A 15-year-old female came to the emergency room with lower abdominal pain for 1 week. The pain was described as constant mild pain with episodes of worsening. She stated she had increased urinary frequency but no urgency, change in urine color or smell. She had normal stooling. The patient had her normal period 2 weeks ago and was sexually active without consistent use of any contraceptive method including condoms. She stated that she had a vaginal discharge but could not describe it further. She was also having some back pain. She had had no fever, chills, rash, and had been eating well. The past medical history was positive for a previous episode of pelvic inflammatory disease caused by Chlamydia several months previous that was diagnosed by cervical cultures and treated as an outpatient. Social history revealed tobacco smoking and beer drinking but no other alcohol or drugs. She denied any violence or being involved with the police. She was taking an anti-depressant.
The pertinent physical exam showed an alert female in no distress with normal vital signs and growth parameters. Abdominal examination showed lower abdominal/suprapubic diffuse tenderness without radiation with no guarding. There was no flank tenderness or pain reproduction with palpation of the back. Her genitourinary examination showed a normal introitus. She had a nulliparous appearing cervix with yellowish discharge from it. Bimanual examination revealed cervical motion tenderness without adnexal fullness or masses. The uterus was anteverted and normal size. The rest of her examination was normal. The work-up included a normal urinalysis and a negative pregnancy test. Urinary screening test for Chlamydia trachomatis was positive as was a cervical culture later on. Urine screening and cervical cultures for Neisseria gonorrhea were negative. The diagnosis of recurrent pelvic inflammatory disease was made. The patient was treated with azithromycin, ceftriaxone in the emergency room and also to continued to take the doxycycline she was already taking for acne. The patient’s mother was very concerned about her daughter but refused human immunodeficiency virus screening as this had previously been done. The mother wanted to followup with a regularly scheduled appointment in 2 days with her daughter’s adolescent medicine specialist. The mother assured the emergency room physician that ongoing gynecological, psychological and social care was being obtained for her daughter, and appointments in the electronic medical record system supported the mother.
Pelvic inflammatory disease (PID) is an inflammatory disease of the uterus, fallopian tubes and adjacent pelvic structures caused by ascending microorganisms from the vagina and cervix particularly Neisseria gonorrhea and Chlamydia trachomatis. Increased risks for PID includes early age at first intercourse, multiple sexual partners, intrauterine device insertion and tobacco smoking. Approximately 11% of reproductive age women are affected. PID increases the risk of dyspareunia, chronic pelvic pain, pyosalpinx, tubo- ovarian abscess, pelvic adhesions, ectopic pregnancy, and infertility. The overall complication rate is ~15-20% and these often require surgical treatment.
After 1 episode of PID, about 12% of women will be infertile. After a second episode this rises to ~25% and after a 3rd episode this increases to ~50%. Overall there is a doubling of the risk of infertility after each episode.
The PEACH (Pelvic Inflammatory Disease Evaluation and Clinical Health) study which evaluated outpatient versus inpatient treatment for PID found a rate of ~18% infertility with a mean long-term followup of 35 months. This study included patients 14-37 years but without subgroup analysis of adolescents. In another study, these researchers found that barrier methods (especially male condoms) significantly helped to prevent chronic pelvic pain, recurrent PID, and infertility.
Questions for Further Discussion
1. What are the recommended treatment options for PID?
2. What are the recommendations for treating partners of patients with known PID and how are the partners contacted locally?
3. What are the legal requirements for treating minors with sexually transmitted infections?
- Age: Teenager
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Ness RB, Soper DE, Holley RL, Peipert J, Randall H, Sweet RL, Sondheimer SJ, Hendrix SL, Amortegui A, Trucco G, Songer T, Lave JR, Hillier SL, Bass DC, Kelsey SF. 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 May;186(5):929-37.
Ness RB, Randall H, Richter HE, Peipert JF, Montagno A, Soper DE, Sweet RL, Nelson DB, Schubeck D, Hendrix SL, Bass DC, Kip KE. Pelvic Inflammatory Disease Evaluation and Clinical Health Study Investigators. Condom use and the risk of recurrent pelvic inflammatory disease, chronic pelvic pain, or infertility following an episode of pelvic inflammatory disease. Am J Public Health. 2004 Aug;94(8):1327-9.
Lareau SM, Beigi RH. Pelvic inflammatory disease and tubo-ovarian abscess. Infect Dis Clin North Am. 2008 Dec;22(4):693-708, vii.
Hills JB, Lockrow E. Pelvic Inflammatory Disease. eMedicine.
Available from the Internet at http://emedicine.medscape.com/article/256448-overview (rev. 8/27/2009, cited 11/30/09).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
19. The health professional works effectively with others as a member or leader of a health care team or other professional group.
22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital