Abstract
Educational Objectives
Identify and treat patients with pelvic inflammatory disease (PID).
Establish and maintain a therapeutic relationship with an adolescent seeking care for PID.
Language for Sex and Gender
We recognize that the majority of people affected by pelvic inflammatory disease [PID] are women and girls. We use language that affirms the identities of all people who are affected by PID, including gender non-binary people and trans boys and men. Therefore, when referring to the patient in this particular case, we use the patient’s pronouns “she” and “her,” and when referring to patients generally with PID, we use gender neutral language to describe both people and anatomy. When referencing other studies, we use the language of the authors, which may not distinguish appropriately between gender and anatomy.
Case Presentation
Day 1
A previously healthy, sexually active, cisgender female adolescent presented to urgent care for several days of bilateral, stabbing back pain. She was advised to take ibuprofen 600 MG as needed, up to three times daily (TID), and do stretching exercises.
Day 15
Two weeks later, the unaccompanied patient was evaluated in her primary care physician’s (PCP) office for four days of intermittent red/orange-appearing urine, urinary frequency, urinary urgency, and a sensation of incomplete voiding. She reported nausea without emesis, reduced appetite, watery diarrhea, diffuse abdominal pain (worse left lower quadrant [LLQ] and suprapubic), and back pain. She had pain with vaginal intercourse in the last few days and red/brown vaginal discharge. She stated that she had sex without a barrier method with a monogamous boyfriend of eight months and had an etonogestrel implant which was placed five months prior. She reported a history of frequent, untreated episodes that she thought were urinary tract infections (UTIs) for which she never sought medical care.
On physical examination, the patient was afebrile and in no apparent distress; she had hypoactive bowel sounds, abdominal tenderness over the right lower quadrant (RLQ) and suprapubic region, no rebound tenderness or tenderness over McBurney point (despite diffuse RLQ tenderness), negative Murphy sign, and positive bilateral costovertebral angle (CVA) tenderness. On genitourinary examination (bimanual and speculum), she had mild cervical motion tenderness (CMT) and no thickened, discolored, or odorous vaginal discharge. Urinalysis, urine culture, HIV antigen/antibody, cervical swab for trichomonas, syphilis, chlamydia, gonorrhea, and vaginal wet mount for bacterial vaginosis (BV) and yeast were all normal or negative. Her C-reactive protein (CRP) was within normal levels (WNL) and erythrocyte sedimentation rate (ESR) was elevated at 27 (normal limit, 0-13 mm/h).
Day 16
The laboratory results were reviewed with the patient the following day and she was treated for pelvic inflammatory disease (PID) with ceftriaxone intramuscular (IM) 500 mg, doxycycline 100 mg by mouth (PO) twice daily (BID) for 14 days, and metronidazole 500 mg (PO) BID for 14 days.
(Although treatment for the partner may have been indicated, it was not pursued in part due to the negative sexually transmitted infection (STI) tests and the patient’s relationship with her partner).
Day 19
Three days after starting the PID treatment, the patient presented to the emergency department (ED) for abdominal pain and back pain. Her examination showed a soft and nondistended abdomen but was notable for RLQ and right CVA tenderness. Repeat urinalysis showed ketones and trace blood with a negative culture. Her pregnancy test was negative. Her transvaginal ultrasound showed normal blood flow to the ovaries, a 1.4 × 1.7 × 2.3 cm left ovarian cyst, consistent with a dominant follicle, and was otherwise unremarkable. Her computed tomography (CT) scan (without contrast) showed no acute pathology within the abdomen or pelvis including no indication of pyelonephritis. She was discharged with instructions to continue PID antibiotic therapy and apply diclofenac gel to her back.
Day 22
The patient returned to her PCP where she reported that her nausea and pain had improved. The patient also had an improved abdominal examination with active bowel sounds and resolution of abdominal tenderness.
Discussion
Clinical Course
A sexually active cisgender female adolescent with a two-week history of back pain presented to clinic with red urine, dysuria, nausea, and diarrhea. On examination, she was found to have CMT and negative STI screens. She was diagnosed with PID. The patient visited the ED for continued abdominal pain three days after initiating treatment for PID. Imaging ruled out tubular ovarian abscess (TOA). She later returned to her PCP’s office with improved nausea and pain.
Final Diagnosis
Pelvic inflammatory disease.
