Patient Presentation
A 15-year-old female came to the emergency room with abdominal pain for about 1 day. She describes the pain as at the lower right abdomen but said that it felt “even deeper” into her pelvis. The pain was constant and increasing in intensity without radiation. She had vomited twice after the pain began that was non-bilious and non-bloody. She was not eating but was trying to drink despite feeling quite nauseous. She denied any dysuria, but had a temperature of up to 102°F. She had had a normal bowel movement just before the pain began and had no history of constipation. During a private interview she confided that she had become sexually active with 1 male partner about 3 months ago and didn’t use condoms consistently or any other form of birth control. Her last intercourse was just before her normal period about 2 1/2 weeks previously and she had noticed increased vaginal discharge since around that time. She could not further describe the discharge. The past medical history was non-contributory. The family history was negative. The review of systems was negative for diarrhea and rashes, There were no previous surgeries.
The pertinent physical exam showed a cooperative adolescent in moderate pain. Her temperature was 101.7°F., pulse of 128, respiratory rate of 30 and had a normal blood pressure. HEENT, lungs and heart were non-contributory. Abdominal examination showed tenderness in the right lower quadrant especially near the pelvis with positive guarding and positive rebound tenderness. There was no abdominal rigidity. Her liver was non-tender and spleen was not palpable. She had no masses. There was no change with straight leg lifts or other skeletal maneuvers. Her external genital examination was negative. Her pelvic examination showed a yellow, slightly smelly vaginal discharge including some from the cervix. She had mild cervical motion tenderness without obvious masses or tenderness of the left ovaries or uterus. The right lower pelvic area was difficult to examine because of patient cooperation secondary to pain.
A working diagnosis of pelvic inflammatory disease versus appendicitis was considered. The laboratory evaluation showed a normal pregnancy test, liver function tests, amylase, lipase, electrolytes, BUN and creatinine. Her urinalysis had a specific gravity of 1.025, pH of 6 with negative nitrites and leukocyte esterase. Urine testing was positive for chlamydia, but negative for gonorrhea. An HIV performed later was negative. Her complete blood count had a normal hemoglobin, hematocrit and platelets. Her white blood cell count was 18.4 x 1000/mm2 with a 65% left shift. Her C-reactive protein was 2.5 mg/dl. The radiologic evaluation of an abdominal ultrasound was positive for an enlarged appendix. Over the next few hours the patient’s clinical course had her taken to the operating room where she had an uneventful appendectomy performed. The uterine structures appeared normal under direct visualization and palpation. She was discharged 48 hours after surgery because of post-op emesis. She was also treated for chlamydia, started on Depo-Provera® for contraception and was counseled about consistent use of condoms to prevent sexually transmitted infections. Treatment was arranged for her partner. Followup with adolescent medicine and surgery was arranged before discharge.
Discussion
Appendicitis results from a closed loop obstruction of a blind-ending tubular structure arising from the cecum. It is a common cause of abdominal pain. It is the most frequent condition leading to emergent abdominal surgery in pediatrics. The combination of obstruction, edema, bacterial overgrowth, increased inflammatory process and increased intraluminal pressure leads to abdominal pain and possibly perforation. Appendicitis occurs in all age groups but is rare in neonates. The peak age is 6-10 years old.
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. The Centers for Disease Control’s Sexually Transmitted Disease Treatment Guidelines can be found here.
The causes of pelvic pain and abdominal pain necessarily overlap a great deal due to the proximity of anatomic structures as this case illustrates.
Acute pelvic pain is defined as 6 months of noncyclic pain that is at the umbilicus or lower.
Complete histories and good general physical examinations are important to guide the differential diagnosis. Pelvic examination may or may not be indicated. Laboratory testing especially to determine pregnancy status also helps guide diagnosis. General testing such as complete blood counts, C-reactive protein and Erythrocyte sedimentation rates can be helpful in addition to urine testing for sexually transmitted diseases. Imaging particularly by ultrasound is also important to narrow the diagnosis and determine treatment plans.
Learning Point
The differential diagnosis of pelvic pain includes:
Acute pelvic pain
Non-pregnant
Simple ovarian cysts
Ruptured or hemorrhagic ovarian cysts
Pelvic inflammatory disease
Endometritis
Pelvic abscesses – tubo-ovarian abscesses
Ovarian torsion
Intrauterine device malpositioned
Pregnant
Pregnancy
Corpus luteum cyst
Subchorionic hemorrhage
Spontaneous abortion
Ectopic pregnancy
Post partum
Retained products of conception
Endometritis
Ovarian vein thromphlebitis
Cesarian section
Other
Appendicitis
Adhesions
Malrotation
Musculoskeletal pain
Sickle cell anemia
Tumor
Renal stones
Urinary tract infection
Chronic pelvic pain
Genitourinary
Ovarian cysts
Endometriosis
Uterine outflow tract obstruction and congenital abnormalities – imperforate hymen
Pelvic inflammatory disease
Gastrointestinal
Constipation
Food sensitivity or intolerance – lactose intolerance
Gastroesophageal reflux
Inflammatory bowel disease
Irritable bowel syndrome
Meckel’s diverticulum
Pancreatitis – chronic, relapsing
Peptic ulcer disease
Neurologic / Psychologic
Abdominal epilepsy
Abdominal migraine
Abuse – physical and sexual
Factitious
Fibromyalgia
Nerve entrapment
Munchausen by proxy
Psychological stress, anxiety, depression
Musculoskeletal
Abdominal wall strain
Pelvic musculature strain
Renal
Cystitis
Hydronephrosis
Renal stones
Miscellaneous
Adhesions
Autoimmune diseases that may have dermatologic or mucous membrane symptoms
Inguinal hernia
Questions for Further Discussion
1. What are indications for referral to gynecology or surgery?
2. What are indications for a pelvic examination?
Related Cases
Disease: Appendicitis | Abdominal Pain | Pelvic Inflammatory Disease | Chlamydia Infections
Symptom/Presentation: Abdominal Pain | Pelvic Pain | Vaginal Discharge
Specialty: Adolescent Medicine | Emergency Medicine | Infectious Diseases | Obstetrics / Gynecology | Surgery
Age: Teenager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Topic
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Cicchiello LA, Hamper UM, Scoutt LM. Ultrasound evaluation of gynecologic causes of pelvic pain. Obstet Gynecol Clin North Am. 2011 Mar;38(1):85-114, viii.
Youngster M, Laufer MR, Divasta AD. Endometriosis for the primary care physician. Curr Opin Pediatr. 2013 Aug;25(4):454-62.
Powell J. The approach to chronic pelvic pain in the adolescent. Obstet Gynecol Clin North Am. 2014 Sep;41(3):343-55.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital