Intended for healthcare professionals

Practice Easily Missed?

Pelvic inflammatory disease

BMJ 2013; 346 doi: (Published 23 May 2013) Cite this as: BMJ 2013;346:f3189
  1. Emily C Bartlett, foundation year 2 doctor in genitourinary medicine1,
  2. Wendy B Levison, general practitioner2,
  3. Pat E Munday, retired consultant genitourinary physician3
  1. 1King’s College Hospital, Denmark Hill, London SE5 9RS, UK
  2. 2Callowland Surgery, Watford, Hertfordshire, UK
  3. 3West Hertfordshire Hospitals NHS Trust, Watford General Hospital, Watford, Hertfordshire, UK
  1. Correspondence to: E C Bartlett Emily.Bartlett{at}
  • Accepted 12 April 2013

A 22 year old woman in a new sexual relationship presented to her general practitioner with slightly painful intermenstrual bleeding for 10 days. She had pelvic tenderness but no cervical excitation on bimanual examination. The doctor suspected that the bleeding was a side effect of the oral contraceptive pill, started three months earlier. However, as he was unable to rule out pelvic inflammatory disease (PID), endocervical swab samples were taken to test for the sexually transmitted infections caused by Neisseria gonorrhoeae and Chlamydia trachomatis, and broad spectrum antibiotics prescribed, after which the symptoms resolved. The swab sample confirmed the presence of C trachomatis.

What is PID?

PID is due to infection of the upper female genital tract resulting in a wide range of pelvic pathology, from mild endometritis to pelvic peritonitis. Causative organisms are either sexually transmitted (such as C trachomatis, N gonorrhoeae, Mycoplasma genitalium) or endogenous vaginal organisms (for example, Bacteroides species) that ascend into the pelvic area from the lower genital tract through the cervix.

How common is PID?

  • Because of the difficulties in diagnosis, the exact prevalence of PID is not known

  • Recent data suggest that the rate of definite PID diagnosis in primary care is about 280/100 000 person years1

  • This may underestimate the true incidence, as many cases are relatively asymptomatic

  • PID is most common in women aged 20-291

Why is PID missed?

PID may present with classic symptoms and signs or with mild and subtle symptoms that may be easy to miss, according to a review of the evidence in national guidelines written by the British Association for Sexual Health and HIV.2

The best recent data on easily missed PID come from a retrospective audit in a walk-in centre for sexual health. This showed significantly different rates for the diagnosis of PID among 23 doctors, compared with similar rates …

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