Making a Diagnosis of PID
PID is a clinical diagnosis, and the Centers for Disease Control and Prevention (CDC) recommends presumptive treatment for women at risk of STIs with pelvic or lower abdominal pain AND at least one of the following four criteria: (1) no other cause for the illness can be identified, (2) CMT, (3) uterine tenderness, or (4) adnexal tenderness. 1
Supportive examination and laboratory findings include fever, vaginal discharge with white blood cells (WBCs) on microscopy, elevated CRP and ESR, and positive STI tests. These are not required for diagnosis. This patient had abdominal pain, CMT, and mildly elevated ESR. Timely diagnosis and prompt treatment should not wait for laboratory results and are imperative to avoid complications. 1 Frequently, as with this patient, STI results may be negative as testing for many implicated pathogens is not readily accessible (see section “Developing a Differential for Abdominal and Flank Pain in a Sexually Active Adolescent Cisgender Female”) and the available STI testing is conducted on a sample collected from the lower reproductive tract, not the upper reproductive organs.
Developing a Differential for Abdominal and Flank Pain in a Sexually Active Adolescent Cisgender Female
Several diagnoses were considered for this patient (Table 1). The differential diagnosis for PID can be even more broad.
Differential Diagnosis for an Adolescent Patient With Abdominal Pain and Flank Pain Who Reported Red/Orange Urine.
Abbreviations: WNL, within normal levels; CT, computed tomography; RLQ, right lower quadrant; TTP, tenderness to palpation; UTI, urinary tract infection; CVA, costovertebral angle; UA, urinalysis; NSAID, nonsteroidal anti-inflammatory drug; STI, sexually transmitted infection; LLQ, left lower quadrant; RLQ, right lower quadrant; PID, pelvic inflammatory disease; CMT, cervical motion tenderness; ESR, erythrocyte sedimentation rate; CRP, C-reactive protein.
Epidemiology of PID
PID is an infection of the uterus, fallopian tubes, and/or ovaries, defined as the progression of anaerobes from the vagina to the endometrium and adnexa for fewer than 30 days. 2
PID is not a reportable disease in the United States, which limits the accuracy and detail (e.g., age specificity) of incidence data relative to that of STIs. 3 The 2013-2014 National Health and Nutrition Survey found that an estimated 4.4% of all sexually experienced reproductive-aged women will develop PID annually. 4 Much of the knowledge of PID epidemiology in adolescents stems from studies conducted in the 1970s and 1980s, including a widely-cited study which found that 12.5% of sexually active female adolescents under 19 will develop PID compared with 1.3% of those over 24,5,6 a difference that is partially attributed to increased rates of STIs in adolescents. 5 However, adolescent sexual behavior may have changed significantly since then, thus limiting the relevance of this study to contemporary populations.
Adolescents may be more susceptible to PID due to a larger proportion of glandular epithelium in the cervix and therefore greater surface area for infection5,7 and because persistently high estrogen levels due to anovulatory cycles may make the cervical mucus easier to penetrate by microorganisms. 5
Because of their association with PID, infections with Chlamydia trachomatis or Neisseria gonorrhoeae are strong risk factors. Both of these infections are more commonly diagnosed in black people. 8 Although black women exhibit the highest infection rates, it is important to note that this disparity is not due to differences in risk behavior but rather because of the greater prevalence of untreated infections in black sexual networks. 8
Microbiology
While most cases of PID occur in sexually active people with uteruses, PID has been identified in sexually naïve people via ascension of non-sexually transmitted pathogens (Table 2).5,12-14
Common Causative Pathogens of PID.
PID has been associated with a variety of pathogens, including those not typically implicated in STIs. This is not an exhaustive list. More comprehensive information is available in Workowski and Bolan. 9
Abbreviations: STI, sexually transmitted infection; PID, pelvic inflammatory disease.
Management of PID
Most patients with PID can be managed outpatient with close follow-up. The CDC recommended outpatient treatment is: ceftriaxone 500 mg IM once, doxcycline 100 mg PO BID × 14 days, and metronidazole 500 mg PO BID for 14 days.1,15
Symptoms should improve within 72 hours after starting treatment. If symptoms do not improve within 72 hours, complications of PID should be considered, such as tubo-ovarian abscess (TOA), or the diagnosis should be re-evaluated.
We had a low threshold for diagnosing and treating this patient for PID because the risks of overtreating PID outweigh the possible complications (see section “Complications of PID”) of undertreatment. 1
Indications for inpatient management include TOA, pregnancy, intolerance of oral medications, intractable vomiting, and lack of improvement with outpatient treatment. 1
Sexual partners within the last 60 days of diagnosis should be notified, advised to seek testing, and empirically treated for gonorrhea and chlamydia, regardless of the patient’s STI test results. Patients with PID should abstain from sex until both the patient and their partner complete treatment. 1
Complications of PID
After a single episode of PID, one in four women will develop a complication including ectopic pregnancy, infertility, recurrent PID, and chronic pelvic pain. 1 Women who delayed care for three or more days of symptoms were three times as likely to experience infertility or ectopic pregnancy compared with women who sought prompt care. 5
Establishing a Therapeutic Relationship With an Adolescent Patient Seeking Care for PID
Confidentiality
Adolescent encounters should include a review of their rights, and the limitations, to confidential care, especially because confidentiality concerns are the leading barrier to care for adolescents. 16 Generally, adolescents can consent to confidential STI testing and treatment in all 50 US states. 17 Providers should be familiar with or refer to state law for more information.
