What Is the Most Likely Diagnosis in Juliet’s Case and Why?

Pelvic inflammatory disease is the patient’s diagnosis. Juliet’s lower abdominal pain in the setting of sexual activity and lack of other symptoms suggesting an alternative process brings PID to the top of the diagnostic list. Diagnostic criteria for PID are met by findings of the bimanual exam, which is indicated in all sexually active patients presenting for abdominal pain. Diagnostic criteria for PID are described in “Discussion” section of this chapter. An incidentally concomitant process has not been ruled out, such as ovarian cyst, constipation, or cystitis. Clinical judgment should be utilized at the time of the visit to determine if further work-up is required.

What Diagnostic Tests Are Indicated? (Table 15.2)

In all patients presenting with abdominal pain, a pregnancy test should always be performed. Juliet has an IUD ; therefore, it is highly unlikely that she is pregnant and is confirmed by the negative pregnancy test. During the pelvic exam, a vaginal swab of the discharge is obtained to test for gonorrhea and chlamydia via nucleic acid amplification test (NAAT). This test result will not be available during the patient encounter and should not change management. Juliet should be treated on the day of presentation as should all patients when the diagnosis is PID. Sexually transmitted infection (STI) testing should always be obtained prior to any treatment.

Additionally during the exam, a second swab of vaginal fluid is obtained to perform a wet mount. Microscopic exam demonstrates >30 white blood cells per high-power field (hpf), 5 red blood cells/hpf, >20% clue cells, no trichomonad visualized, and a pH of 6.0 with a positive “whiff test” on KOH application. Juliet has just been diagnosed with a second condition based on these findings: bacterial vaginosis (BV) by Amsel criteria. The Amsel criteria are a set of four conditions that must be present: a homogenous, nonviscous milky-white discharge adherent vaginal walls, vaginal pH >4.5, >20% per hpf of “clue cells” (epithelial cells speckled with bacteria), and positive amine or “whiff” test when 10% KOH solution is applied to vaginal fluid. Greater or equal to three out of the four of these criteria indicates a diagnosis of bacterial vaginosis (a vaginal bacterial overgrowth syndrome). BV on its own does not cause inflammation in the vagina, which makes the amount of white blood cells seems concerning and even more consistent with PID. The presence of an IUD can increase the number of WBC seen on vaginal fluid smear due to the induction of a mild local foreign body reaction [2]. However, seeing large amounts of WBC is concerning for sexually transmitted infection [3].

See Table 15.3: PID diagnostic criteria

What Treatment, if Any, Is Indicated at Today’s Visit?

Treatment guidelines for PID cover presumed gonorrhea and chlamydia with consideration for anaerobic bacteria as well. In the clinic, the patient should receive 250 mg ceftriaxone intramuscularly and be given a prescription for doxycycline 100 mg twice a day for a 2-week (14 day) course. In this case, Juliet also has BV, which, in isolation, is treated with 500 mg of metronidazole orally for 7 days twice a day. However, in the setting of PID, the Center for Disease Control (CDC) recommends extending the treatment for a total of 14 days. Studies have found aerobic bacteria associated with BV in the fallopian tubes on laparoscopy of asymptomatic women treated with standard second-generation cephalosporin and doxycycline antibiotics [5]. There is, therefore, a suggested recommendation to broaden PID treatment to triple antibiotic therapy by adding metronidazole for a 14-day course to cover for anaerobic bacteria [1].

See Table 15.4 for antibiotic treatment recommendations in PID.

Intrauterine Devices in Adolescents with PID

PID is often diagnosed in locations and by providers who may not be as familiar with intrauterine devices (IUDs) . Important knowledge for this case is that IUDs are not only safe and effective in adolescents but that if present during PID diagnosis should be left in place. The American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) both have approved of these contraceptives in the teen and young adult populations as well as older women [6, 7]. If PID is diagnosed in an individual with an IUD in place, the device does not have to be removed prior, during, or after antibiotic treatment. There is even evidence to suggest that women with IUDs have decrease risk of acquiring PID by thinning the endometrium and thickening cervical mucus [8]. It is important to keep the patient’s highly effective method of pregnancy prevention and treat her infection separately.

What Are the Next Steps in Management?

Juliet should return within 72 h for repeat vital signs and abdominal and bimanual exams. If symptoms and exam are improved at that time, then Juliet should continue her doxycycline and metronidazole treatment and have repeat STI testing in 3 months if either gonorrhea or chlamydia was positive at the time of PID diagnosis. Additionally, sexual partners within the past 60 days of Juliet’s symptom onset should be evaluated, tested, and empirically treated for gonorrhea and chlamydia infections (ceftriaxone 250 mg IM + azithromycin 1 g PO for urethritis/cervicitis) [1]. If the last time Juliet had sex was >60 days ago, then her most recent sexual partner should still be treated. Juliet and any partners should be advised to abstain from sexual intercourse during symptoms and treatment and for 7 days after current partner is treated, whichever is longer.