Sexually Transmissible Infections in Clinical Practice

14. A Young Woman with Abdominal Pain (1)

Alexander McMillan1, 2  

(1)

Department of Genitourinary Medicine, NHS Lothian, Edinburgh Royal Infirmary, Edinburgh, Uk

(2)

University of Edinburgh, Edinburgh, Uk

Alexander McMillanFormerly, Consultant Physician, part-time Senior Lecturer

Email: a.amcmm@btinternet.com

Abstract

Sarah, an 18-year-old woman, presents to her General Practitioner with a 1-week history of intermittent cramping lower abdominal pain and increased vaginal discharge. She has felt feverish. Her bowel movements have been normal and she has had no urinary symptoms. For the past 4 months she has been in a regular relationship with a young man. They last had sex 3 days previously during which Sarah experienced lower abdominal pain. Her menstrual cycle has always been regular, the last period having been 3 weeks previously and normal. She has, however, noticed intermittent slight vaginal bleeding since then. Condoms are used for contraception, but occasionally, most recently 3 weeks ago, intercourse has been unprotected.

Sarah, an 18-year-old woman, presents to her General Practitioner with a 1-week history of intermittent cramping lower abdominal pain and increased vaginal discharge. She has felt feverish. Her bowel movements have been normal and she has had no urinary symptoms. For the past 4 months she has been in a regular relationship with a young man. They last had sex 3 days previously during which Sarah experienced lower abdominal pain. Her menstrual cycle has always been regular, the last period having been 3 weeks previously and normal. She has, however, noticed intermittent slight vaginal bleeding since then. Condoms are used for contraception, but occasionally, most recently 3 weeks ago, intercourse has been unprotected.

14.1 What Conditions Do You Consider in the Differential Diagnosis?

Table 14.1 shows some conditions associated with lower abdominal pain in a young woman.

Table 14.1.

Causes of lower abdominal pain in a young woman.

Ectopic pregnancy

Pelvic inflammatory disease

Acute appendicitis

Ruptured ovarian cyst/follicle

Ovarian torsion

Miscarriage

Urinary tract infection

Urinary calculi

Enteritis

In a young sexually active woman, pelvic inflammatory disease (PID) or ectopic pregnancy must be considered high on the list of probabilities. In acute appendicitis, the nausea is usually more pronounced, and constipation is a common feature. As the pain is severe and usually of sudden onset, rupture of an ovarian or endometriotic cyst is an unlikely cause. The lack of urinary and gastrointestinal symptoms makes conditions such as cystitis or enteritis, respectively, unlikely.

She looks well and is not in obvious distress. Her temperature is 37.2°C, her pulse is 75 per minute, and her blood pressure is 130/75 mmHg. The abdomen moves well with respiration. She has tenderness but no guarding in both iliac fossae. Neither liver nor spleen is palpable. Bowel sounds are present. When she is examined vaginally, mucopus exudes from the cervical os. Movement of the cervix elicits pain in the lower abdomen, and she is tender in both vaginal fornices. A urine test for pregnancy is negative.

14.2 What Are the Most Likely Diagnoses?

The clinical findings strongly support the diagnosis of PID: bilateral abdominal tenderness, pain on moving the cervix, and tenderness in both vaginal fornices. An additional sign is that of inflammation of the endocervical canal. In the case of ectopic pregnancy, tenderness is usually unilateral and not bilateral as is usually found in PID. Clinical signs, however, are unreliable in differentiating between ectopic pregnancy and PID. In acute appendicitis tenderness in the right iliac fossa is more likely than bilateral tenderness as in this case.

Table 14.2 shows the organisms associated with PID. In geographical areas where the prevalence of gonorrhoea is low, such as the United Kingdom, Chlamydia trachomatisis the most common cause of PID.

Table 14.2.

Micro-organisms associated with pelvic inflammatory disease.

Chlamydia trachomatis

Neisseria gonorrhoeae

Mycoplasma genitalium

Anaerobica and facultative bacteria, including: Peptostreptococcus spp., Prevotella spp., Gardnerella vaginalis

aParticularly in older women, in those using an intrauterine contraceptive device, and in those with suppurative disease.

As the diagnosis is likely to be PID, the GP refers Sarah to a Sexual Health clinic where the history and physical findings are confirmed. A serum level of human chorionic gonadotrophin (hCG) is <100 m I.U./mL. Gram-stained smears of urethral and endocervical material are prepared as described in Case 2and specimens are sent for the detection of gonococcal and chlamydial infections by nucleic acid amplification assays.

