Pelvic Inflammatory Disease

Dr Vicky Worsnop, Dr Rhys Beynon

Picture the scene – you are 8 hours into a twilight shift covering the emergency department. The next patient to be seen is a re-attender called Anna. The nurse gives you the notes with an eye roll, saying: “she was in with the same thing last week…careful how you go!”

Anna

Anna is a 14-year-old girl. You find out that this is her third presentation with abdominal pain within a month. She has previously had bloods which were all normal, and urine bHCG which was negative. She was observed in the department and given analgesia which improved her pain. She was sent home after having something to eat and drink. The previous impression was written as “constipation”.

Because you’ve recently read an article on adolescent health you start the consultation by saying:

“Hello Anna, my name is … Because you are 14, I see you as more of an adult. Is it ok that I treat you like one and see you by yourself and then we can all chat together afterwards?”

Anna comes with you alone. She is quiet but answers all your questions.

History and examination

Anna has a 2-month history of colicky abdominal pain associated with loss of appetite and nausea. The pain has gotten worse in the last 2 days and she has developed fevers. There are no exacerbating factors for the pain. She last opened her bowels 2 days ago which was painful. She has no significant past medical history and her immunisations are up to date. She was on a child protection plan 3 years ago due to domestic violence but the case has since been closed. Her father is no longer at home. On examination, there is diffuse abdominal tenderness in the lower quadrants with guarding in the left iliac fossa. Obs show she is febrile and tachycardic.

Bloods – CRP 121, WCC 16. Urine dip – Protein +, Blood +, bHCG negative

Anna was reviewed by the surgical team who wrote: “not convinced of appendicitis. Paeds/ED to arrange CT and will re-review if surgical cause for pain found.”

So, what next?

I hope that like me, you are an avid FOAMed reader/listener and you are currently shouting “HEEADSSS exam!” at your screen. If you’re not familiar with the HEEADSSS assessment or have forgotten what all the ‘E’s and ‘S’s stand for then a really good summary can be found here.

All adolescents to be opportunistically risk assessed using appropriate psychometric tools and the required actions to be taken’
Royal College of Emergency Medicine Care of Children National Report

HEEADSSS has been well covered by lots of blogs, podcasts, lectures, and guidelines. Although it is common in the FOAMed world, it is not yet being routinely used on the shop floor. One of the recommendations from the Royal College of Emergency Medicine Care of Children National Report is that ‘all adolescents to be opportunistically risk assessed using appropriate psychometric tools and the required actions to be taken’. Yes, ALL! This has caused some controversy in the paediatric emergency medicine world. In an informal Twitter poll, most people admitted that they prefer using a targeted approach, rather than asking every teen who presents to the ED. Sounds sensible, however I am going to suggest to you that we need a cultural shift when it comes to assessing young people.

*QUALITY IMPROVEMENT PROJECT ALERT* – Audit your own department. How many 10-19 year olds have had a HEEADSSS or any psychometric assessment completed?

Ideally, we should have 100% compliance. However, actual compliance is rock bottom – the mean compliance in the RCEM Care of Children QIP was 18%. Hospitals in Australia have had successes with electronic assessment tools which were given to young people to complete. Other solutions could lie in running simulation, bedside teaching or clerking proformas. The benefits of aiming for 100% compliance are that if you do it every time, your communication skills will be better when it matters.

What if I open up a can of worms?

This is a common barrier and it feels uncomfortable to explore problems which are often overwhelming within the time-pressured environment of the ED. However, RCPCH & US tells us that young people appreciate it when we ask and listen to them about their wellbeing. If you need more motivation, view this video made by the Leicester Safeguarding Children Partnership Board. Ways that we can help include asking if you can support them in disclosing to their parent/guardian. You could also signpost to local services. The Well Centre have some great National and London-centred links. Alternatively, RCPCH&Us have produced a list of services that the young people’s working group found particularly helpful.

Why does it matter?

The recent State of the Child 2020 publication by RCPCH states that adolescent mortality has increased since 2014, from 17.5 to 18 deaths per 100,000. Adolescents (from 10-19 years), therefore have the second highest risk of death among children and young people. The top three causes of death are accidental injury, cancer, and intentional self harm. This is reflected internationally. The World Health Organisation quoted the following as the top priorities for preventable health issues for adolescents:

Accidental Injuries (RTAs are leading cause of death internationally)
Violence
Mental Health and self inflicted injuries
Substance Misuse
Sexual Health including pregnancy

It is these priorities (and others) that we are trying to address by screening ED patients with the HEEADSSS examination.

