Acute abdominal pain in a 16-year-old woman: the pitfalls of sexual history

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A 16-year-old woman presented to the authors' emergency department in the early hours of the morning with a 3-day history of cramping lower abdominal pain and watery diarrhoea, following a meal of reheated rice. The remainder of her history (including gynaecological history) was unremarkable. Examination revealed that she was clinically dehydrated, had a tachycardia of 100 beats per minute, and although she did not display any signs of peritonism, she did have lower abdominal tenderness, not more so on any one side. Rectal examination was deferred by the patient. Chest and abdominal radiographs (Figures 1 and 2) were unremarkable, and initial blood tests revealed a white blood cell count of 3.4×109/litre, with C-reactive protein of 156 mg/litre. Her urine did not contain nitrites, leucocytes or blood, and a beta-human chorionic gonadotrophin pregnancy test was negative. A diagnosis of gastroenteritis and tachycardia secondary to dehydration was made and the patient was admitted to hospital. The following day her abdominal pain worsened and despite rehydration she remained tachycardic, developing profound swinging pyrexia (peak of 40°C). On examination, her abdomen was noted to be extremely tender and peritonitic below the umbilicus, with marked guarding on examination. She was immediately referred to both general surgery and gynaecology teams. The on-call gynaecologist was able to question the patient about her sexual history separate from her family, who until now had been with her at all times. At this stage, the patient admitted that she had sexual intercourse for the first time 4 days before admission, but denied any relation to the onset of symptoms. Vaginal examination was refused, but the patient did allow a rectal examination, performed by the general surgical consultant, revealing marked tenderness and fullness in the pouch of Douglas. Although the sexual history was noted, it was felt that appendicitis was the most likely cause for her pain, and the patient was taken to theatre for a diagnostic laparoscopy. At laparoscopy, a large amount of pus was seen in the abdomen limiting visualization and necessitating conversion to laparotomy. Although a mildly inflamed appendix was seen and appendicectomy performed, this did not account for the pus, and further careful examination of the abdominal cavity was carried out. In the pelvis and careful palpation of the pouch of Douglas revealed a traumatic, full thickness, 1 cm transverse tear of the posterior vaginal wall, through which the cervix could be felt. After discussion with the gynaecology team, this was treated with copious pelvic lavage and a carefully placed pelvic drain. Further questioning during the postoperative period revealed that the intercourse had been consensual but very painful. The patient had an uneventful postoperative recovery and was discharged after 7 days to be followed up in the gynaecology outpatient department.