Case Report: Gastroenterology

Salpingitis in an Adolescent Female With Constipation and

Abdominal Pain
*Gal Barak, MD, MED, †Matthew R. Carroll, MD, and *Andrea Dean, MD

Abstract: Abdominal pain is one of the most common presenting complaints complicated by encopresis. She had poor adherence to these medica-
in the emergency room for pediatric patients. While constipation is one of the tions. Menarche was 10 months prior with regular cycles, and last
most common causes for abdominal pain in pediatrics, serious intra-abdomi- menstrual period was 2 weeks prior to presentation. In a protected
nal pathology must always be excluded. We report a pre-coital post-menarchal social history, the patient denied romantic partners, sexual activity, or
adolescent female who presented with severe abdominal pain and constipa- sexual abuse. The remainder of her past medical, surgical, and social
tion and had radiographic findings of salpingitis. It was suspected that uterine history was unremarkable.
and adnexal changes seen on imaging resulted from the fecal mass compress- On general survey, the patient was anxious and visibly upset.
ing the genitourinary tract leading to fluid collection manifesting as radio- Vital signs were notable for tachycardia with heart rate 108. Physical
graphic evidence of salpingitis. This mechanism is similar to bladder outlet examination revealed right lower quadrant tenderness with guarding and
obstruction resulting from compression by intestinal stool burden, leading to rebound. Pelvic examination was declined by the patient and her family.
urinary stasis, bacteriuria, and ascending urinary tract infection. This case Diagnostic laboratory testing revealed leukocytosis to 16 000
demonstrates how a common pediatric problem, constipation, can lead to a with elevated absolute neutrophil count and elevated C-reactive pro-
condition rarely found in the pre-coital adolescent population. tein of 5.2. Urine pregnancy test was negative. Urinalysis was suspi-
cious for urinary tract infection (UTI) with evidence of pyuria and
Key Words: abdominal pain, adolescent, constipation, salpingitis urine nitrites. Appendix and pelvic ultrasounds demonstrated an
unremarkable appendix, fluid-filled uterus, and bilateral hydrosalpin-
INTRODUCTION ges with a complex fluid collection in the left fallopian tube (Fig. 1).
Abdominal pain is one of the most common complaints of Findings were reported as consistent with salpingitis. Debris was
pediatric patients presenting to emergency center and represents a noted in the urinary bladder and significant stool burden was seen in
significant burden to families, contributing to increased health care the rectum, which was also confirmed on upright x-ray.
costs (1–3). A broad understanding of the pathologies and sequelae Given the findings of fecal impaction, the patient was admitted
causing abdominal pain is important to the pediatric gastroenterolo- to the hospitalist service for bowel cleanout. The pediatric gynecol-
gist. Constipation accounts for 20% of all cases of pediatric abdomi- ogy service recommended empiric treatment for Pelvic Inflamma-
nal pain (3). Other serious intra-abdominal pathologies, such as tory Disease (PID) and further imaging to evaluate for a Mullerian
appendicitis and gynecologic conditions, require prompt recognition anomaly to explain an obstruction of the fallopian tubes. A contrast
(4). We present a case of a 12-year-old girl with abdominal pain with computed tomography (CT) scan of the abdomen and pelvis obtained
radiographic salpingitis associated with fecal impaction. early in her hospitalization demonstrated bilateral adnexal hyperemia
consistent with salpingitis in addition to bladder distension, fluid in
the endometrium, and mass effect of distended intestine on gyneco-
CASE REPORT logic structures (Fig. 2).
A 12-year-old girl presented to the hospital emergency depart- The patient’s initial tachycardia resolved with intravenous
ment for evaluation of acute onset right lower quadrant abdominal hydration and intravenous ketorolac. Empiric intravenous doxycycline
pain. It started 3 days prior to presentation and was sharp, constant,
and worse with movement. It did not radiate and was 8 of 10 in sever-
ity. This pain was accompanied by constipation, anorexia, and dys-
uria. She had been treated by her pediatrician for chronic constipation

Received March 22, 2022;accepted October 10, 2022.

