Discitis Caused by Acute Pelvic Inflammatory Disease：A Case Report and Literature Review

Discitis Caused by Acute Pelvic Inflammatory Disease：A Case Report and Literature Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Discitis Caused by Acute Pelvic Inflammatory Disease：A Case Report and Literature Review Qi Wu, Suning Bai, Liyun Song, lina Han This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7401243/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 22 You are reading this latest preprint version Abstract Background: Pelvic inflammatory disease (PID), a common gynecological infection, includes endometritis, tubo-ovarian abscess, and pelvic peritonitis [1] . Uterine operations like abortion or intrauterine Device (IUD) removal may induce pelvic infection, causing lumbago, abdominal pain, menstrual disorders, or even systemic infection. Post-abortion pelvic infection incidence is 5.88%-8.79% [2-3] .This case report describes a patient who developed acute PID following a difficult IUD removal procedure, ultimately progressing to rare discitis with restricted lumbar mobility. While PID represents a common gynecological condition, its complication of secondary discitis causing significant motor impairment has been scarcely documented in medical literature. Through comprehensive imaging studies and pathogenetic analyses, this case confirmed the pathogenic spread of infection across anatomical boundaries. It highlights the critical need for prompt management of pelvic infections to prevent their potentially severe transcompartmental dissemination. This report serves to alert obstetric and gynecological practitioners about PID's underrecognized complications while emphasizing the importance of enhanced diagnostic vigilance and preventive strategies. Case presentation: A 44-year-old female underwent difficult IUD removal lasting nearly 2 hours, developing septic shock postoperatively. After antibiotic treatment, she had residual lumbosacral pain and left lower limb convulsive pain. Transferred to our hospital, she was diagnosed with discitis via examinations and multidisciplinary collaboration. Laparoscopic exploration was performed promptly, with full recovery and symptom resolution. Conclusion: By analyzing this case and literature, we explore antibiotic selection, surgical timing and methods, summarizing lessons to improve clinicians' understanding of PID and discitis, aiding standardized diagnosis, treatment, and related research. Discitis Pelvic inflammatory disease Case Report Figures Figure 1 Figure 2 Background Uterine cavity operations such as diagnostic curettage, intrauterine device (IUD) removal, etc. are basic operations in gynecology. However, the ascending infection cannot be ignored. Timely diagnosis and standardized treatment are the key issues in the treatment of pelvic inflammatory diseases. Antibacterial drugs are mainly used for treatment, and the treatment principles are broad-spectrum, sufficient dosage, full treatment course and individualized. Discitis is an infectious lesion occurring in the intervertebral disc space and adjacent vertebral bodies or cartilage plates [ 4 ] . It is generally considered that discitis is caused by hematogenous spread of bacterial infection [ 5 ] . However, at present, there are no reports about cases of discitis caused by uterine cavity infection. Case Presentation The patient, a 44-year-old female, came to the orthopedics department of our hospital on September 8 , 2021 due to "low back pain for more than one month after the removal of the intrauterine device (IUD), and left lower limb pain accompanied by walking disorder for 5 days". Present medical history: The patient once visited the local county hospital because of vaginal bleeding accompanied by severe anemia for more than one month. Ultrasonic examination showed the presence of uterine fibroids, endometrial lesions, and an intrauterine device. After blood transfusion, she underwent diagnostic curettage and IUD removal operation. The operation was rather difficult and took about 2 hours, and the IUD removal failed. Two days after the operation, the patient had high fever, chills, and lumbosacral pain simultaneously, with the highest body temperature reaching 41℃. After 9 days of anti-inflammatory treatment in the ICU, the body temperature returned to normal, the lumbosacral pain was slightly relieved compared with before, and the lower limb movement returned to normal. But the low-back pain still persisted. The pain was sharp like an electric shock, occurring intermittently and being more obvious at night. This pain was not related to activities, postural changes, defecation, etc. The patient could not maintain the supine position for a long time, but there was no weakness or abnormal sensation in both lower limbs. The patient had a lumbar CT examination in the local hospital, and the results showed "protrusion of the lumbar 3-4 and lumbar 4-5 intervertebral discs, calcification of the lumbar 4-5 intervertebral disc, and lumbar vertebra hyperplasia". Subsequently, the patient had convulsive-like pain in the left lower limb, felt weak and had difficulty walking. Each pain attack lasted for about several minutes. After 5 days of continuous pain, she came to the orthopedics department of our hospital for treatment and was hospitalized. Past medical history: One month ago, she also received blood transfusion treatment due to "severe anemia".Three months ago, she was diagnosed with "uterine fibroids". Physical examination: Body temperature was 36.3℃,pulse was 98 beats per minute, respiration was 20 times per minute, and blood pressure was122/69 mmHg (1 mmHg =0.133 kPa). The