A 24-year-old female presented to the ED with complaints of lower abdominal pain. She reported that the pain started a few hours prior to presentation and had progressively worsened. She denied having pain like this previously. She denied dysuria, urinary frequency, abnormal vaginal bleeding or discharge, fever, chills, vomiting, and diarrhea. She reported that her LMP was about 2 weeks prior to being seen in the ED.

 

Initial VS: BP 115/60, HR 70, RR 12, afebrile

 

Physical exam revealed as soft and non-distended abdomen with suprapubic tenderness to palpation.

 

Initial work-up included a UA, which was negative for infection and RBCs, and a UPT, which was also negative. A pelvic exam was then completed to collect swabs for a wet prep and gonorrhea and chlamydia. The physician taking care of the patient noted that she had cervical motion tenderness (CMT) on bimanual exam raising the concern for pelvic inflammatory disease (PID).

 

Because of the rapidity of onset of symptoms, the provider decided to perform a bedside pelvic ultrasound to look for other tubo-ovarian pathology.

 

Here are images of the uterus in longitudinal view:

 

You can see that the uterus has a somewhat thickened endometrial stripe. What else do you notice?

 

There is a large hypoechoic structure sitting below the cervix.

 

Here are images of the uterus in transverse:

 

You again can see the structure below the uterus and slightly to the right (screen left).

 

The left adnexal area was imaged:

The left ovary appears normal in size.

 

Here are its measurements:

PID left

 

Color Doppler was placed over the ovary:

There is flow present.

 

Pulsed-wave Doppler was then used to assess for arterial and venous flow:

Arterial:

PID left arterial

Venous:

PID left venous

Arterial and venous flow are both present.

 

Next the right adnexal area was imaged:

 

 

You can see that the large structure that was seen is actually the right ovary. It appears as though there is a cyst within the right ovary. It also appears that the cyst has ruptured, and you can see free fluid coming out of the cyst.

 

The ovary measured slightly enlarged as seen below:

PID right

 

Color Doppler was placed over the ovary:

There is flow present.

 

Pulsed-wave Doppler was then used to assess for arterial and venous flow:

Arterial:

PID right arterial

Venous:

PID right venous

Arterial and venous flow are both present making torsion less likely.

 

In our ED, we often use the ultrasound transducer to guide the physical exam. We assess where pain is present by using the ultrasound transducer to press on the right and left ovaries and the cervix, and then ask the patient if that is where the pain is the greatest.

 

When this was done over the right ovary, there was exquisite tenderness, and the patient felt that that is where her pain was originating.

 

If you look as the longitudinal image of the uterus again, you can see that the right ovary sits just below the cervix:

long still

When the cervix was manipulated, the right ovary was also manipulated, and this is why she had CMT on bimanual exam.

 

The patient was diagnosed with a ruptured hemorrhagic cyst. She was feeling better with pain medications, and was discharged home with follow-up with gynecology. Her swabs for gonorrhea and chlamydia came back negative. At follow-up she was doing well, and the pain had resolved.

 

Bottom Line: CMT does not always equal PID. When the cervix is manipulated on bimanual exam, the other pelvic structures (and sometimes even intraabdominal structures) are also manipulated, which can generate pain. Take caution when diagnosing PID based only upon CMT because you do not know what else you could be manipulating that is causing pain. A bedside pelvic ultrasound only adds about 5-10 minutes to a speculum exam, and the information gained, in our opinion, is worth the extra time.

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