Counterpoint: Pelvic Exam Is Necessary

Written by Clay Smith

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This letter to the editor presents compelling reasons why a pelvic exam is needed to diagnose cervicitis or pelvic inflammatory disease (PID).

Why does this matter?
Recently, Annals of EM published an article that questioned the utility of routine pelvic exam for adolescent STI diagnosis in the ED. This is a counterpoint to the original paper.

Bad news for interns across the country…
We rarely, if ever, cover a letter to the editor, but since the original article was such a controversial topic with high associated morbidity, it is important to show the other side. The letter advocates that a pelvic exam is needed to diagnose cervicitis or PID based on the following:

  • PID and cervicitis are clinical diagnoses that cannot be made without a pelvic exam.

  • The CDC recommends it; in fact, the diagnostic criteria for PID are based on cervical, uterine or adnexal tenderness. Diagnostic specificity is enhanced with presence of mucopurulent discharge or WBCs on saline wet mount, which requires a pelvic exam.

  • Relying solely on positive testing for N. gonorrhea, chlamydia, or trichomoniasis as determinative for the diagnosis of STI will miss cases, as PID may be caused by other organisms, is often polymicrobial, and is a clinical not microbiological diagnosis.

  • Skipping the exam will also miss genital herpes, other vaginitis, or foreign body.

  • The authors of the original article state that ACOG, AAP, and CDC do not recommend pelvic exam in asymptomatic patients, which is true. But that was not the population they studied. The patients in the original article were symptomatic, and all three organizations recommend pelvic exam in such patients.

  • Failing to detect PID risks complications of worsening infection, abscess, scarring, and infertility.

Source
Why a Pelvic Exam is Needed to Diagnose Cervicitis and Pelvic Inflammatory Disease. Ann Emerg Med. 2019 Apr;73(4):424-425. doi: 10.1016/j.annemergmed.2018.11.028.

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Reviewed by Thomas Davis

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