patient was conscious, articulate, and cooperative during the physical examination. No obvious abnormalities were found in the cardiopulmonary and abdominal examinations. The spine had no deformities or scoliosis, and there was no tenderness or percussion pain in each vertebra, and the movement was normal. There was tenderness between the lateral sides of the bilateral sacrum and the ischial tuberosities, no tenderness in the bilateral sacroiliac joints, negative bilateral straight - leg - raising tests, negative bilateral Faber tests (4-sign), negative pelvic separation tests, and negative pelvic compression tests. There was no deformity or edema in both lower limbs, the movement was normal, no redness or swelling in each joint, and the movement was not restricted. There was no muscle atrophy, and the muscle strength was normal.Laboratory examinations: Erythrocyte sedimentation rate and C-reactive protein were elevated, while white blood cell count and procalcitonin were normal. Imaging examinations:gynecological ultrasonic examination, and the results showed that the size of the uterus was approximately 82mm×96mm×88mm. A heterogeneous hypoechoic mass with a size of 75mm×75mm×62mm could be seen on the posterior wall, most of which protruded into the uterine cavity, and abundant blood - flow signals could be detected around it. The echo of the intrauterine device was visible in the uterine cavity, and part of the intrauterine device was located in the myometrium[Figure 1]. The results of lumbar spine MRI plain scan showed abnormal signals in the L5 and S1 vertebral bodies, some of their appendages, and the epidural area behind the vertebral bodies. An infectious lesion was considered[Figure 2]. PET-CT examination showed increased metabolism at the upper and lower edges of the L5-S1 vertebral bodies accompanied by bone destruction, and multiple mildly hypermetabolic lymph nodes in the abdominal and pelvic cavities. Intervertebral discitis accompanied by lymphadenitis was considered. So cefoperazone sodium and sulbactam sodium combined with ornidazole were given by intravenous drip for anti-infection, and dexmedetomidine hydrochloride and dezocine were continuously pumped intravenously for analgesia and sedation. But the patient still complained of paroxysmal pain in the waist and left calf, and at the same time, there was severe pain in both buttocks, which was more obvious in the sitting position and could be slightly relieved in the lateral decubitus position. she was transferred to the gynecology department for laparoscopic hysterectomy and intervertebral disc exploration. During the operation, it was found that the uterus was evenly enlarged as in the3 - month pregnancy, with a smooth surface and no adhesion to the surrounding tissues. Both fallopian tubes were congested and small vesicles of inflammatory exudation were seen, and the appearance of both ovaries was normal. After the uterus was removed from the body, upon dissection, purulent infection was found in the uterine cavity. A submucosal fibroid with a diameter of 7 cm was visible, with purulent membranes attached to its surface. Part of the fibroid tissue was necrotic and pus cavities and gray-white pus were seen locally, with a foul smell. One GyneFix IN IUD was seen in the uterine cavity, which was incarcerated and pierced into the myometrium of the posterior uterine wall. Through vaginal exploration, a pus cavity was found between the posterior vaginal wall and the rectum. The wall of the pus cavity was taken for bacterial culture. The orthopedic surgeon performed laparoscopic intervertebral disc exploration. A thick needle was used to puncture the L5-S1 intervertebral disc, and no pus flowed out. After separating the intervertebral disc space, about 20 ml of dark red bloody-watery exudate flowed out. Post-operative pathological results:(1) Submucosal leiomyoma of the uterus,with local infarction, surface ulceration and necrosis, accompanied by suppurative inflammation and adenomyosis; (2) Endometrium in the proliferative phase; (3) Mild chronic inflammation of the cervix, with squamous metaplasia of the glands; (4) Congestion of (both) fallopian tubes, accompanied by vesicular appendages. Bacterial identification of the tissues in the uterine cavity and in front of the rectum: Escherichia coli infection. The results of bacterial culture showed that Escherichia coli was sensitive to cefoperazone sodium and sulbactam sodium, so the antibiotics were not adjusted any more. After the operation, cefoperazone sodium and sulbactam sodium combined with ornidazole were continuously given for a total course of 14 days. On the fifth day after the operation, all the patient's symptoms were relieved, the pain in the waist disappeared, the movement of both lower limbs was free. Two months after the operation, Re-examination of lumbar MRI showed normal. Discussion and conclusion Pelvic inflammatory disease (PID) is a group of diseases caused by infections in the female upper genital tract, including endometritis, salpingitis, tubo-ovarian abscess and pelvic peritonitis. The main pathogens of PID are Neisseria gonorrhoeae and Chlamydia trachomatis, and genital mycoplasma infection is also one of the causes that cannot be ignored. Purulent infection in the uterine cavity develops from endometritis and is a special and severe form of PID. In this patient, due to the incarceration of the intrauterine device combined with submucous myoma, it was difficult to remove the intrauterine device, and the operation time in the uterine cavity was long, which led to endometritis after endometrial injury. Moreover, because of the concurrent submucous myoma of the uterus, the drainage of inflammatory exudate was not smooth, resulting in purulent infection in the uterine cavity. The treatment of PID is mainly based on antimicrobial drugs. Correct and standardized use of antimicrobial drugs can cure more than 90% of PID patients. Antimicrobial drug treatment should last for at least 14 days, and surgical treatment is required when necessary. Since this patient had been treated with multiple antibiotics outside the hospital with poor results, after admission, cefoperazone sodium and sulbactam sodium combined with ornidazole were given intravenously for anti - infection treatment, and laparoscopic hysterectomy and intervertebral disc exploration were performed. Intervertebral discitis, also known as suppurative intervertebral discitis, intervertebral space infection, etc., refers to infectious lesions in the intervertebral disc space and adjacent vertebral bodies or cartilage plates. There are mainly the following three theories regarding its etiology [5] : hematogenous bacterial infection, aseptic inflammation, and the body's autoimmune response. The spinal vertebral body - intervertebral disc is anatomically similar to a joint. In particular, the anterior part of the vertebral body has a rich distribution of terminal branches of arterial blood vessels. Therefore, hematogenous infection first and most commonly involves the sub - end - plate bone in the anterior part of the vertebral body. Subsequently, the inflammation can break through the cortex and invade the sub-ligamentous area, the intervertebral disc, adjacent vertebral bodies, the posterior column, and the spinal canal. Therefore, it is considered that this case may be caused by hematogenous bacterial infection. Through consulting relevant literatures, up to now, there are no reports on the occurrence of purulent infection in the uterine cavity caused by intrauterine device (IUD) removal, which further leads to lumbar intervertebral discitis. Some domestic scholars reported a female patient who had lower abdominal and lumbar pain after undergoing posterior fornix puncture due to ectopic pregnancy. She was misdiagnosed as having lumbar tuberculosis, and her disease course was protracted for about three months. Eventually, she was finally diagnosed with Escherichia coli infection in the lumbar intervertebral space. GENTILE et al. [6] reported a female patient who underwent laparoscopic Y - mesh sacrohysteropexy for "uterine prolapse of degree III". One month after the operation, the patient had symptoms such as persistent lumbosacral stiffness accompanied by low back pain and right lower limb pain, and then the symptoms worsened to the point where she could not stand or walk. Eventually, she was diagnosed with purulent lumbar intervertebral discitis. In combination with this case, it is suggested to clinicians that when a patient has persistent low back pain after undergoing invasive pelvic operations, accompanied by a significant increase in erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) as well as abnormal changes in lumbar MRI, the possibility of intervertebral space infection should be considered. This case report aims to remind the vast number of gynecologists that after intra-uterine cavity operations, if the patient has a series of infection symptoms accompanied by persistent lumbosacral pain, the possibility of discitis infection should be considered. Intra-uterine cavity operations carry a certain risk of infection. Therefore, in addition to strictly following the aseptic operation specifications, the surgical operation should be gentle. When difficulties are encountered during the operation, an experienced doctor should take over to prevent adverse consequences such as intra-uterine cavity infection and uterine perforation caused by rough surgical operations.At the same time, it also reminds orthopedic doctors that when treating female patients with discitis, they should ask about the medical history in detail, be vigilant about the situation possibly caused by pelvic inflammation, achieve early diagnosis and early treatment, completely eradicate the primary lesion, thereby shortening the course of the disease, alleviating the pain of patients and avoiding the occurrence of serious consequences. Abbreviations PID Pelvic inflammatory disease (IUD Intrauterine Device Declarations Acknowledgment We would like to thank the patient for giving consent to the publication of her case details. Funding NO Ethical statement This case report has anonymized the patient's private information, and the publication of the article has obtained ethical approval. Availability of data and materials The datasets used and/or analyzed in this study are available from the corresponding author upon reasonable request. Authors' contributions Qi Wu is responsible for Conceptualization and Writing–review & editing. Suning Bai is in charge of Resources, and Supervision. Liyun Song undertakes Validation and Writing–original draft. Lina Han is responsible for Funding acquisition administration. Consent for publication Informed consent for publication of this case report was obtained from the patient. Conflicts of Interest The authors have no conflicts of interest to declare References Infectious Diseases Collaborative Group, Obstetrics and Gynecology Branch of Chinese Medical Association. Diagnostic and treatment guidelines for pelvic inflammatory disease (revised edition in2019) [J]. Chin J Obstet Gynecol. 2019;54(7):433–7. 10.3760/cma.j.issn.0529-567x.201 9.07.001 . HAN T, NOLAN S M REGARDM. Mycoplasma genitalium as a cause of pelvic inflammatory disease [J]. J Pediatr Adolesc Gynecol. 2020;33(6):739–41. 