Acute and chronic pelvic pain in female adolescents

Ultrasonography-triggered diagnosis of putrid, ulcero-phlegmonous, hemorrhagic appendicitis and periappendicitis with an atypical symptom pattern: a case report

BACKGROUND

Asymptomatic and oligosymptomatic appendicitis are rare and challenging diagnoses that should not be missed.

CASE PRESENTATION

A young female patient presented with mild to moderate pain in the middle and lower abdomen, and the results of physical examination, including digital rectal examination, were otherwise non-contributory. Ultrasonography demonstrated a marked increase of the outer appendiceal diameter up to 12 mm and a trace of free liquid around the terminal ileum. Subsequent surgical exploration and histological examination allowed for a final diagnosis of putrid, ulcero-phlegmonous, hemorrhagic appendicitis and periappendicitis.

CONCLUSIONS

Ultrasonography is increasingly used for the diagnosis of appendiceal inflammation, particularly in military medical settings. Increases in the outer appendiceal diameter up to >6 mm under compression have recently been demonstrated to be indicative of acute appendicitis. At a minimum, in cases with doubtful physical examination results, ultrasonography should be considered as an element in the diagnosis of acute appendicitis.

Uterine remnants and pelvic pain in females with Mayer-Rokitansky-Küster-Hauser syndrome

OBJECTIVE

To assess the association between pelvic pain and uterine remnants and review the management of pelvic pain in females with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome.

DESIGN

Retrospective cohort.

SETTING

Department of Obstetrics and Gynecology at a tertiary referring medical center.

PATIENTS

Forty-eight females with MRKH presenting from 1997 to 2011 with anatomy confirmed by magnetic resonance imaging (MRI).

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Prevalence Of uterine remnants and the association of uterine remnants with pelvic pain in females with MRKH.

RESULTS

Of the 48 females with MRKH, 23 (48%) had uterine remnants and 22 (46%) had pelvic pain. Presence of endometrium was associated with pelvic pain (RR = 2.3; 95% CI = 1.2-4.7) in females with MRKH. Of the females with MKRH and pain, 9/22 had laparoscopy, with endometriosis seen in 5/9 of the uterine remnants at stages higher than are usually seen in teenagers (56%). Nine patients with pain and uterine remnants (8 with endometrium, 1 without) had laparoscopic removal of uterine remnants with resolution of pain.

CONCLUSIONS

Given the high prevalence of uterine remnants in females with MRKH, anatomic evaluation with MRI should be considered when assessing the etiology of pelvic pain. Presence of endometrium within uterine remnants, and subsequent endometriosis, in females with MRKH may be associated with pelvic pain necessitating surgical or medical management.

Use of an institutional intervention to improve quality of care for adolescents treated in pediatric ambulatory settings for pelvic inflammatory disease

PURPOSE

To evaluate the impact of a quality improvement intervention for outpatient management of pelvic inflammatory disease (PID) on provider compliance with published guidelines and to explore issues affecting patient adherence to outpatient care regimens.

METHODS

This study utilized an interrupted time series design. The intervention included an algorithm and clinical practice guideline based on the 2002 Centers for Disease Control STD Guidelines, a complete course of medications to be given at discharge after initial doses given in the site, standardized discharge instructions, close follow-up at 24-48 hours and after two weeks of treatment by a member of the PID team, and a referral for follow-up.

RESULTS

At baseline, 38% of patients did not receive an appropriate medication regimen and only 10% of clinic outpatients returned for follow-up evaluations within 72 hours. In the postintervention group, 91% of patients received an appropriate outpatient regimen and 43% of emergency department and clinic patients returned for care. Based on the results of logistic regression models, adolescents in the postintervention group were 8.4 times more likely (adjusted odds ratio [AOR]: 8.4, confidence interval [CI]: 2.6-26.8, p <. 001) to receive an appropriate outpatient medication regimen than girls in the baseline group. Follow-up interview revealed that 61% of postintervention patients completed all doses of the medication, 67% practiced temporary abstinence, 86% notified their partner for treatment, and 96% were satisfied with their care.

CONCLUSIONS

Interventions utilizing a multi-level approach to the management of outpatient PID improve provider compliance with published guidelines and quality of care delivered to adolescents in academic settings. Many adolescents, however, continue to have difficulty with adherence. Additional research is warranted to address adherence to outpatient regimens for the treatment of PID in adolescent girls.

Pelvic inflammatory disease in adolescents: care delivery in pediatric ambulatory settings

OBJECTIVES

To evaluate care delivery patterns in patients treated for pelvic inflammatory disease in pediatric outpatient settings and to determine the effect of practice type on care delivery.

DESIGN/SETTING

Retrospective review of medical records for patients treated as outpatients in an urban academic pediatric facility. Care patterns were evaluated according to the Centers for Disease Control sexually transmitted disease guidelines.

PARTICIPANTS

Fifty-six adolescent patients who were diagnosed with pelvic inflammatory disease in pediatric ambulatory settings between January 1, 2002, and December 31, 2002.

MAIN OUTCOME MEASURES

Demographic information, documented patient history and examination, laboratory data, and discharge instructions.

RESULTS

Forty percent of patients were prescribed inadequate courses of medications. Patients who were seen in the pediatric emergency department were less likely to receive a standard medication regimen than those seen in the ambulatory setting. Most patients did not receive adequate instruction for self-care on review of written discharge instructions, and there were no differences based on location of care.

CONCLUSIONS

Many adolescents treated as outpatients for pelvic inflammatory disease may not receive adequate medications and instructions for self-care at discharge in pediatric ambulatory settings. This study suggests a need for aggressive quality improvement measures to enhance the care of adolescents with pelvic inflammatory disease in pediatric outpatient settings.

Pelvic inflammatory disease: new diagnostic criteria and treatment

PID is a common infection in reproductive-age women that presents an enormous public health and economic burden. It is responsible for much short- and long-term morbidity that may necessitate interventions subsequent to the original infection. Mild PID seems to be much more common than severe or "classic" PID, and the importance of early recognition and treatment cannot be understated. Current treatment regimens seem to be effective in terms of immediate clinical efficacy. As we learn more about the frequency and importance of subclinical PID, the true burden of upper genital tract infection upon reproductive age women continues to be elucidated.