The patient reported that she is open with her godmother, but that she cannot share sexual health information with her mother.
Strategies:
Encourage patient to keep an honest relationship with a trusted adult about their health 18 ;
Protect patient’s note (ie, make inaccessible via patient portal);
Obtain secure phone number to directly reach patient;
Maintain close, in-person follow-up 19 to allow the patient to speak freely with the provider.
Examination
The male physician informed the patient of the need for a gynecological examination and described the examination. The physician asked the patient what she needed from the care team, and the patient requested a “female doctor.”
Strategies:
Communicate what the examination entails, including the possibility of discomfort the patient will experience 20 ;
Offer patient the opportunity to communicate needs and remind the patient that they are in control of what happens to their body during the examination;
Seek the support of the care team (in this case, a female resident) to meet the patient’s stated need (demonstrating that all pediatricians should be capable of performing a pelvic examination);
Narrate aloud what the examiner is doing and what is about to happen during the examination using trauma-informed language to help the patient position their own body appropriately
20
: (i) Do not touch or guide the patient’s legs or knees; (ii) Use neutral and medical verbiage (e.g., “allow your knees to fall to the sides,” not “spread” or “open” legs/knees)
Counseling an Adolescent on PID
The patient wondered if she should question her boyfriend’s sexual history.
Strategies:
Ask patient about safety and ability to communicate with an adult about the relationship;
Carefully discuss uncertainty, including informing the patient that: (i) PID cannot be diagnosed with any test; (ii) PID is the most likely cause of (at least some of) the patient’s symptoms, and risks of undertreatment far outweigh the risk of overtreatment;
Clearly communicate treatment recommendations, including the: (i) Importance of completion of antibiotic therapy; (ii) Recommendation to abstain from sex during the course of treatment and use condoms once resuming sexual activity; (iii) Importance of seeking medical care if symptoms do not improve within 72 hours or worsen.
Conclusion
We present a sexually active adolescent with a two-week history of back pain who reported red urine, dysuria, nausea, and diarrhea, who on examination was found to have CMT and negative STI screenings, and who was ultimately diagnosed with PID. Diagnoses of UTI, pyelonephritis, and STIs were all high on the differential based on the patient’s history. This case shows the importance of integrating physical examination, laboratory results, and imaging into a clinical picture, particularly in the setting of caring for an unaccompanied adolescent with multiple symptoms. The case further illustrates that PID is a clinical diagnosis, and the absence of a positive gonorrhea or chlamydia test, particularly in a sexually active adolescent, should not rule out PID. Moreover, reassuring/unremarkable imaging should also not rule out PID, particularly when collected after therapy was initiated. Finally, the case addresses the unique considerations of working with adolescents, including confidentiality, counseling on safe sex practices/PID, and establishing a therapeutic relationship.
Author Contributions
Dr. Orr, Emma Tayloe, Harini Sridhar, and Emma Hergenrother all contributed to the care of this patient. Dr. Orr and Emma Tayloe contributed to the conception of the project. Emma Tayloe and Harini Sridhar were the lead writers of this piece. Emma Tayloe, Harini Sridhar, and Emma Hergenrother drafted the manuscript. Heather Horne and Dr. MacDonald critically edited the paper. All authors approved of the final manuscript and agree to be accountable for all aspects of the work.
Footnotes
Acknowledgements
The authors thank Maria Ansar, MD, PhD, for her contribution to the care of the patient described in this submission and thank the staff at UNC Children’s Primary and Specialty Care at Carolina Pointe II for their support of this submission.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethical Approval/Patient Assent
There are no data or materials used in the research, thus there is nothing to be publicly posted or shared upon request other than the article itself. The patient provided written assent for this case report to Dr Orr. The consent document cannot be shared with any person to protect confidentiality. In this paper, patient details have been de-identified to protect privacy. The patient came to her appointments unaccompanied and requested her health information not be shared with family or guardians. The N.C.G.S. 90-21.5, North Carolina’s minor consent law, allows for minors to receive treatment for sexual health concerns without parental consent.