10.1016/j. jpag.2020.06.015. RAVEL J, MORENO I. Bacterial vaginosis and its association with infertility, endometritis, and pelvic inflammatory disease [J]. Am J Obstet Gynecol. 2021;224(3):251–7. 10.1016/j.ajog.2020.10.019 . QU D C, CHEN H B, YANG M M et al. Management of lumbar spondylodiscitis developing after laparoscopic sacrohysteropexy with a mesh: a case report and review of the literature [J]. Medicine (Baltimore), 2019, 98༈49༉:e18252. 10.1097/MD.0000000000018252 Xu Aiqiang. Diagnosis and Treatment of Adult Primary Discitis [D]. Suzhou: Soochow University; 2015. GENTILE L, BENAZZO F, DE ROSA F, et al. A systematic review: characteristics, complications and treatment of spondylodiscitis [J]. Eur Rev Med Pharmacol Sci. 2019;23(2 Suppl):117–28. 10.26355/eurrev_201904_17481 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 19 Mar, 2026 Reviews received at journal 19 Mar, 2026 Reviews received at journal 18 Mar, 2026 Reviewers agreed at journal 18 Mar, 2026 Reviews received at journal 18 Mar, 2026 Reviewers agreed at journal 18 Mar, 2026 Reviews received at journal 18 Mar, 2026 Reviewers agreed at journal 18 Mar, 2026 Reviews received at journal 18 Mar, 2026 Reviewers agreed at journal 18 Mar, 2026 Reviewers agreed at journal 17 Mar, 2026 Reviewers agreed at journal 17 Mar, 2026 Reviewers agreed at journal 17 Mar, 2026 Reviews received at journal 10 Mar, 2026 Reviews received at journal 03 Oct, 2025 Reviewers agreed at journal 29 Sep, 2025 Reviewers agreed at journal 27 Sep, 2025 Reviewers invited by journal 25 Sep, 2025 Editor assigned by journal 16 Sep, 2025 Editor invited by journal 26 Aug, 2025 Submission checks completed at journal 25 Aug, 2025 First submitted to journal 25 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7401243","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":524920835,"identity":"f74de0de-8bca-4981-bfcb-0069401eb436","order_by":0,"name":"Qi Wu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYJCCA4l//vGwsTcffPCBp0aOjb39AGEtDxsOyPDxHEs2nCFzzJiP50wCQS2MQC02chI5ZtIcNsyJ8yQcDPAqN7iRvPFA4o47PGxAW4wZctjS2yQYEhh+VGzDoyWt4EDimWdgvzwuOCOT2ybdeICx58xtnFrMbuQYHEhgY4bYMrOHLbdN5kACM2MbMVpAfuH9x5zOJpFgQFhLYtthiBYeHuYEglrszzwrOJBwJg3sMMMZPMcM24CBfBCfXyTbkzd//FFhYy/fDolKefn29oMPflTg1gIEWGLhAD712LWMglEwCkbBKEAGACJ8X1Uqt0QzAAAAAElFTkSuQmCC","orcid":"","institution":"Hebei General Hospital","correspondingAuthor":true,"prefix":"","firstName":"Qi","middleName":"","lastName":"Wu","suffix":""},{"id":524920836,"identity":"3a5bf902-2ae6-4d7c-8101-e037c444c11a","order_by":1,"name":"Suning Bai","email":"","orcid":"","institution":"Hebei General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Suning","middleName":"","lastName":"Bai","suffix":""},{"id":524920837,"identity":"9157576d-e7f8-4a40-b466-8d5078443e9c","order_by":2,"name":"Liyun Song","email":"","orcid":"","institution":"Hebei General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Liyun","middleName":"","lastName":"Song","suffix":""},{"id":524920838,"identity":"2bca923f-333e-48fa-a197-f175684989aa","order_by":3,"name":"lina Han","email":"","orcid":"","institution":"Hebei General Hospital","correspondingAuthor":false,"prefix":"","firstName":"lina","middleName":"","lastName":"Han","suffix":""}],"badges":[],"createdAt":"2025-08-18 15:38:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7401243/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7401243/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":93062609,"identity":"83a9f410-bfde-4dd7-94e7-3ee898c5c925","added_by":"auto","created_at":"2025-10-08 16:38:00","extension":"doc","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":172032,"visible":true,"origin":"","legend":"","description":"","filename":"revisedmanuscript.doc","url":"https://assets-eu.researchsquare.com/files/rs-7401243/v1/fe8c34ab9b20b91ad7c98d2f.doc"},{"id":93062529,"identity":"5dc9d22d-cddb-4897-9ff9-d216a77c14cf","added_by":"auto","created_at":"2025-10-08 16:37:59","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":6309,"visible":true,"origin":"","legend":"","description":"","filename":"398c22c1c6884bd79a0182bf10d2ad6b.json","url":"https://assets-eu.researchsquare.com/files/rs-7401243/v1/b2612528599c5bfd66a71459.json"},{"id":93062702,"identity":"bea5b838-9f5d-41d1-9448-e1d4c5405417","added_by":"auto","created_at":"2025-10-08 16:38:02","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":32844,"visible":true,"origin":"","legend":"","description":"","filename":"398c22c1c6884bd79a0182bf10d2ad6b1enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7401243/v1/25bb2fff352265fc658ff5d7.xml"},{"id":93062724,"identity":"5682a9df-d287-455c-854e-3896e1f716ca","added_by":"auto","created_at":"2025-10-08 16:38:02","extension":"png","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":109050,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7401243/v1/1b24bd4795fdb24485712608.png"},{"id":93063226,"identity":"70649e63-a4cd-46dd-b1d1-f55e84a80eae","added_by":"auto","created_at":"2025-10-08 16:38:10","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":110627,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7401243/v1/109376c82bac5c7bb44b9b61.png"},{"id":93063222,"identity":"dedb56e7-d9fe-44ab-9f3b-cb26f1d6858b","added_by":"auto","created_at":"2025-10-08 16:38:10","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":30838,"visible":true,"origin":"","legend":"","description":"","filename":"398c22c1c6884bd79a0182bf10d2ad6b1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7401243/v1/e6d0eb53733d72107a3be46d.xml"},{"id":93062720,"identity":"0c924c3a-f09d-4802-869b-f0f0b0c23ccf","added_by":"auto","created_at":"2025-10-08 