pelvic pain: From adhesions — affects ~30% of women after PID
- Fitz-Hugh-Curtis syndrome: Perihepatitis — "violin string" adhesions between liver capsule and anterior abdominal wall. RUQ pain mimicking cholecystitis
UKMLA Exam Tips
- 1Cervical excitation (motion tenderness) = PID (or ectopic pregnancy). Classic exam finding
- 2Treat empirically — do NOT wait for swab results. Low threshold to treat
- 3BASHH regimen: ceftriaxone IM STAT + doxycycline 14 days + metronidazole 14 days
- 4Fitz-Hugh-Curtis: RUQ pain + PID. Violin string adhesions on laparoscopy. May mimic cholecystitis
- 5Single episode of PID → 15–20% risk of tubal subfertility
- 6IUD does NOT need routine removal in PID — leave in situ unless clinical deterioration
- 7Contact tracing: all partners in preceding 6 months
practicetest your knowledge on pelvic inflammatory diseaseApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — obstetrics and beyond.
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