Emergency Department Evaluation of Abdominal Pain in Adolescent Females

Abdominal pain is a very common chief complaint among adolescents presenting to the emergency department (ED) and poses a challenge to physicians given the vast differential diagnosis varying with patient age and gender. Consideration of ovarian and gynecologic pathologies is necessary in female patients to avoid missing sexually transmitted infections (STIs), pregnancy, sexual abuse, ectopic pregnancies, ovarian pathology, and more. Despite the profound importance of screening for gynecologic etiologies in the setting of acute abdominal pain, few data exist on how effective children's hospitals are in this context. This retrospective cohort study aimed to determine the frequency of evaluation of gynecologic causes of abdominal pain in adolescent girls at a single quaternary children's hospital. Female patients aged 11 to 21 years presenting to the ED or urgent care (UC) clinic between January and December 2016 were included in this analysis. Sociodemographic information was collected in addition to documentation of the medical evaluation including associated symptoms, history, physical examination, laboratory testing, and imaging. The primary study outcomes were the proportions of patients who received reproductive health history screening and a gynecologic examination. Secondary outcomes included documentation of menarchal status, sexual activity, and test results for STIs. A composite variable was created to identify those patients with 1 or more symptoms of concern for a reproductive health problem, including dysuria, fever, vaginal discharge, or vaginal bleeding. Log binomial regression was conducted to determine the risk ratios associated with age, race, insurance status, place of visit, and presenting symptoms of concern. A total of 1082 patients presented for acute abdominal pain, with gynecologic etiologies accounting for 7.3% of discharge diagnoses. The prevalence of presentation with 1 or more symptoms of concern was 22%. Menarche status was documented in 88% of patients, and among these, 97% had last menstrual period recorded. Sexual activity status and contraception use were documented in 50% and 27% of patients, respectively. Sexual activity status, contraception, and menarche were documented more frequently in ED visits versus UC visits. Of patients reporting that they were sexually active, 75% were asked about contraception, and 30% were tested for STI. Pregnancy testing was performed in 78% of adolescent patients. Fewer than 5% of total patients had a pelvic examination (speculum or bimanual) performed, whereas 12.2% of patients presenting with fever, vaginal discharge, vaginal bleeding, or dysuria had a pelvic examination performed. Compared with White race, Black race was associated with greater likelihood to undergo STI testing (adjusted risk ratio [aRR], 1.25; confidence interval [CI], 1.13-1.70) and pelvic examination (aRR, 2.45; CI, 1.34-4.50), but less likely to receive imaging (aRR, 0.69; CI, 0.59-0.81). This retrospective cohort study demonstrates that adolescent patients presenting to pediatric acute care facilities with a chief complaint of abdominal pain are often not fully evaluated in a reproductive health context. Sociodemographic disparities in the evaluation of these patients raise concern for possible physician bias and warrant further investigation.