Lawrence S. Neinstein, M.D., F.A.C.P.
Professor of Pediatrics and Medicine
USC Keck School of Medicine
Executive Director
University Park Health Center
Associate Dean of Student Affairs
   

 

 

Sexuality - Sexually Transmitted Infections - Pelvic Pain (B3)

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PELVIC PAIN

Adolescent females presenting with pelvic pain or lower abdominal pain make up the next symptom complex of STDs. The differential diagnosis includes:

  • Pelvic inflammatory disease
  • Trichomoniasis
  • Herpes Simplex
  • Ectopic Pregnancy
  • Ruptured Ovarian Cyst or torsion of the ovary
  • Cystitis
  • Appendicitis

Pelvic inflammatory disease always has to be considered in the evaluation of lower abdominal pain or pelvic pain in the adolescent and can be a difficult clinical diagnosis. Both hospitalizations and visits for presumed PID appear to be falling in recent years. This is likely due to the falling prevalence of both chlamydia and gonorrhea infections. Symptoms and signs of PID may include

  • Abdominal Pain: Usually bilateral and lower in location but 8% of cases are unilateral
  • Pelvic Tenderness - present 100% of time
  • Abnormal Uterine Bleeding - about 35% of cases
  • Vaginal discharge in about 20% of cases
  • Nausea and Vomiting in about 25% of cases
  • Fever in about 35% of cases
  • Elevated White Count in about 50% of cases
  • Elevated ESR in about 75% of cases
  • RUQ tenderness - 10%-20% of cases

Some comments on the above signs and symptoms. None of them are both highly sensitive and highly specific for the diagnosis of PID. Significant nausea and vomiting is probably more indicative of a gastrointestinal process and might raise more concern about an appendicitis. Most teens do not have a fever and the elevated white count or sed rate, if present, is often not significant and not very specific. The presence of right upper quadrant tenderness with associated pelvic signs and symptoms can be very helpful as this can lead one to the diagnosis of Fitz-Hugh Curtis syndrome (perihepatitis). This is a perihepatitis that is associated with a chlamydial or gonorrhea infection.

The minimal criteria for diagnosis according to CDC include uterine or adnexal tenderness OR cervical motion tenderness.

Other criteria suggestive of infection include:

  • Oral temperature > 101 F
  • Abnormal cervical or vaginal mucopurulent DC
  • WBCs on wet prep of vaginal secretions
  • Elevated ESR or CRP
  • Positive cervical GC or CT test

It should be noted that most females with PID have a mucopurulent discharge OR evidence of WBCs on a vaginal fluid wet prep. The diagnosis of PID is unlikely without a cervical discharge or WBCs on wet prep of vaginal secretions.

The most common organisms involved in PID are N. Gonorrhoeae and C. Trachomatis. However, most women have mixed infections with either one or both of these organisms and other nongonococcal/nonchlamydial organisms. The longer the duration of the infection, the more likely the infection is with mixed flora.

As mentioned, the clinical diagnosis is difficult because there is no combination of highly sensitive and specific clinical criteria. If one uses more general criteria such as lower abdominal pain or tenderness, one can be 100% sensitive in the diagnosis, but specificity is below 20%. If one adds multiple other criteria such as fever, elevated sedimentation rate and adnexal mass, one can reach a 96% specificity but one would only diagnose 17% of the cases (17% sensitivity).

In fact, clinical criteria can be quite inaccurate compared to laparoscopic findings as this older study from Sweden demonstrates. Table 1 shows the findings in over 800 woman admitted to the hospital with the clinical diagnosis of salpingitis and the final diagnosis made after laparoscopy.

Table 1: Women with clinical diagnosis of Salpingitis
Laproscopic Findings Number

Acute salpingitis
532
Normal findings 184
Acute appendicitis 24
Endometriosis 16
Corpus Luteum bleeding 12
Ectopic pregnancy 11
Chronic PID adhesions 6
Ovarian tumor 7
Mesenteric lymphadenitis 6
Misc. 16

Table 2 shows the women with other clinical diagnoses on hospital admission but with a final diagnosis of salpingitis after laproscopy

Table 2: Women with laproscopic salpingitis but other clinical diagnoses on admission
Clinical Diagnosis on Admission Number

Ovarian cyst
20
Acute Appendicitis 18
Ectopic Pregnancy 16
Chronic Salpingitis 10
Other (fibroids, endometriosis) 27

Thus there were many clinical false and positive diagnoses.

So, if one clinical suspects PID what are the indications for hospitalization? In fact, there are no studies to demonstrate cost-effectiveness of any of these modalities. However, the CDC suggests the following criteria for hospital admission.

  • The diagnosis is uncertain (e.g. one suspects an appendicitis or ectopic pregnancy)
  • Pelvic abscess is suspected
  • Patient is pregnant
  • Patient is adolescent
  • Patient has HIV
  • Severe illness or nausea and vomiting
  • Patient is unable to follow/tolerate outpatient treatment
  • Failure to respond to outpatient therapy or unable to return for follow-up

While the CDC guidelines review complete treatment options, some general guidelines include:

  • Complete a course of 14 days of antibiotics
  • Treat partners in past 60 days
  • Use a non-steroidal anti-inflammatory medication for pain
  • The single dose azithromycin regimen should not be used for PID
  • If a tubo-ovarian abscess is diagnosed than clindamycin or metronidazole should be part of the treatment

One major complication of PID is infertility. However, after one episode, the infertility rate is very similar to the general population. Even after three episodes, many women become pregnant. Infertility should not be used as a consequence to "enhance compliance". This can be counterproductive as the teen may feel that if they are not compliant, they may be infertile and thus do not need contraception. The duration of pain might be a better counseling tool for enhancing compliance.

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Copyright (©) 2004-2013 Lawrence S. Neinstein, University of Southern California . All rights reserved. Republication or redistribution of the text, table, graphs and photos is expressly prohibited. The University of Southern California shall not be liable for any errors or delays in the content, or for any actions taken in reliance thereon.