GYN CHRONICLES
Pelvic Inflammatory Disease ( PID ): The Real And The False
Dr . Maureen Owiti
Scratching my head and in view of the festivities fast approaching , I wanted to write on something light but nothing came to mind until Imelda ( not her real name ) walks in and says she has been diagnosed with Pelvic Inflammatory Disease ( PID ).
A little background on Imelda , she is a young tech guru who works for one of these technology incubation companies but what is most refreshing about her , excuse my ancientness is the fact that she is still a virgin . I go through the usual questions : When was you last period ? Are you sexually active ? Do you have pain ? Where is the pain located ? What makes it worse ? What makes it better ?
In typical fashion she had some pain , which surprisingly on day of the consultation , was no longer there . I think illness knows when patients are coming to see the Doctor . I say the illness is afraid as it knows we will deal with it thoroughly but I think the disease just wants to humiliate us so we are unable to make an accurate diagnosis .
She had had her period about 3 weeks before the visit to my clinic and was diagnosed with this PID about a week prior . The pain was very sharp sudden onset mostly on the left side radiating to her back . She took some buscopan , which alleviated her symptoms . At that time she went to a health facility and a scan was done which showed she had fluid in the Pouch of Douglas . The Pouch of Douglas is the area behind the uterus and in front of the rectum .
I will agree with a differential diagnosis of PID in view of the Ultrasound findings but would like to remind some of our Ultrasound radiographers that not all fluid in the Pouch of Douglas signifies PID . Fluid in this region can signify natural physiological events and notably these are menstruation and ovulation . I ’ m sure most of my doctor colleagues if they do read this column had guessed this as I was writing . Yes all Imelda was suffering from was Mittelshmerz , which is the medical term for pain during ovulation .
Mittelschmerz is one-sided , lower abdominal pain associated with ovulation . German for “ middle pain ,” mittelschmerz occurs midway through a menstrual cycle ; about 14 days before the next menstrual period . In most cases , mittelschmerz doesn ’ t
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Mittelschmerz is one-sided , lower abdominal pain associated with ovulation . German for “ middle pain ,” mittelschmerz occurs midway through a menstrual cycle ; about 14 days before the next menstrual period . In most cases , mittelschmerz doesn ’ t require medical attention . require medical attention .
The only challenge is that this pain can be so severe one may think they are dying . It can literally make one double up and crawl on the floor . The interesting thing about it is that this ovulation pain does not necessarily come every month . Some months there are no symptoms and some months accident and emergency review required to control the pain .
The pain is postulated to be as a result of the stretching capsule of the ovary but most often as a result of bleeding into the abdominal cavity . The blood causes irritation of the peritoneum , which is the lining of the uterus and leads to severe pain very much like an ectopic gestation .
This reminds me of Kadzo , a patient we had when I was still working at the coast who had negative pregnancy test ( sensitive blood pregnancy test ) and all features of an ectopic . We thought she had a ruptured spleen but the surgeons insisted the gynaecogical team to operate . We did surgery and at surgery found 3L of blood but no evidence of an ectopic pregnancy , liver of splenic injury . All that was present was miniscule dot on her left ovary . My consultant at the time said it was ovulation . This is where you put that emoji of the lady who doesn ’ t know what ’ s up ? Wonders never cease so we leave it at that !
Back to the Ultrasound findings . The fluid was definitely as a result of ovulation as for someone who is not sexually active and has never engaged in intercourse , it is very unlikely that she has pelvic inflammatory disease . A similar picture can be seen during menstruation and our radiography colleagues should just report fluid in the pouch of Douglas clinical correlation
24 MAL51 / 22 ISSUE