Severe PID (peritonism, high fever), suspected tubo-ovarian abscess, pregnancy, or failure of oral treatment: admit for IV antibiotics, imaging, and gynaecology review. Always exclude an ectopic pregnancy.
Features
- Lower abdominal or pelvic pain, deep dyspareunia
- Abnormal bleeding or discharge
- Cervical motion tenderness, adnexal tenderness
- Fever in more severe disease
Organisms and tests
- Chlamydia and gonorrhoea; also Mycoplasma genitalium and anaerobes
- Endocervical or vulvovaginal NAAT swabs, plus microscopy if available
- Pregnancy test (exclude ectopic), HIV and syphilis serology
- A negative swab does not exclude PID
Mild to moderate
- Pelvic pain, discharge, tenderness
- Outpatient ceftriaxone, doxycycline, metronidazole
- Test for STIs, review at 72 h
Severe
- Fever, vomiting, signs of sepsis
- Admit for IV antibiotics
- Exclude an abscess
Tubo-ovarian abscess / sepsis
- Mass on imaging, septic
- IV antibiotics, surgical or IR drainage
- Resuscitate
Treatment
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1. Treat empirically
Do not wait for swab results if PID is likely: a typical outpatient regimen is ceftriaxone IM, plus doxycycline and metronidazole for 14 days (follow local or BASHH guidance).
Do not wait for swab results if PID is likely: a typical outpatient regimen is ceftriaxone IM, plus doxycycline and metronidazole for 14 days (follow local or BASHH guidance).
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2. Analgesia and advice
Pain relief, rest, and avoid unprotected intercourse until she and partners are treated. Remove an IUD only if no improvement, after discussion.
Pain relief, rest, and avoid unprotected intercourse until she and partners are treated. Remove an IUD only if no improvement, after discussion.
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3. Partner notification
Test and treat recent sexual partners and arrange sexual health follow-up.
Test and treat recent sexual partners and arrange sexual health follow-up.
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4. Review
Review at 72 h: if no improvement, reconsider the diagnosis, consider admission, IV antibiotics or imaging, and laparoscopy if needed.
Review at 72 h: if no improvement, reconsider the diagnosis, consider admission, IV antibiotics or imaging, and laparoscopy if needed.
Complications to warn about
- Tubo-ovarian abscess
- Fitz-Hugh-Curtis (perihepatitis)
- Chronic pelvic pain, infertility, and future ectopic risk
Pitfalls
- Waiting for swabs before treating
- Missing an ectopic pregnancy
- Too short a course or stopping early
- Not treating partners (reinfection)
MedPrep - www.medprep.uk - Educational revision aid only. Not clinical guidance. Doses are adult examples; check the BNF, current guidelines and local policy, and seek senior advice. Nov 2026