Ultrasound killed the pelvic examination: Over-reliance on ultrasound resulted in delayed diagnosis of Fitz-Hugh–Curtis syndrome and potential loss of fertility in a young female patient

We describe a case of multiple missed opportunities to diagnose Fitz-Hugh–Curtis syndrome in a sexually active 26-year-old woman in the emergency department (ED). Repeat ultrasound scans showed a hemorrhagic ovarian cyst. Multiple ED providers relied exclusively on these ultrasound findings as the presumed cause of her pelvic pain, to the detriment of their physical examination. A manual pelvic examination was not performed until her fourth ED return visit, which showed mucopurulent discharge. On the basis of our findings, obstetrics and gynecology team was consulted and the patient underwent diagnostic laparoscopy, which revealed extensive adhesions suggestive of pelvic inflammatory disease (PID) and Fitz-Hugh–Curtis syndrome. With the advent of ultrasound, we have noticed providers rely on technology to the detriment of their physical examination skills. Many ED providers are hesitant to perform a pelvic examination when a transvaginal ultrasound has already suggested a cause of the patient's pain. Ultrasound will not and cannot diagnose PID.

Keywords: Fitz-Hugh–Curtis, pelvic examination, pelvic inflammatory disease, ultrasound

How to cite this article:
Lin L, Tirado A, Mateer E, Galwankar S, Tucci V. Ultrasound killed the pelvic examination: Over-reliance on ultrasound resulted in delayed diagnosis of Fitz-Hugh–Curtis syndrome and potential loss of fertility in a young female patient. J Emerg Trauma Shock 2022;15:146-8
How to cite this URL:
Lin L, Tirado A, Mateer E, Galwankar S, Tucci V. Ultrasound killed the pelvic examination: Over-reliance on ultrasound resulted in delayed diagnosis of Fitz-Hugh–Curtis syndrome and potential loss of fertility in a young female patient. J Emerg Trauma Shock [serial online] 2022 [cited 2022 Sep 29];15:146-8. Available from: https://www.onlinejets.org/text.asp?2022/15/3/146/357238

Introduction

PID is an infection of the female reproductive tract. PID includes salpingitis, endometritis, myometritis, parametritis, oophoritis, tubo-ovarian abscess, periappendicitis, and perihepatitis (Fitz-Hugh–Curtis syndrome). It should be diagnosed early and treated empirically to prevent long-term sequelae such as infertility and ectopic pregnancy. With the advent of ultrasound, we have noticed providers rely on technology to the detriment of their physical examination skills. Many ED providers are hesitant to perform a pelvic examination when a transvaginal ultrasound has already suggested a cause of the patient's pain. Ultrasound will not and cannot diagnose PID. We describe a case of multiple missed opportunities to diagnose Fitz-Hugh–Curtis syndrome in a sexually active 26-year-old woman in the emergency department (ED).

Case Report

A 26-year-old woman presented to the emergency department (ED) for recurrent abdominal/pelvic pain which most recently started 2 days prior to presenting to our team. Over the past year, she has had fou ED visits for similar complaints. Her past medical history included Chlamydia infection, which was treated years ago. On the day before this visit, a computed tomography (CT) of the abdomen and pelvis and pelvic ultrasound were performed. Both the scans revealed a hemorrhagic ovarian cyst with a small amount of para-ovarian fluid and tiny free fluid in the cul-de-sac, which was the presumed cause of her pelvic pain [Figure 1]. She was discharged with a diagnosis of pelvic pain secondary to a ruptured ovarian cyst with instruction to follow-up with an Obstetrics and Gynecology (OBGYN).

The patient returned to the ED the following day with severe pain. She was afebrile and her physical examination revealed bilateral abdominal tenderness worse in the right lower quadrant, with significant guarding. Manual pelvic examination had never been performed during prior ED visits at three different hospitals. During this ED visit, manual pelvic examination was performed, which showed mucopurulent discharge. The ED physicians initiated treatment for pelvic inflammatory disease (PID) with antibiotics. In view of the patient's pain and discharge, OBGYN was consulted and the patient underwent an exploratory laparoscopy, which confirmed extensive PID. Multiple filmy adhesions were visualized throughout the Fallopian tubes, ovaries, bowel, and pelvic sidewalls. Furthermore, adhesions to the liver were also found conferring a diagnosis of Fitz-Hugh–Curtis syndrome, which is inflammation of the liver capsule due to infection by Chlamydia.

OBGYN lysed her adhesions by electrocautery. The patient was transferred back to the floor and continued her antibiotic course. The following day, she reported significant improvement of her pelvic pain and was discharged with doxycycline and metronidazole.

Discussion

PID is an infection of the female reproductive tract. PID includes salpingitis, endometritis, myometritis, parametritis, oophoritis, tubo-ovarian abscess, periappendicitis, and perihepatitis (Fitz-Hugh–Curtis syndrome).[1] PID is a common cause of abdominal pain among sexually active women, which regardless of their age should be considered. It should be diagnosed early and treated empirically to prevent long-term sequelae such as infertility and ectopic pregnancy. Tubo-ovarian abscess has been reported to be between 18% to one-third of women hospitalized for PID.[2] The most common cause of death from PID is rupture of a tubo-ovarian abscess (5%–10% mortality even with treatment).[3]

It is important to perform a bimanual and speculum examination because PID is a clinical diagnosis. Adnexal tenderness has a sensitivity of 95% and abnormal vaginal discharge is present in 75% of individuals with PID.[4],[5] Furthermore, patients may present with peritoneal signs including involuntary guarding and rebound tenderness. Peritoneal signs should increase the index of suspicion and warrant early surgical/OBGYN consultation. The Centers for Disease Control and Prevention (CDC) has published diagnostic criteria for PID, which include a minimum clinical criteria present on pelvic examination of uterine or adnexal tenderness or cervical motion tenderness.[6] If the patient satisfies the minimum clinical criteria, ED providers should initiate empiric treatment for PID.

