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Gynecological Problems Causing Acute Abdominal Symptoms in Adolescent Girls JOHN F. J. CLARK, M.D., Professor and Chairman, and BERTRAM E. STEPHENS, M.D., Resident, Department of Obstetrics and Gynecology, Howard University College of Medicine and Howard University Hospital, Washington, D. C.

THE ADOLESCENT girl is at an im-

portant stage of her development and growth. During this transitional period between girlhood and adulthood, she is not only afflicted with emotional problems, but by real distressing physical illnesses which often present with atypical symptoms. MATERIALS AND METHODS

We have reviewed 90 cases of adolescent girls, 16 years and under, admitted to Howard University Hospital with acute abdominal symptoms, between 1965 and 1970. In arriving at a diagnosis, a good history is very important, but the patient may be confused, in distress, or be fearful of society's scorn on youthful sexual promiscuity. She is therefore, likely to be untruthful about her sexual activities. This confuses the picture. Next in evaluating a patient is a good physical examination, however, the patient may never have had a pelvic examination and is apt to be very uncooperative. Thus, establishing a diagnosis is further complicated. An acute abdomen suggests an urgent intra-abdominal problem. Sudden abdominal pain, in a previously well person, that persists for more than six hours, is often indicative of a condition requiring surgical intervention.1 There are, however, a number of medical conditions which mimic intraabdominal emergencies, chief among which is sickle cell crisis. Typhoid fever, pericarditis, lower lobe pneumonia, nephritis and tuberculous peritonitis may also present as abdominal emergencies. More urgent are the

surgical entities, appendicitis, diverticulitis, perforated peptic ulcer, splenic rupture and perforated bowel with peritonitis. But of greatest interest to us are the gynecological diseases, ectopic pregnancy, ovarian cysts, pelvic inflammatory disease and Mittelschmerz. These entities may present in an atypical fashion in the adolescent, making it difficult to arrive at a diagnosis. RESULTS

The 90 cases reviewed were divided into three groups: surgical-24, medical-23, and gynecological 43, which accounted for the largest group (Table 1). Table 1. GYNECOLOGICAL CASES Diagnosis

Number

Ovarian Cysts Acute Pelvic Inflammatory Disease Dysfunctional Uterine Bleeding Puerperal Sepsis Torsion of Adnexa Ovarian Cancer Vaginitis Vaginal Polyp Foreign Body in Vagina Pelvic Cellulitis

II 1 11 3 2 I

Of the 43 patients seen on the gynecological service, many were transfers from other services to which they had been admitted with other initial diagnoses. Eleven patients had a final diagnosis of ovarian cyst of various types, (Table 2). Their ages ranged between 11 and 16 years. All presented with abdominal pain. Pelvic masses were palpable in six cases.

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Four patients had nausea and vomiting, while three had vaginal bleeding. Only one patient presented with full blown peritonitis and fever; but one other patient had severe shoulder pain. The differential diagnoses included appendicitis, ectopic pregnancy, pyosalpinx, Mittelschmerz and intestinal obstruction. The correct diagnosis was initially made in six cases. Diagnostic procedures included exploratory laparotomy, examination under anesthesia, dilatation and curettage, culdocentesis and colpotomy. Table 2. OVARIAN CYSTS Number

Diagnosis Ruptured Ovarian Cyst Corpus Luteum Cyst Teratoma Tubo-Ovarian Abscess Hemorrhagic Follicular Cyst

4 3

2 I

I

Some of the more interesting symptom complexes included one patient who presented with peri-umbilical pain of sudden onset which localized in the right lower quadrant. At surgery, she had a teratoma. Another patient presented with sharp cramping hypogastric pain, a missed menstrual period, and a mass in the right adnexal area. She had an unruptured corpus luteum cyst. Yet another young lady was admitted with bilateral lower abdominal pain, fever, and rebound tenderness. She was explored after two days on antibiotic therapy, and progressive abdominal rigidity to only find a ruptured physiologic cyst. A fourth patient, a 15-year-old, had sudden onset of abdominal pain one day prior to admission. There was nausea, vomiting, anorexia and hypoactive bowel sounds. At surgery only polycystic ovaries were found. A wedge resection was done. Dysfunctional uterine bleeding was a frequent diagnosis in this age group, but there were 11 cases admitted with abdominal pain along with vaginal bleeding. Six patients had dizziness and anemia, and two had syncope. Four others had nausea and vomiting. Since dysfunctional uterine bleeding is most often anovulatory and painless,2 it is obvious how confusing these symptoms ap-