From the *Department of Pediatrics, Baylor College of Medicine/ Texas Children’s
Hospital, Houston, TX; and †Department of Obstetrics and Gynecology, Bay-
lor College of Medicine, Houston, TX. Correspondence: Gal Barak, MD, MEd,
Department of Pediatrics, Texas Children’s Hospital, 1102 Bates Avenue FC
1860, Houston, TX 77030. Email: [email protected]
The authors report no conflicts of interest.
Publication costs were generously supported by the Texas Children’s Hospital
Young Investigators Endowed Fund.
The patient provided assent and her legal guardians provided informed consent for
publication of the details of this case.
Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on
behalf of the European Society for Pediatric Gastroenterology, Hepatology,
and Nutrition and the North American Society for Pediatric Gastroenterology,
Hepatology, and Nutrition. This is an open-access article distributed under the
terms of the Creative Commons Attribution-Non Commercial-No Derivatives
License 4.0 (CCBY-NC-ND), where it is permissible to download and share
the work provided it is properly cited. The work cannot be changed in any way FIGURE 1. Pelvic ultrasound demonstrating a fluid-filled
or used commercially without permission from the journal.
JPGN Reports (2022) 3:4(e271)
endometrial canal (E) measuring 8 mm in thickness. Abdomi-
ISSN: 2691-171X nal wall (Abd), stool filled bowel (S), and bladder (B) are also
DOI: 10.1097/PG9.0000000000000271 visualized.

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Case Report

FIGURE 2. Coronal views of patient’s computed tomography (CT) scan demonstrating distended rectum (R) with stool burden,
adnexal (A) swelling and hyperemia, displaced and fluid-filled uterus (U), and significant bladder (B) distension.

TABLE 1. Reports of pre-coital pelvic inflammatory disease without tubo-ovarian abscess

Case Organism Proposed etiology Source
11-year-old pre-coital female (F) with diffuse Streptococcus pneumoniae Hematogenous distribution Van der Putten et al (13) 2008
abdominal pain and fever isolated from fallopian fibrin
and blood cultures
11-, 12-, and 16-year-old pre-coital F with history Cultures not obtained Postsurgical complication or a congenital Merlini et al (9) 2008
of Hirschsprung status post surgery in infancy defect of the autonomous innervation in
who presented with bilateral hydrosalpinx the context of a neurocristopathy
15-year-old pre-coital F with right lower quadrant None isolated, + polymorpho- Ascending infection Kielly et al (10) 2014
(RLQ) pain and severe diarrhea, presented in nuclear leukocytes (PMNs) in
Cervical ectopy
shock with acute abdomen peritoneal fluid
11-year-old pre-coital and pre-menarchal F with None isolated, +PMNs in Ascending infection Kielly et al (10) 2014
constipation and encopresis with RLQ pain and peritoneal fluid
Cervical ectopy
emesis
Seeding from bowel
17-year-old pre-coital, post-menarchal F with Cultures not obtained Adhesions of left tubal fimbria second- Takeda et al (11) 2017
history of inguinal hernia repair in infancy with ary to prior inguinal surgery resulting
left lower quadrant (LLQ) pain found to have in blockage of left fallopian tube and
hydrosalpinx with tubal torsion subsequent hydrosalpinx
12-year-old pre-coital F with RLQ pain, intraopera- Peptostreptococcus anaero- Obstructed hemivagina due to Mullerian Maraqa et al (12) 2017
tive diagnosis of bilateral pyosalpinx with recur- bius, Prevotella bivia, and duct anomaly with resultant retrograde
rence 9 weeks later Streptococcus anginosus menstruation

and ceftriaxone were started for UTI and PID. A Golytely drip via fluid on imaging would need emergent surgery for ruptured ectopic
nasogastric tube was initiated. Abdominal pain quickly resolved with pregnancy if their urine pregnancy test was positive; however, the
passage of multiple large volume stools. Based on negative gonorrhea same patient with a negative pregnancy test would be a candidate
and chlamydia testing, antibiotics for PID were stopped. Admission for conservative treatment if it were believed they had a ruptured
urine culture grew Escherichia coli, so the patient was discharged to ovarian cyst.
complete a course of oral amoxicillin-clavulanic acid. She was also Although not well described in the literature, this patient’s
discharged home on a bowel regimen with education on constipation uterine and adnexal changes resulted from the fecal mass compress-
management. She has remained well since that time with no recur- ing reproductive structures and obstructing normal outward drainage.
rence of symptoms. Her final primary diagnosis was fecal impaction, This mechanism resembles bladder outlet obstruction, a more com-
which explained her clinical picture and radiographic, noninfectious monly encountered effect of constipation, in which urinary retention
salpingitis. leads to bacteriuria and can result in ascending UTI that was also seen
in this patient (6). In addition, it was hypothesized that translocation
of enteric bacteria, for which constipation is a risk factor, directly
DISCUSSION to adnexal structures also contributed to localized inflammation (7).
Efficient triage and treatment of patients with abdominal pain In our patient, the radiographic finding of salpingitis was alarming,
is an important skill for pediatricians. Acute gynecologic conditions and even raised concern for sexual abuse, but was ultimately due to
are not an uncommon cause for emergency center visits in chil- constipation rather than an underlying infectious process.
dren and adolescents (5). In addition to PID adnexal complications, Classically, PID is defined as inflammation of the cervix,
including tubal ectopic pregnancy, ovarian torsion, or cyst rupture uterus, or adnexa and can include endometritis, salpingitis, tubo-
can present similarly with lower abdominal or pelvic pain, nausea, ovarian abscess (TOA), and pelvic peritonitis (8). Although typically
and/or vomiting. Differentiation is accomplished largely by clinical caused by sexually transmitted infections chlamydia or gonorrhea,
history and imaging as the physical examination can be similar for PID can be considered a polymicrobial infection from ascending bac-
each of these conditions. A patient with pain, tenderness, and free teria from the vagina or cervix. Approximately 15% of PID cases

