Right question resolves teen’s pain dilemma
A 16-year-old girl presents to an emergency department (ED) accompanied by her boyfriend to report a 24-hour history of right lower quadrant pain. The pain is associated with midline lower back pain and light vaginal bleeding (1 to 2 tampons per day). She has experienced some nausea but no vomiting. Review of systems is negative for fever, diarrhea, constipation, dysuria, abnormal vaginal discharge, blood in her stool, or blood in her urine.
History and examination
Vaginal bleeding suggests a gynecologic cause, which may be divided into pregnancy-related conditions (the most life-threatening of which is ectopic pregnancy) and non–pregnancy-related conditions. Gastrointestinal causes (of which acute appendicitis would be most life-threatening), urinary system causes, musculoskeletal pain, and intra-abdominal lymphadenitis are also common conditions to consider.
History and physical examination include a full review of systems and a confidential sexual history. The emergency medicine physician speaks to the patient alone without her boyfriend present. She tells the doctor that she is worried she might be pregnant. She thinks that her last menstrual period was 4 to 5 weeks earlier but she is having difficulty remembering. She regularly has unprotected sex with her boyfriend and is not on any contraception. Her last unprotected sexual activity was 10 days ago. She tested negative for chlamydia and gonorrhea at a public health clinic 2 weeks earlier. Her boyfriend is the only sexual partner she has had for several months.
On physical examination, the patient appears well and is in no acute distress. Her blood pressure (BP) is 124/79 mm Hg and her heart rate is 110 beats per minute (bpm). Her temperature is 99.6° F. Examination of her eyes, ears, nose, and throat is unremarkable. No head or neck lymphadenopathy is detected. She has no respiratory distress and she has clear and equal breath sounds bilaterally. Her cardiovascular examination is normal except for mild tachycardia. Upon abdominal examination, she has tenderness to palpation in the left lower quadrant, suprapubic region, and right lower quadrant; the worst pain is in the right lower quadrant. She does not exhibit guarding or rebound tenderness. No other physical examination is performed.
Urinalysis demonstrates 3+ leukocytes and 1+ blood. Urine beta-human chorionic gonadotropin (β-HCG) test is negative. An ultrasound is performed that shows a normal appendix, normal ovaries, and no evidence of an intrauterine or ectopic pregnancy. No other laboratory studies are obtained.
The patient is diagnosed with a presumed urinary cystitis. Her urine is sent for culture and she is discharged with a course of oral cephalexin.
It is worth noting that although urinary cystitis may present with suprapubic pain, it is unusual for it to cause right or left lower quadrant tenderness. It also does not explain the patient’s vaginal bleeding. The patient’s tachycardia may be related to anxiety, but it also may be related to a disease process more invasive than an ordinary urinary cystitis.
Although the patient had a negative urine β-HCG, the patient reports that her last unprotected sexual activity was only 10 days ago, and urine β-HCG may not be sensitive enough to detect a pregnancy conceived less than 2 weeks earlier. Therefore, at this stage, one cannot be sure that the patient is not pregnant.
The patient’s boyfriend brings her back to the ED 3 days later because her right lower quadrant pain and back pain are worse, and she has now developed fever and dysuria for 24 hours. She continues to have light vaginal bleeding. She felt too unwell to take oral medication so she never started the cephalexin that was prescribed to her. She has not engaged in sexual activity since she was last discharged from the ED.
On physical examination, her BP is 106/54 mm Hg and her heart rate is 78 bpm. She is febrile (100.8° F) and appears more unwell. Head and neck, cardiovascular, respiratory, and abdominal examination are repeated and are essentially unchanged, but she continues to demonstrate discomfort with lower abdominal palpation and is particularly tender in the right lower quadrant.
A renal and pelvic ultrasound is repeated and continues to show a normal appendix, no ovarian pathology, no intrauterine or ectopic pregnancy, no abscess, and no evidence of urinary obstruction. Urine β-HCG remains negative, but this time a serum β-HCG is obtained and is also negative. Her complete blood count (CBC) shows an elevation in white blood cells (20,100 cells/µL) with 20% bandemia; hemoglobin and platelets are normal; and C-reactive protein (CRP) is elevated (24.4 mg/dL). Serum electrolytes, blood urea nitrogen, and creatinine are normal. Urinalysis demonstrates 1+ leukocytes and 3+ blood. The urine culture that was sent when she presented 3 days earlier is now positive for Staphylococcus saprophyticus (>100,000 organisms/mL).
The patient is tentatively diagnosed with pyelonephritis. She receives intravenous (IV) fluids and is started on IV clindamycin. She is kept for observation overnight. By morning, she is afebrile and is able to tolerate oral clindamycin, but her abdominal pain, back pain, vaginal bleeding, and dysuria have not improved. She is discharged on oral clindamycin with instructions to see her primary care physician within 48 hours. When she asks why she is being discharged even though she still feels sick, she is told that her symptoms are “probably related to her pyelonephritis” and should resolve if she completes her antibiotics.
The providers effectively ruled out pregnancy-related causes by documenting a negative serum β-HCG and urine β-HCG about 2 weeks after the patient’s last sexual intercourse. Her blood work (which demonstrates leukocytosis, a left shift, and an elevated CRP) in combination with her fever and unwell appearance are highly suggestive of an inflammatory or invasive infectious cause. Although back pain, fever, dysuria, urine leukocytes, and a positive urine culture may be consistent with pyelonephritis, vaginal bleeding is out of keeping with pyelonephritis and should prompt consideration of a gynecologic diagnosis, which also can present with dysuria and urine leukocytes if urethritis is present.