MARCH, 1976

peared. Two patients presented with pelvic masses. In these, ectopic pregnancy and ovarian cyst had to be ruled out. Threatened and incomplete abortion had to be considered in patients who had abdominal pain. In one case, hemorrhagic cystitis was found coexisting with dysfunctional uterine bleeding. Correct diagnosis was made on admission in seven cases. Diagnostic procedures, in most cases, included dilatation and curettage and examination under anesthesia. One patient had culdoscopy and one patient was treated successfully with estrogen and progesterore. The series includes 11 cases of pelvic inflammatory disease. Age range was 12 to 16 years. All presented with acute abdominal symptoms and fever. Six patients had significant vaginal discharge and four nausea and vomiting, while another four patients had peritonitis. One 12 year-old presented with vaginal bleeding and lesions of secondary syphilis about the vulva. It was this group that gave the most difficulty in arriving at a correct diagnosis, possibly because it was not suspected in such young patients. Correct diagnosis was made on admission in only five patients. The differential diagnoses included appendicitis, ectopic pregnancy, cystitis, tubo-ovarian abscess, Mittelschmerz, and in one patient, collagen disease. This patient presented with a history of generalized abdominal pains, rebound tenderness, fever and joint pain for two weeks, but had no significant vaginal discharge. Three patients were explored and appendectomies performed because of periappendicitis. Culdocentesis and cystoscopy on two patients helped to establish the diagnosis. These patients responded well to bed rest and antibiotic therapy. Concerning the other gynecological entities reviewed in this series, the two cases of torsion of the adnexa were diagnosed at surgery. The patient with ovarian carcinoma was diagnosed at surgery, and accounted for the only mortality in the series. There was no difficulty in diagnosing puerperal sepsis, but the three cases mentioned had peritonitis and abdominal rigidity. Mention is made of three cases which

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Gynecological Problems

seem unlikely to be associated with an acute abdomen, however, three patients respectively, with vaginal polyp, foreign body in the vagina and pelvic cellulitis, presented with symptoms of severe abdominal pain in addition to other complaints. DISCUSSION

Diagnosis often poses a problem in the adolescent girl with an acute abdomen.3 The list of differential diagnoses is always long; childhood illnesses as well as adult afflictions having to be considered. It has been noted that acute pelvic conditions are often accompanied by a sudden deterioration in the patient's condition and diagnosis depends on the triad of history, physical examination and investigation.4 Table 3. ADOLESCENT DELIVERIES AT

FREEDMEN'S HOSPITAL

Year

Number

1967 1968 1969 1970 1971

106 149 164 187 118

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Finally, it must be emphasized that the single most prevalent cause of adolescent hospitalization is pregnancy. This entity must always be a consideration in adolescent girls in the segment of the population seen at Howard University Hospital. The incidence has shown only a slight decrease even with the present-day sophisticated modes of contraception. This, however, is one acute abdomen relatively easy to diagnose. SUMMARY

This was a review over a five-year period of 90 cases sub-divided into 24 surgical cases, 23 medical cases and 43 gynecological cases. This paper dealt particularly with the gynecological acute admissions. Problems related to ovarian cyst, particularly the physiological variety, have been eliminated since the development of the laparoscope. The laparoscope, however, was not utilized in this series. It is now a frequent tool in our present diagnostic workup with acute abdomen. This has minimized the surgical exploration for physiological cysts. LITERATURE CITED

The decision whether to operate or not is crucial. To subject a patient in sickle cell crisis to a major abdominal operation would be tragic, but to procrastinate with the patient stricken by ectopic pregnancy, could be fatal. Both of these patients may present with similar symptoms of an acute abdomen, both could have low hematocrits, and because their menstrual cycles are not well established, both could give a history of missed menses. The final diagnosis is often made at surgery3'5. Sometimes at surgery no cause for the distressing symptoms can be found and must be labelled psychosomatic in origin.6

1. JUDGE and ZUIDEMA. Physical Diagnosis. 1st Edition, Little, Brown and Company, Boston, Mass., Pages 207-209. 2. DANFORTH, D. N. Textbook of Obstetrics and Gynecology. 2nd Edition, Harper and Row, Publishers, Inc., New York, Pages 754-755. 3. BERTONCELLO et al. Gynecological Acute Abdomen. Poensa Med. Argent., 59:419, 1972. 4. CHAMBERLAIN, G. Gynecological Aspects of the Acute Abdomen. Ann. Roy. Coll. Surg., Eng.,

45:174, 1969. 5. BATT, R. E. and STURGIS, S. H. Adolescent's Gynecologic Problems. Clin. Pediat., 7:17, 1968. 6. KESTENBERG, J. Adolescence. Psychiatric Problems in Ob-Gyn. MSS Information Corporation, New York. Page 247.

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Gynecological problems causing acute abdominal symptoms in adolescent girls.

Vol. 68, No. 2 117 Gynecological Problems Causing Acute Abdominal Symptoms in Adolescent Girls JOHN F. J. CLARK, M.D., Professor and Chairman, and B...
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