Written by Vivian Lei
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Pelvic examination added little to clinical judgment when evaluating for sexually transmitted infections (STIs) in young women.
Why does this matter?
STIs are rampant, and diagnosis is often based on a combination of historical features and physical exam findings. This study examined whether the pelvic examination continues to be a useful “test” in evaluating adolescent patients for suspected cervicitis or pelvic inflammatory disease.
Drop the speculum
Investigators enrolled 288 women aged 14 to 20 years who presented to an academic pediatric ED with a complaint of vaginal discharge or lower abdominal pain. Each patient provided a urine sample for STI testing. A standardized history was obtained from each patient to assess for cervicitis or pelvic inflammatory disease and a pelvic examination was performed. Of the 288 patients, 79 tested positive for an STI (overall prevalence 27.4%; 22.6% chlamydia, 6% gonorrhea, 3.5% trichomonas, and 4.5% coinfection). Before the pelvic examination, 127 patients were thought to have cervicitis or pelvic inflammatory disease. After the pelvic examination, management changed in 71 cases. However, 35 of those cases correlated with a positive urine STI test and 36 did not, meaning that any information obtained by the pelvic examination did not consistently redirect the clinician to better identify an STI.
From cited article
Of course, there are other clinically important reasons for performing a pelvic exam. However, this study supports that there is little clinical or diagnostic benefit of a routine pelvic exam in a pediatric ED setting when evaluating for STI. Additionally, the authors comment that adolescent women may be less likely to engage in healthcare if a routine pelvic exam is expected.
Source
The Additive Value of Pelvic Examinations to History in Predicting Sexually Transmitted Infections for Young Female Patients With Suspected Cervicitis or Pelvic Inflammatory Disease. Ann Emerg Med. 2018 Dec;72(6):703-712.e1. doi: 10.1016/j.annemergmed.2018.05.004. Epub 2018 Jul 2.
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Reviewed by Clay Smith
The value of doing a pelvic exam is not in detecting STIs – it is to distinguish upper from lower genital tract infection. If there is cervical motion tenderness one should treat for PID which is a much longer course than simple STI. PID is the most common infectious cause of lower abdominal pain in women and often missed. Skipping the pelvic exam will not help.
I agree that PID treatment is categorically different than cervicitis treatment, and it is important to point out that the CDC diagnostic criteria for diagnosing PID rely heavily on the pelvic exam and presence of cervical motion tenderness (CMT), uterine tenderness, or adnexal tenderness. However, interrater reliability for detecting CMT is very poor, with positive agreement in just 17%. See https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071590/. So, the authors of this study argue, "Our study suggests that the clinical features that determine pelvic inflammatory disease (cervical motion tenderness, adnexal tenderness, or uterine tenderness) are not present more in patients with sexually transmitted infection, and perhaps the guidelines need to be reconsidered." Even more concerning about the pelvic exam is than we would expect that after the exam, those who tested negative for GC, chlamydia, or trichomonas would have a lower post-test provider rating of having cervicitis or PID on visual analog scale and those with confirmed STI would have shown that the pelvic exam improved the post-test VAS, but it did not. The authors state, "After performance of the pelvic examination, the second VAS values did not show a decreasing trend in the sexually transmitted infection negative cases or an increasing trend in the sexually transmitted infection positive cases." It seems your statement is that we need to do a pelvic to know whether there is PID or just cervicitis. But based on prior study showing poor interrater agreement and this study that showed the providers were no more certain if PID or cervicitis was present in women with confirmed STI after doing the pelvic exam, that we need to reconsider whether or not it is a helpful test. Of course, PID can be caused by organisms other than GC/chlamydia. So, I see why you sound a note of caution. Thanks for the discussion. I am interested in what others might have to say.