Back to Anna

Whilst waiting for the CT, you start improving your department’s HEEADSSS compliance by assessing Anna.

Home	Lives with Mum, No contact with Dad. Mum works a lot. Often home alone.
Education	Virtual school due to the pandemic, finding it difficult to concentrate.
Eating	No appetite over last 2 days but ok before then. Has free school meals delivered. No excessive exercise.
Activity	Used to play football but now doesn’t do anything.
Drugs	Smokes cannabis with ‘friends’ when Mum is at work. Doesn’t pay for it. Gets it from ‘Jay’ who’s 20, he lives on the estate. Gives her clothes sometimes.
Sex	Has sex with some boys on the estate. Complains its become painful in the last week and she’s started getting some vaginal discharge.
Social media	On snapchat and TikTok. Follows friends.
Suicide/self harm	Feeling a bit low, misses school but no thoughts of self harm.
Safety	Feels safe at home but sometimes she is threatened by some of the boys on the estate. Doesn’t think it’s too much of a problem because they are nice to her if she’s good.

*CT image: Right Tubo-ovarian abscess*. *Image from* *radiopedia.org*

Pelvic inflammatory disease (PID) is an infection in the genital tract. Most infections are caused by Chlamydia or Gonorrhoea. PID must be in your differential in any sexually active women presenting with lower abdominal pain. There should be a low threshold to start empirical treatment if there is clinical suspicion. Prevalence is highest amongst those aged 15-24 and you can find your local prevalence rates, along with some other interesting data here. Once PID is confirmed, contact tracing is vital.

Symptoms

Lower, often bilateral abdominal pain
Vaginal discharge
Deep dyspareunia
Abnormal vaginal bleeding or secondary dysmenorrhea

Signs

Fever in moderate or severe disease
Cervical tenderness on bimanual examination

Note on Bimanual Examination: an intimate examination needs some thought! Is it needed? If yes, ensure a private room, experienced practitioner, and performed once so get the swabs ready. A quarter of patients with appendicitis will also have cervical tenderness so you may need to think about US or CT to rule out appendicitis. Absence of endocervical or vaginal pus cells on gram staining has a good negative predictive value (95%) so its good to do.

Investigations

Ultrasound is of limited value
CT and MRI are predominantly used for ruling out other differentials such as appendicitis. MRI is preferred due to the radiation risks associated with CT.
HIV Testing

Note on HIV – The prevalence of HIV in age groups 15-59 in London is 5.7/1000; the National average is 2.3/1000. In December 2020, RCEM produced a guideline concerning routine HIV testing in adults presenting to the Emergency Department. If you live in an area where the prevalence of HIV is over 2/1000, RCEM is recommending routine HIV of all adults who are undergoing a blood test.

Treatment

Uncomplicated PID can be treated empirically, BASHH recommend age appropriate stat dose of ceftriaxone +/- azithromycin but remember to correlate with your local guidelines. IV antibiotics may be needed for patients who are systemically unwell, or when there is a suspicion of a tubo-ovarian abscess or peritonitis. Tubo-ovarian abscesses require surgical drainage by the gynaecologists.

Complications:

Co-infection with HIV
Tubo-ovarian abscess
Fitz-Hugh Curtis Syndrome
Future infertility and increased likelihood of ectopic pregnancy

Anna’s progress

Anna’s CT scan showed a tube-ovarian abscess and she is referred to the gynaecologists. They ask if her care can be shared with paediatrics because of the safeguarding issues. Luckily you’re an avid reader of PaediatricFOAM and remember this article on child sexual exploitation! The nurses have called social services and are awaiting a call back from the duty social worker. Anna is informed of her diagnosis and consents to both medical and safeguarding plans. She is admitted and transferred to the ward.

Key Learning Points

Preventable causes of adolescent mortality can be screened for using HEEADSSS.
Audit and improve your departments use of HEEADSSS.
Not all right iliac fossa pain is appendicitis.
STIs and their complications are most prevalent in those aged 15-24.
Co-infection with HIV must be considered in those presenting with STIs.

Dr Vicky Worsnop, ST6 Emergency Medicine and Paediatric Emergency Medicine. Consultant reviewer Dr Rhys Beynon, Adult and Paediatric Emergency Medicine Consultant at St George’s Hospital, London

Anna

So, what next?

What if I open up a can of worms?

Why does it matter?

Back to Anna