Pelvic Inflammatory Disease With Presumptive Tubo-Ovarian Abscess Presenting With Rectal Spasm

Pelvic inflammatory disease (PID) is an infectious process of the upper female genital tract, commonly caused by Chlamydia trachomatis, Neisseria gonorrhoeae, or Mycoplasma genitalium. Complications may include tubo-ovarian abscess (TOA) due to localized infection. Typical symptoms include pelvic pain, vaginal discharge, dyspareunia, and abnormal bleeding, with diagnosis often made clinically and supported by imaging and laboratory testing. Empiric antibiotic therapy is recommended promptly to prevent long-term sequelae. Rectal spasms, or proctalgia fugax, are characterized by fleeting anorectal pain episodes and are not well described in association with PID or TOA.

A 43-year-old female G12P5065 with noninsulin dependent diabetes presented with severe, spasmodic rectal pain and a 1-week history of lower abdominal discomfort with vaginal discharge and malodor. She had recently been prescribed metronidazole for presumed bacterial vaginosis but had not initiated therapy. Examination revealed foul-smelling vaginal fluid, an erythematous cervix with cervical motion tenderness, and active anal sphincter spasm without palpable masses or fluctuance. Laboratory studies showed leukocytosis (16.9 k/uL); imaging revealed right ovarian soft tissue thickening abutting pelvic structures concerning for PID/TOA. Transvaginal ultrasound demonstrated benign right ovarian cysts. STI panel was positive for C. trachomatis, Trichomonas vaginalis, and bacterial vaginosis. Empiric therapy with ceftriaxone, doxycycline, and metronidazole was initiated. The patient was admitted for pain control, including methocarbamol for rectal spasms, and discharged after clinical improvement with outpatient follow-up.

This case highlights atypical presentation of PID with severe rectal spasms, likely secondary to local inflammation adjacent to the rectum. While PID commonly presents with pelvic pain and vaginal symptoms, clinicians should maintain a broad differential for rectal pain and consider pelvic pathology when initial rectal evaluation is unrevealing. Prompt examination, imaging, empiric therapy, and specialist consultation remain critical in managing complicated PID presentations.