16:38:02","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":36919,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7401243/v1/20004c904a606d8ecddc48c2.html"},{"id":93063070,"identity":"00eab7fc-d1b9-4ee9-8fbd-ce07a5f84ff3","added_by":"auto","created_at":"2025-10-08 16:38:07","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":469376,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7401243/v1/1ca5ceed187e53eb0a815d38.jpeg"},{"id":93062859,"identity":"a0a03bec-b0ad-4669-886d-a966c20c1cea","added_by":"auto","created_at":"2025-10-08 16:38:04","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":472763,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7401243/v1/5120138b3550446c47002f43.jpeg"},{"id":93064252,"identity":"a94ebf72-63c3-4d6a-81b9-3fd4f01911b1","added_by":"auto","created_at":"2025-10-08 16:41:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1267742,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7401243/v1/21adbb67-664e-4e23-bdd4-f88a30ebd487.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Discitis Caused by Acute Pelvic Inflammatory Disease：A Case Report and Literature Review","fulltext":[{"header":"Background","content":"\u003cp\u003eUterine cavity operations such as diagnostic curettage, intrauterine device (IUD) removal, etc. are basic operations in gynecology. However, the ascending infection cannot be ignored. Timely diagnosis and standardized treatment are the key issues in the treatment of pelvic inflammatory diseases. Antibacterial drugs are mainly used for treatment, and the treatment principles are broad-spectrum, sufficient dosage, full treatment course and individualized. Discitis is an infectious lesion occurring in the intervertebral disc space and adjacent vertebral bodies or cartilage plates\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e4\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e. It is generally considered that discitis is caused by hematogenous spread of bacterial infection \u003csup\u003e[\u003c/sup\u003e\u003csup\u003e5\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e. However, at present, there are no reports about cases of discitis caused by uterine cavity infection.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eThe patient, a 44-year-old female, came to the orthopedics department of our hospital on September 8 , 2021 due to \"low back pain for more than one month after the removal of the intrauterine device (IUD), and left lower limb pain accompanied by walking disorder for 5 days\". Present medical history: The patient once visited the local county hospital because of vaginal bleeding accompanied by severe anemia for more than one month. Ultrasonic examination showed the presence of uterine fibroids, endometrial lesions, and an intrauterine device. After blood transfusion, she underwent diagnostic curettage and IUD removal operation. The operation was rather difficult and took about 2 hours, and the IUD removal failed. Two days after the operation, the patient had high fever, chills, and lumbosacral pain simultaneously, with the highest body temperature reaching 41℃. After 9 days of anti-inflammatory treatment in the ICU, the body temperature returned to normal, the lumbosacral pain was slightly relieved compared with before, and the lower limb movement returned to normal. But the low-back pain still persisted. The pain was sharp like an electric shock, occurring intermittently and being more obvious at night. This pain was not related to activities, postural changes, defecation, etc. The patient could not maintain the supine position for a long time, but there was no weakness or abnormal sensation in both lower limbs. The patient had a lumbar CT examination in the local hospital, and the results showed \"protrusion of the lumbar 3-4 and lumbar 4-5 intervertebral discs, calcification of the lumbar 4-5 intervertebral disc, and lumbar vertebra hyperplasia\". Subsequently, the patient had convulsive-like pain in the left lower limb, felt weak and had difficulty walking. Each pain attack lasted for about several minutes. After 5 days of continuous pain, she came to the orthopedics department of our hospital for treatment and was hospitalized. Past medical history: One month ago, she also received blood transfusion treatment due to \"severe anemia\".Three months ago, she was diagnosed with \"uterine fibroids\". Physical examination: Body temperature was 36.3℃,pulse was 98 beats per minute, respiration was 20 times per minute, and blood pressure was122/69 mmHg (1 mmHg =0.133 kPa). The patient was conscious, articulate, and cooperative during the physical examination. No obvious abnormalities were found in the cardiopulmonary and abdominal examinations. The spine had no deformities or scoliosis, and there was no tenderness or percussion pain in each vertebra, and the movement was normal. There was tenderness between the lateral sides of the bilateral sacrum and the ischial tuberosities, no tenderness in the bilateral sacroiliac joints, negative bilateral straight - leg - raising tests, negative bilateral Faber tests (4-sign), negative pelvic separation tests, and negative pelvic compression tests. There was no deformity or edema in both lower limbs, the movement was normal, no redness or swelling in each joint, and the movement was not restricted. There was no muscle atrophy, and the muscle strength was normal.Laboratory examinations: Erythrocyte sedimentation rate and C-reactive protein were elevated, while white blood cell count and procalcitonin were normal. Imaging examinations:gynecological ultrasonic examination, and the results showed that the size of the uterus was approximately 82mm×96mm×88mm. A heterogeneous hypoechoic mass with a size of 75mm×75mm×62mm could be seen on the posterior wall, most of which protruded into the uterine cavity, and abundant blood - flow signals could be detected around it. The echo of the intrauterine device was visible in the uterine cavity, and part of the intrauterine device was located in the myometrium[Figure 1]. The results of lumbar spine MRI plain scan showed abnormal signals in the L5 and S1 vertebral bodies, some of their appendages, and the epidural area behind the vertebral bodies. An infectious lesion was considered[Figure 2]. PET-CT examination showed increased metabolism at the upper and lower edges of the L5-S1 vertebral bodies accompanied by bone destruction, and multiple mildly hypermetabolic lymph nodes in the abdominal and pelvic cavities. Intervertebral discitis accompanied by lymphadenitis was considered. So cefoperazone sodium and sulbactam sodium combined with ornidazole were given by intravenous drip for anti-infection, and dexmedetomidine hydrochloride and dezocine were continuously pumped intravenously for analgesia and sedation. But the patient still complained of paroxysmal pain in the waist and left calf, and at the same time, there was severe pain in both buttocks, which was more obvious in the sitting position and could be slightly relieved in the lateral decubitus position. she was transferred to the gynecology department for laparoscopic hysterectomy and intervertebral disc exploration. During the operation, it was found that the uterus was evenly enlarged as in the3 - month pregnancy, with a smooth surface and no adhesion to the surrounding tissues. Both fallopian tubes were congested and small vesicles of inflammatory exudation were seen, and the appearance of both ovaries was normal. After the uterus was removed from the body, upon dissection, purulent infection was found in the uterine cavity. A submucosal fibroid with a diameter of 7 cm was visible, with purulent membranes attached to its surface. Part of the fibroid tissue was necrotic and pus cavities and gray-white pus were seen locally, with a foul smell. One GyneFix IN IUD was seen in the uterine cavity, which was incarcerated and pierced into the myometrium of the posterior uterine wall. Through vaginal exploration, a pus cavity was found between the posterior vaginal wall and the rectum. The wall of the pus cavity was taken for bacterial culture. The orthopedic surgeon performed laparoscopic intervertebral disc exploration. A thick needle was used to puncture the L5-S1 intervertebral disc, and no pus flowed out. After separating the intervertebral disc space, about 20 ml of dark red bloody-watery exudate flowed out. Post-operative pathological results:(1) Submucosal leiomyoma of the uterus,with local infarction, surface ulceration and necrosis, accompanied by suppurative inflammation and adenomyosis; (2) Endometrium in the proliferative phase; (3) Mild chronic inflammation of the cervix, with squamous metaplasia of the glands; (4) Congestion of (both) fallopian tubes, accompanied by vesicular appendages. Bacterial identification of the tissues in the uterine cavity and in front of the rectum: Escherichia coli infection. The results of bacterial culture showed that Escherichia coli was sensitive to cefoperazone sodium and sulbactam sodium, so the antibiotics were not adjusted any more. After the operation, cefoperazone sodium and sulbactam sodium combined with ornidazole were continuously given for a total course of 14 days. On the fifth day after the operation, all the patient's symptoms were relieved, the pain in the waist disappeared, the movement of both lower limbs was free. Two months after the operation, Re-examination of lumbar MRI showed normal.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Discussion and conclusion","content":"\u003cp\u003ePelvic inflammatory disease (PID) is a group of diseases caused by infections in the female upper genital tract, including endometritis, salpingitis, tubo-ovarian abscess and pelvic peritonitis. The main pathogens of PID are Neisseria gonorrhoeae and Chlamydia trachomatis, and genital mycoplasma infection is also one of the causes that cannot be ignored. Purulent infection in the uterine cavity develops from endometritis and is a special and severe form of PID. In this patient, due to the incarceration of the intrauterine device combined with submucous myoma, it was difficult to remove the intrauterine device, and the operation time in the uterine cavity was long, which led to endometritis after endometrial injury. Moreover, because of the concurrent submucous myoma of the uterus, the drainage of inflammatory exudate was not smooth, resulting in purulent infection in the uterine cavity. The treatment of PID is mainly based on antimicrobial drugs. Correct and standardized use of antimicrobial drugs can cure more than 90% of PID patients. Antimicrobial drug treatment should last for at least 14 days, and surgical treatment is required when necessary. Since this patient had been treated with multiple antibiotics outside the hospital with poor results, after admission, cefoperazone sodium and sulbactam sodium combined with ornidazole were given intravenously for anti - infection treatment, and laparoscopic hysterectomy and intervertebral disc exploration were performed.\u003c/p\u003e\n\u003cp\u003eIntervertebral discitis, also known as suppurative intervertebral discitis, intervertebral space infection, etc., refers to infectious lesions in the intervertebral disc space and adjacent vertebral bodies or cartilage plates. There are mainly the following three theories regarding its etiology\u003csup\u003e[5]\u003c/sup\u003e: hematogenous bacterial infection, aseptic inflammation, and the body's autoimmune response. The spinal vertebral body - intervertebral disc is anatomically similar to a joint. In particular, the anterior part of the vertebral body has a rich distribution of terminal branches of arterial blood vessels. Therefore, hematogenous infection first and most commonly involves the sub - end - plate bone in the anterior part of the vertebral body. Subsequently, the inflammation can break through the cortex and invade the sub-ligamentous area, the intervertebral disc, adjacent vertebral bodies, the posterior column, and the spinal canal. Therefore, it is considered that this case may be caused by hematogenous bacterial infection.\u003c/p\u003e\n\u003cp\u003eThrough consulting relevant literatures, up to now, there are no reports on the occurrence of purulent infection in the uterine cavity caused by intrauterine device (IUD) removal, which further leads to lumbar intervertebral discitis. Some domestic scholars reported a female patient who had lower abdominal and lumbar pain after undergoing posterior fornix puncture due to ectopic pregnancy. She was misdiagnosed as having lumbar tuberculosis, and her disease course was protracted for about three months. Eventually, she was finally diagnosed with Escherichia coli infection in the lumbar intervertebral space. GENTILE et al.\u003csup\u003e[6]\u003c/sup\u003e reported a female patient who underwent laparoscopic Y - mesh sacrohysteropexy for \"uterine prolapse of degree III\". One month after the operation, the patient had symptoms such as persistent lumbosacral stiffness accompanied by low back pain and right lower limb pain, and then the symptoms worsened to the point where she could not stand or walk. Eventually, she was diagnosed with purulent lumbar intervertebral discitis. In combination with this case, it is suggested to clinicians that when a patient has persistent low back pain after undergoing invasive pelvic operations, accompanied by a significant increase in erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) as well as abnormal changes in lumbar MRI, the possibility of intervertebral space infection should be considered.\u003c/p\u003e\n\u003cp\u003eThis case report aims to remind the vast number of gynecologists that after intra-uterine cavity operations, if the patient has a series of infection symptoms accompanied by persistent lumbosacral pain, the possibility of discitis infection should be considered. Intra-uterine cavity operations carry a certain risk of infection. Therefore, in addition to strictly following the aseptic operation specifications, the surgical operation should be gentle. When difficulties are encountered during the operation, an experienced doctor should take over to prevent adverse consequences such as intra-uterine cavity infection and uterine perforation caused by rough surgical operations.At the same time, it also reminds orthopedic doctors that when treating female patients with discitis, they should ask about the medical history in detail, be vigilant about the situation possibly caused by pelvic inflammation, achieve early diagnosis and early treatment, completely eradicate the primary lesion, thereby shortening the course of the disease, alleviating the pain of patients and avoiding the occurrence of serious consequences.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePID\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePelvic inflammatory disease\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e(IUD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntrauterine Device\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the patient for giving consent to the publication of her case details.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNO\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case report has anonymized the patient's private information, and the publication of the article has obtained ethical approval.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed in this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQi Wu is responsible for Conceptualization and Writing–review \u0026amp; editing. Suning Bai is in charge of Resources, and Supervision. Liyun Song undertakes Validation and Writing–original draft. Lina Han is responsible for Funding acquisition administration.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent for publication of this case report was obtained from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eInfectious Diseases Collaborative Group, Obstetrics and Gynecology Branch of Chinese Medical Association. Diagnostic and treatment guidelines for pelvic inflammatory disease (revised edition in2019) [J]. Chin J Obstet Gynecol. 2019;54(7):433\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3760/cma.j.issn.0529-567x.201 9.07.001\u003c/span\u003e\u003cspan address=\"10.3760/cma.j.issn.0529-567x.201 9.07.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHAN T, NOLAN S M REGARDM. Mycoplasma genitalium as a cause of pelvic inflammatory disease [J]. J Pediatr Adolesc Gynecol. 2020;33(6):739\u0026ndash;41. 10.1016/j. jpag.2020.06.015.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRAVEL J, MORENO I. Bacterial vaginosis and its association with infertility, endometritis, and pelvic inflammatory disease [J]. Am J Obstet Gynecol. 2021;224(3):251\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ajog.2020.10.019\u003c/span\u003e\u003cspan address=\"10.1016/j.ajog.2020.10.019\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eQU D C, CHEN H B, YANG M M et al. Management of lumbar spondylodiscitis developing after laparoscopic sacrohysteropexy with a mesh: a case report and review of the literature [J]. Medicine (Baltimore), 2019, 98༈49༉:e18252. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/MD.0000000000018252\u003c/span\u003e\u003cspan address=\"10.1097/MD.0000000000018252\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eXu Aiqiang. Diagnosis and Treatment of Adult Primary Discitis [D]. Suzhou: Soochow University; 2015.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGENTILE L, BENAZZO F, DE ROSA F, et al. A systematic review: characteristics, complications and treatment of spondylodiscitis [J]. Eur Rev Med Pharmacol Sci. 2019;23(2 Suppl):117\u0026ndash;28. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.26355/eurrev_201904_17481\u003c/span\u003e\u003cspan address=\"10.26355/eurrev_201904_17481\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Discitis, Pelvic inflammatory disease, Case Report","lastPublishedDoi":"10.21203/rs.3.rs-7401243/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7401243/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Pelvic inflammatory disease (PID), a common gynecological infection, includes endometritis, tubo-ovarian abscess, and pelvic peritonitis\u003csup\u003e[1]\u003c/sup\u003e. Uterine operations like abortion or intrauterine Device (IUD) removal may induce pelvic infection, causing lumbago, abdominal pain, menstrual disorders, or even systemic infection. Post-abortion pelvic infection incidence is 5.88%-8.79%\u003csup\u003e[2-3]\u003c/sup\u003e.This case report describes a patient who developed acute PID following a difficult IUD removal procedure, ultimately progressing to rare discitis with restricted lumbar mobility. While PID represents a common gynecological condition, its complication of secondary discitis causing significant motor impairment has been scarcely documented in medical literature. Through comprehensive imaging studies and pathogenetic analyses, this case confirmed the pathogenic spread of infection across anatomical boundaries. It highlights the critical need for prompt management of pelvic infections to prevent their potentially severe transcompartmental dissemination. This report serves to alert obstetric and gynecological practitioners about PID's underrecognized complications while emphasizing the importance of enhanced diagnostic vigilance and preventive strategies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation:\u003c/strong\u003e A 44-year-old female underwent difficult IUD removal lasting nearly 2 hours, developing septic shock postoperatively. After antibiotic treatment, she had residual lumbosacral pain and left lower limb convulsive pain. Transferred to our hospital, she was diagnosed with discitis via examinations and multidisciplinary collaboration. Laparoscopic exploration was performed promptly, with full recovery and symptom resolution.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eBy analyzing this case and literature, we explore antibiotic selection, surgical timing and methods, summarizing lessons to improve clinicians' understanding of PID and discitis, aiding standardized diagnosis, treatment, and related research.\u003c/p\u003e","manuscriptTitle":"Discitis Caused by Acute Pelvic Inflammatory Disease：A Case Report and Literature Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-08 16:00:01","doi":"10.21203/rs.3.rs-7401243/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-19T20:36:56+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-19T11:59:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-18T18:21:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"20798065359815399165864358833579932110","date":"2026-03-18T18:18:01+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-18T17:53:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"102185014207593892903068746222167489158","date":"2026-03-18T17:46:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-18T17:37:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"159453094304281748907209384866419777425","date":"2026-03-18T17:28:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-18T15:40:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"50567426082882119895057286893896277295","date":"2026-03-18T14:22:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"294709910599885612748641099491949132560","date":"2026-03-17T23:06:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"109321599979826478305557177792072016047","date":"2026-03-17T22:29:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"328405385085966153053280012999387176425","date":"2026-03-17T22:16:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-10T10:14:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-03T11:31:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"338484641119964913920764931409592849327","date":"2025-09-29T07:17:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"146941991743216115509393143665938412563","date":"2025-09-27T14:27:54+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-25T14:13:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-16T19:07:48+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-26T09:06:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-25T13:03:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2025-08-25T12:52:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e5024580-64bc-4563-aae0-5c35084f6da8","owner":[],"postedDate":"October 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-05T13:11:20+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-08 16:00:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7401243","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7401243","identity":"rs-7401243","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}