In addition to the clinical criteria espoused by the CDC, clinicians can increase the likelihood of a PID diagnosis if the patient has any of the following: temperature > 101°F (>38.3°C), abnormal cervical mucopurulent discharge or cervical friability, presence of an abundant white blood cell count on saline microscopy of vaginal fluid, elevated erythrocyte sedimentation rate, elevated C-reactive protein, and laboratory documentation of cervical infection with Neisseria gonorrhoeae or Chlamydia trachomatis. However, many of the aforementioned laboratory tests are not typically performed in the ED setting for women presenting with lower abdominal pain with the exception of polymerase chain reaction antigen testing for either N. gonorrhea or C. trachomatis.

As in our case, many episodes of PID go unrecognized because ED providers do not perform a pelvic examination. Possible reasons for not performing a pelvic examination may be due to a patient or provider discomfort, lack of confidence and skills, or hospital factors including staffing and chaperone unavailability, equipment unavailability, and department case flow. In addition, providers may incorrectly rely solely on ultrasound or CT imaging to rule out PID and be hesitant to perform a manual pelvic examination when a pelvic ultrasound has already suggested an alternative source of the patient's pain. Our patient's ultrasound revealed a ruptured ovarian cyst. Unfortunately, para-ovarian fluid or free pelvic fluid can also be due to PID. Ultrasound is useful in diagnosing tubo-ovarian abscesses but has no benefit in detecting adhesions seen in Fitz-Hugh–Curtis syndrome. Exploratory laparoscopy is the appropriate modality for visualizing such adhesions and formally diagnosing Fitz-Hugh–Curtis syndrome.[7]

Our patient's PID went unrecognized for over a year at three different EDs because providers never performed a pelvic examination. Her PID could have been identified and treated much earlier without the subsequent complications and progression to Fitz-Hugh–Curtis syndrome. Her fertility may have been permanently jeopardized by this delay in diagnosis. Her cervical swabs at this visit were negative for both C. trachomatis and N. gonorrhea, which are the two organisms most commonly associated with PID.[8] Other organisms associated with PID include Trichomonas vaginalis and Gardnerella vaginalis, both of which our patient was treated empirically for with metronidazole.[9],[10] The necessity to identify causative organisms through cervical swabbing further reinforces the importance of performing a manual pelvic examination.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for his images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Research quality and ethics statement

The authors followed applicable EQUATOR Network (http://www.equator-network.org/) guidelines, notably the CARE guideline, during the conduct of this report.

Financial support and sponsorship

Nil.

Conflicts of interest

One of the authors is on the editorial board of this journal.

References

1.Ness RB, Smith KJ, Chang CC, Schisterman EF, Bass DC; Gynecologic Infection Follow-Through; GIFT, Investigators. Prediction of pelvic inflammatory disease among young, single, sexually active women. Sex Transm Dis 2006;33:137-42.

2.Chan Y, Parchment W, Skurnick JH, Goldsmith L, Apuzzio JJ. Epidemiology and clinical outcome of patients hospitalized with pelvic inflammatory disease complicated by tubo-ovarian abscess. Infect Dis Obstet Gynecol 1995;3:135-9.

3.Romero R, Espinoza J, Mazor M. Can endometrial infection/inflammation explain implantation failure, spontaneous abortion, and preterm birth after in vitro fertilization? Fertil Steril 2004;82:799-804.

4.Peipert JF, Ness RB, Blume J, Soper DE, Holley R, Randall H, et al. Clinical predictors of endometritis in women with symptoms and signs of pelvic inflammatory disease. Am J Obstet Gynecol 2001;184:856-63.

5.Toth M, Patton DL, Esquenazi B, Shevchuk M, Thaler H, Divon M. Association between Chlamydia trachomatis and abnormal uterine bleeding. Am J Reprod Immunol 2007;57:361-6.

6.Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep 2010;59:1-110.

7.Risser WL, Risser JM, Benjamins LJ, Feldmann JM. Incidence of Fitz-Hugh-Curtis syndrome in adolescents who have pelvic inflammatory disease. J Pediatr Adolesc Gynecol 2007;20:179-80.

8.Walker CK, Workowski KA, Washington AE, Soper D, Sweet RL. Anaerobes in pelvic inflammatory disease: Implications for the Centers for Disease Control and Prevention's guidelines for treatment of sexually transmitted diseases. Clin Infect Dis 1999;28:29-36.

9.Cherpes TL, Wiesenfeld HC, Melan MA, Kant JA, Cosentino LA, Meyn LA, et al. The associations between pelvic inflammatory disease, Trichomonas vaginalis infection, and positive herpes simplex virus type 2 serology. Sex Transm Dis 2006;33:747-52.