Just three months after having a normal physical examination, a young woman complains of lower-abdominal pain. What did her clinician miss?
This is the second of a three-part series on sexually transmitted diseases. Part 3 will appear in the July issue.
A 19-year-old woman requests a physical exam required for her application as a camp counselor. She has no significant medical history, takes no medications, and has no known drug allergies. Immunizations are up to date. Her menses started at age 14 and are regular, with the last menstrual period (LMP) two weeks earlier. Findings on her physical exam are normal.
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Three months later, she presents with a complaint of intermittent lower-abdominal pain during the previous week. The pain is not related to food intake, and she has no nausea, vomiting, diarrhea, fever, or chills. She reports no vaginal discharge or dyspareunia, and she has no dysuria, frequency, or urgency. Her LMP was a week before. She has one current boyfriend.
Gather additional history
A sexual history should be part of the usual workup, particularly in this scenario. The patient, who has been sexually active for one year, has no history of sexually transmitted disease (STD). She has been with her current boyfriend for two months (before him, she had two other partners). She engages in vaginal and occasional oral sex. With her current partner, she uses condoms most of the time for vaginal sex but not for oral sex. He has no symptoms. Her last sexual encounter occurred approximately two weeks ago.
On examination, her temperature is 98.4°F, pulse 70 beats per minute, BP 110/74 mm Hg; the patient is in no distress.
Abdominal examination reveals normal bowel sounds and liver and spleen of normal size. There is no abdominal tenderness, costovertebral angle tenderness, rigidity, or rebound. The patient has normal external genitalia without any lesions and scant vaginal discharge. There is no cervical discharge or friability. On bimanual exam, cervical motion tenderness is found. The uterus appears of normal size and is slightly tender. The adnexa are within normal limits and nontender, with no masses palpable.
Search for a probable diagnosis
There is a broad differential for lower-abdominal pain in a young woman, but this patient’s symptoms are most consistent with pelvic inflammatory disease (PID), given the cervical motion and uterine tenderness. Women with PID can experience lower-abdominal pain, cramping, dyspareunia, postcoital bleeding, vaginal discharge, and/or dysuria. The clinical presentation varies in intensity and may be minimal.1 Many cases of acute salpingitis cause no symptoms.
Because PID is difficult to accurately diagnose in an office setting without ultrasound or laparoscopy, the CDC has developed minimum criteria: uterine tenderness or adnexal tenderness or cervical motion tenderness. The criteria are useful in sexually active young women and other women at risk for STDs. The clinical diagnosis of PID is imprecise, but the potential long-term repercussions of missing a case are thought to outweigh the risk of overdiagnosis.2
Other possible diagnoses include ectopic pregnancy, ovarian cyst, appendicitis, UTI, and mittelschmerz. These diagnoses are unlikely. Even less likely are more chronic causes of lower-abdominal pain, such as endometriosis, inflammatory bowel disease, and other GI conditions.
Clarify the diagnosis with laboratory testing
Ectopic pregnancy can present with similar symptoms, and even though this patient had a period since her last sexual encounter, a urine pregnancy test should be done to rule out early pregnancy with vaginal spotting.
A wet mount of vaginal discharge to assess for WBCs and evidence of bacterial vaginosis (BV) should be done. The presence of abundant WBCs on saline microscopy of vaginal discharge provides additional support for a diagnosis of PID.2,3 BV, which has been linked to PID,2,4 is diagnosed when any three of the following are found: homogeneous adherent discharge, clue cells on microscopy, vaginal fluid pH >4.5, and positive whiff test (amine/fishy odor of vaginal fluid alone or with the addition of 10% KOH solution).
Other criteria that enhance the specificity of a clinical PID diagnosis are oral temperature >101ºF (>38.3°C), abnormal cervical or vaginal mucopurulent discharge, elevated erythrocyte sedimentation rate, elevated C-reactive protein, and laboratory documentation of chlamydia or gonorrhea infection.
Nucleic acid amplification tests (NAATs) for cervical chlamydia and gonorrhea should be performed. While Chlamydia trachomatis and Neisseria gonorrhoeae are frequent PID pathogens, negative screening results do not rule out upper-tract infection. Some experts would recommend screening for syphilis and HIV because having one STD puts a woman at risk for others.