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described are not sexually transmitted and are associated with enteric 2. Harris BR, Chinta SS, Colvin R, et al. Undifferentiated abdominal pain in chil-
or respiratory pathogens that have colonized the lower genital tract. dren presenting to the pediatric emergency department. Clin Pediatr (Phila).
2019;58:1212–1223.
While the majority of published cases of pre-coital PID are those
3. Magnúsdóttir MB, Róbertsson V, Þorgrímsson S, et al. Abdominal pain is a
with TOA, several prior studies have identified cases of pre-coital common and recurring problem in paediatric emergency departments. Acta
PID without TOA in patients who presented with surgical abdomen Paediatr. 2019;108:1905–1910.
requiring intraoperative treatment (Table 1) (9–13). Some of these 4. Lee WH, O’Brien S, Skarin D, et al; PREDICT. Pediatric abdominal pain
cases were found to be sterile inflammatory processes, although in children presenting to the emergency department. Pediatr Emerg Care.
applicability of literature review to our patient is limited, as all pub- 2021;37:593–598.
lished cases were severe enough to require surgical treatment. 5. Lawrence AE, Ervin E, Sebastião YV, et al. Emergency department evalu-
In our patient, a sterile process was suspected and the gynecol- ation of abdominal pain in female adolescents. J Pediatr Adolesc Gynecol.
2021;34:649–655.
ogy team recommended against antibiotic treatment for salpingitis.
6. dos Santos J, Varghese A, Williams K, Koyle MA. Recommendations for
While it is possibile that a nascent infection was present in the tubes the management of bladder bowel dysfunction in children. Pediatr Ther.
from either ascending vaginal flora or translocation of bacteria from 2014;4:191.
the intestine, her rapid improvement with bowel cleanout argues that 7. Balzan S, de Almeida Quadros C, de Cleva R, et al. Bacterial transloca-
mass effect from impacted feces was the primary cause of fluid build- tion: overview of mechanisms and clinical impact. J Gastroenterol Hepatol.
up and sterile inflammation, resulting in salpingitis. 2007;22:464–471.
This case adds to the few reports that constipation can result 8. Hillier SL, Bernstein KT, Aral S. A review of the challenges and complexities
in the diagnosis, etiology, epidemiology, and pathogenesis of pelvic inflamma-
not only in urinary stasis and ascending UTI but also in obstruction, tory disease. J Infect Dis. 2021;224(suppl_2):S23–S28.
congestion, and inflammation of the reproductive organs.
9. Merlini L, Anooshiravani M, Peiry B, et al. Bilateral hydrosalpinx in adoles-
cent girls with Hirschsprung’s disease: association of two rare conditions. Am
J Roentgenol. 2008;190:W278–W282.
ACKNOWLEDGMENTS 10. Kielly M, Jamieson MA. Pelvic inflammatory disease in virginal adoles-
G.B. and M.R.C. participated in data collection and analysis, cent females without tubo-ovarian abscess. J Pediatr Adolesc Gynecol.
drafted the initial article, and reviewed and revised the article. A.L.D. con- 2014;27:e5–e7.
ceptualized and designed the study, assisted in drafting the initial article, 11. Takeda M, Miyatake T, Tanaka A, et al. Rare hydrosalpinx in a sexually inac-
and reviewed and revised the article. All authors approved the final article tive adolescent successfully treated with laparoscopy. Gynecol Minim Invasive
Ther. 2017;6:76–78.
as submitted and agree to be accountable for all aspects of the work.
12. Maraqa T, Mohamed M, Coffey D, Sachwani-Daswani GR, Alvarez C,
Mercer L. Bilateral recurrent pyosalpinx in a sexually inactive 12-year-old
REFERENCES girl secondary to rare variant of Mullerian duct anomaly. BMJ Case Rep.
1. Groenewald CB, Wright DR, Palermo TM. Health care expenditures asso- 2017;2017:bcr2016218924.
ciated with pediatric pain-related conditions in the United States. Pain. 13. van der Putten ME, Engel M, van Well GS. A rare cause of acute abdomen in
2015;156:951–957. a sexually inactive girl: a case report. Cases J. 2008;1:326.

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