The Gram-stained smear of cervical exudate shows large numbers of polymorphonuclear leucocytes (>30 per ×1,000 microscopical field), but Gram-negative diplococci are not seen in this or in the urethral sample.

14.3 What Is Your Next Course of Action?

Although the low levels of hCG make pregnancy unlikely,1 if there is any doubt, referral to a gynecologist is advised. Abdominal and/or transvaginal ultrasonography, together with knowledge of the hCG levels, can be useful in the diagnosis of ectopic pregnancy.

Although the finding of many white cells in the cervical specimen makes alternative diagnoses less likely, this test has a low positive predictive value. Having made a presumptive diagnosis of PID, however, Sarah should be treated before the results of the microbiological laboratory tests are available. There is some evidence that delay in initiating therapy is associated with increased subsequent morbidity, including the risk of infertility due to tubal fibrosis, increased risk of ectopic pregnancy from damage to ciliary motility, and chronic pelvic pain resulting from pelvic adhesions.

Table 14.3 shows the outpatient drug regimens used in the treatment of mild to moderate PID. In severe disease,2 initial treatment is by the parenteral route, with a switch to oral therapy 24 h after clinical improvement.

Table 14.3.

Drug regimens for the treatment of mild to moderate pelvic inflammatory disease.

Ceftriaxone 250 mg as a single intramuscular injection

PLUS

Doxycycline 100 mg twice daily by mouth PLUS metronidazole 400 mg twice daily by mouth, both given for 14 days

OR

Ofloxacin 400 mg twice daily by mouth PLUS metronidazole 400 mg twice daily by mouth both given for 14 days

Paracetamol is provided as analgesia, and Sarah is advised to abstain from sexual intercourse until she and her partner has completed treatment.

As women with mild PID are less likely to have anaerobic bacteria isolated from the uterine tubes than those with severe, suppurative infection, metronidazole may be discontinued if the patient is unable to tolerate his drug.

Partner notification is undertaken, and her partner attends the next day for treatment. He is symptomless, and a subsequent urine sample for the detection of C. trachomatis and N. gonorrhoeae yields negative results. Nevertheless, as false-negative results for chlamydiae can occur, he receives empirical treatment with a single oral dose of 1 g of azithromycin.

Sarah is reviewed 72 h after initiation of therapy with doxycycline and metronidazole. Her abdominal pain has improved considerably, and she is tolerating the antimicrobial regimen well. Chlamydia trachomatis but not N. gonorrhoeae was detected in the endocervical specimen taken at the first attendance.

It is recommended that patients with PID are reviewed 4 weeks after therapy to ensure that the clinical response has been satisfactory and that partner notification has been completed (see Case 6).

Six months later, Sarah has now married her partner and both wish to start a family. She has heard that chlamydia and PID may cause infertility and wishes to discuss this with you.

In gonococcal and chlamydial salpingitis, the inflammatory process affects chiefly the mucosal lining of the uterine tubes, the organisms having ascended from the endocervical canal by way of the endometrium. There is destruction of tubal epithelium and a purulent exudate fills the lumen. If untreated, fibrous adhesions form within the tube and tubal infertility may result. However, the magnitude of the risk of infertility is difficult to quantify. Scandinavian studies conducted in the 1980s suggested that between 8 and 16% of women were involuntarily infertile after an episode of PID. However, the spectrum of severity of PID varies widely, and it is difficult to draw firm conclusions based on studies of women who may have had more severe disease. (It is known that among patients with only one episode of PID, the incidence of tubal infertility is higher in those who have severe inflammation at laparoscopy than mild inflammation). Repeated or chronic infection with C. trachomatis increases the likelihood of long-term sequelae. In women with repeated episodes of pelvic inflammatory disease, the risk of permanent tubal damage and consequent infertility doubles with each recurrent episode. This is not the case here, however, as Sarah has experienced only one episode of mild-to-moderately severe PID.

A recent study suggested that about 7% of women who had ever been treated for chlamydial infection had infertility, a lower rate than previously reported. This is therefore reassuring for Sarah and her partner.

Footnotes

1

Serum chorionic gonadotrophin (hCG) assays on serum and urine can detect pregnancy within 7–10 days and 14–18 days post-ovulation, respectively. It is therefore possible to diagnose pregnancy before the first missed period.

2

Severe disease is associated with fever (temperature >38°C), malaise, anorexia, and vomiting. There is tenderness and guarding in the lower abdomen. The total white cell count in the peripheral blood is elevated and both the erythrocyte sedimentation rate (ESR) and the C-reactive protein concentration are raised, particularly in chlamydial PID.