In this case, the wet mount reveals numerous WBCs. Vaginal pH is normal (4.0). No trichomonads, clue cells, hyphae, or yeast cells are seen. The whiff test is negative, as is the pregnancy test. NAATs are sent for gonorrhea and chlamydia, with results pending. HIV and syphilis testing is also performed.
Presumptive treatment first
Empiric outpatient treatment for PID is warranted.5 Since the etiology of PID is polymicrobial, broad-spectrum regimens are utilized.2 Inpatient treatment is recommended in any of the following scenarios: inability to rule out surgical emergencies, such as appendicitis; pregnancy; failure to respond to outpatient oral therapy; inability to tolerate outpatient oral regimen; severe illness, nausea and vomiting, or high fever; or tubo-ovarian abscess.
The patient is treated with ceftriaxone 250 mg IM and doxycycline 100 mg orally twice a day for 14 days. Fluoroquinolone regimens should be used with caution in areas with high rates of drug-resistant gonorrhea (e.g., California and Hawaii). She is counseled about PID and how to reduce her risk for re-infection as well as other STDs. In addition, she is instructed to maintain abstinence until completion of therapy and to avoid douching. Birth-control options are also discussed.
Don’t forget to treat the partner(s)
All sexual partners during the 60 days prior to the appearance of symptoms should be evaluated and treated. Empiric treatment for both chlamydia and gonorrhea are recommended regardless of the patient’s test results.
Ensure close follow-up
At follow-up three days later, the patient is showing improvement. The lower-abdominal pain has almost resolved. Her partner has been tested and started on treatment. The woman’s lab results are positive for chlamydia and negative for gonorrhea. All other tests are negative.
Women recently diagnosed with chlamydia are at high risk for reinfection.2 Retest the patient for chlamydia in three months.
Prevent PID in the next patient
The patient’s exam for her summer job was a missed opportunity to assess STD risk and to perform chlamydia and gonorrhea screening. The U.S. Preventive Services Task Force, CDC, and other medical associations recommend routine chlamydia screening for women 25 years and younger.6 Studies show chlamydia screening reduces the incidence of PID.7 Gonorrhea screening is similarly recommended for women 25 years and younger.8
For more information about STDs, see the resources page of the California STD/HIV Prevention Training Center at www.stdhivtraining.org. For further information about STD training, visit www.stdhivpreventiontraining, the Web site of the National Network of STD/HIV Prevention Training Centers (NNPTC).
Dr. Adler, a family physician by training, is a clinical instructor at the California STD/HIV Prevention Training Center in Oakland. She wishes to credit her colleagues Heidi Bauer, MD, MS, MPH, Helene Calvet, MD, and Linda Creegan, MS, FNP, for their assistance.
References
1. Crossman SH. The challenge of pelvic inflammatory disease. Am Fam Physician. 2006;73:859-864.
2. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2006. MMWR. 2006;55(RR-11):1-94. Available at: www.cdc.gov/std/treatment/default.htm. Accessed May 14, 2007.
3. Yudin MH, Hillier SL, Wiesenfeld HC, et al. Vaginal polymorphonuclear leukocytes and bacterial vaginosis as markers for histologic endometritis among women without symptoms of pelvic inflammatory disease. Am J Obstet Gynecol. 2003;188:318-323.
4. Ness RB, Hillier SL, Kip KE, et al. Bacterial vaginosis and risk of pelvic inflammatory disease. Obstet Gynecol. 2004;104:761-769.
5. Ness RB, Soper DE, Holley RL, et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol. 2002;186:929-937.
6. U.S. Preventive Services Task Force. Screening for chlamydial infection: recommendations and rationale. Am J Prev Med. 2001;20(3 Suppl):90-94. Available at www.ahrq.gov/clinic/ajpmsuppl/chlarr.pdf. Accessed May 14, 2007.
7. Scholes D, Stergachis A, Heidrich FE, et al. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. N Engl J Med. 1996;334:1362-1366.
8. U.S. Preventive Services Task Force. Screening for gonorrhea: recommendation statement. Ann Fam Med. 2005;3:263-267. Available at www.ahrq.gov/clinic/uspstf05/gonorrhea/gonrs.htm. Accessed May 14, 2007.
