Sexually Transmissible Infections in Clinical Practice

27. A Young Woman with Abdominal Pain

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

Amanda, a 21-year-old student, attends a Sexual Health clinic because her boyfriend had been diagnosed as having urethral chlamydial infection 2 days previously. She tells you that for the past 2 weeks she has had intermittent lower abdominal discomfort, particularly on the right side. She also complains of persistent pain in the right upper abdomen, the pain radiating intermittently to the right shoulder, and being exacerbated by deep inspiration. Her periods have been regular, the most recent having been 14 days previously, and had been normal. She has not noticed increased vaginal discharge, but she has had some vaginal bleeding during the past week. There are no urinary or gastrointestinal symptoms. She has been in a regular relationship for 3 months, and she had had unprotected vaginal intercourse with her partner 2 days prior to her clinic attendance. Over the preceding 3 weeks she has had lower abdominal pain during intercourse. For 5 years she has used the combined oral contraceptive, and she has not missed any pills in the recent past. Her general health has been good, and she has not had any serious illnesses in the past.

Amanda, a 21-year-old student, attends a Sexual Health clinic because her boyfriend had been diagnosed as having urethral chlamydial infection 2 days previously. She tells you that for the past 2 weeks she has had intermittent lower abdominal discomfort, particularly on the right side. She also complains of persistent pain in the right upper abdomen, the pain radiating intermittently to the right shoulder, and being exacerbated by deep inspiration. Her periods have been regular, the most recent having been 14 days previously, and had been normal. She has not noticed increased vaginal discharge, but she has had some vaginal bleeding during the past week. There are no urinary or gastrointestinal symptoms. She has been in a regular relationship for 3 months, and she had had unprotected vaginal intercourse with her partner 2 days prior to her clinic attendance. Over the preceding 3 weeks she has had lower abdominal pain during intercourse. For 5 years she has used the combined oral contraceptive, and she has not missed any pills in the recent past. Her general health has been good, and she has not had any serious illnesses in the past.

27.1 What Conditions Would You Consider as Causes of Her Abdominal Symptoms?

Amanda is a known sexual contact of a man with chlamydiae, and it is highly likely that she will also be infected. A common complication of chlamydial infection in women is pelvic inflammatory disease (PID) – an estimated 10% of infected women develop PID – and the history is compatible with this diagnosis. Pain in the right upper abdomen may be a manifestation of perihepatitis (Fitz–Hugh–Curtis syndrome), resulting from chlamydiae tracking from the uterine tubes to the liver capsule.

Other conditions, however, need to be considered (see Case 14, Table 14.1). Acute appendicitis, mesenteric lymphadenitis, and regional ileitis can produce right-sided lower abdominal pain, and, of course, ectopic pregnancy has to be excluded. The absence of urinary symptoms speaks against urinary tract infection or ureteric calculus. Pain in the right hypochondrium may result from acute cholecystitis, or from right-sided pleurisy.

Amanda looks distressed and in considerable abdominal pain. Her temperature is 37.5°C, and her pulse rate 90 per minute. There are no abnormal chest findings. The abdomen moves with respiration. She is tender over the right hypochondrium but the liver is not palpable. There is tenderness with rebound in the right but not the left iliac fossa. Bowel sounds are present, but a friction rub is not heard over the right hypochondrium. The cervix appears normal, and pain is not elicited when it is moved. There is minimal tenderness in the right but not in the left fornix; the uterine tubes cannot be felt, and there are no pelvic masses. A pregnancy test on a urine sample is negative. Gram-smear microscopy of endocervical material shows numerous polymorphonuclear leucocytes but no Gram-negative diplococci.

The hemoglobin concentration in the peripheral blood is 118 g/L, the total white cell count is 9.9 × 10 9 /L, and the polymorphonuclear count is 8.2 × 10 9 /L. The erythrocyte sedimentation rate (ESR) is 90 mm. The plasma bilirubin concentration and plasma enzyme tests of liver function are normal.

27.2 Do the Clinical and Laboratory Findings Aid the Differential Diagnosis?

Although a negative pregnancy test does not rule out ectopic pregnancy, this is an unlikely diagnosis because she had a normal period some 14 days previously, she uses oral contraception consistently, and a mass is not found on pelvic examination. The most likely diagnosis remains PID with perihepatitis. However, the predominantly right-sided abdominal pain with minimal pelvic tenderness raises the possibility that she has acute appendicitis. Laparoscopy is therefore arranged.

Fibrinous adhesions between the liver, diaphragm, and anterior abdominal wall were found. The uterine tubes appeared normal.

The laparoscopic findings confirm the diagnosis of perihepatitis, most likely caused by chlamydiae. Indeed a subsequent report from the microbiology laboratory confirmed that Chlamydia trachomatis had been identified in endocervical specimen taken on the day of her clinic attendance; nucleic acid amplification assay for Neisseria gonorrhoeae yielded negative results.

Laparoscopy is not a routine investigation in women with suspected PID. If there is doubt about the diagnosis, in particular if a surgical emergency cannot be ruled out from the clinical findings as in this case, however, laparoscopy is a useful tool. The tubes may appear edematous and reddened, and exudate may be seen on the tubal surface. In early PID, the inflammatory reaction in the tubes may not extend to the serosal surface, and therefore the tubes may appear normal at laparoscopy. This may explain the finding in this case.

Amanda is treated with ofloxacin and metronidazole (see Case 14, Table 14.3) and is reviewed 72 h after initiation of therapy. Her abdominal pain has improved considerably, and she is tolerating the antimicrobial regimen well.

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.