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The Additive Value of Pelvic Examinations to History in Predicting Sexually Transmitted Infections f

Bottom Line: When cervicitis or pelvic inflammatory disease (PID) is suspected in young, healthy women, a pelvic exam does not change sensitivity or specificity when compared to history alone.

The Article: 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. December 2018.

The Idea:

Gonorrhea and Chlamydia are very common in cervicitis and pelvic inflammatory disease in women ages 15-24 years old. However, there is no specific history, physical exam, or laboratory test to confirm this infection; instead, a combination of all of these help with the diagnosis. Typically, the diagnosis of cervicitis is visualizing an inflamed cervix or discharge in the vaginal canal or at the cervix. The diagnosis of PID typically presents with lower abdominal pain without another cause and an abnormal bimanual exam.

Recently, however, the American College of Gynecology, the American Academy of Pediatrics, and the CDC, reported that gonorrhea and chlamydia laboratory tests are good enough for diagnosis in an asymptomatic woman and that a pelvic exam is unnecessary. This recommendation is for asymptomatic women and has not been tested in women with symptoms who normally present to the Emergency Department.

The Study:

This study was a prospective study that aims to determine if pelvic examinations are useful in the diagnosis of cervicitis or PID. This study took place from 10/2015-10/2017 in an urban academic pediatric emergency department using a convenient sample (only when researchers were there during the day to enroll patients).

Participants were females, aged 14-20 years of age with abdominal pain or discharge at all pregnancy statuses. Exclusion criteria were anyone unstable (HR >110, SBP <90), requiring critical care, refused, no prior pelvic examination, or non-English speaking.

An attending, resident, fellow, or advanced practice provider first took a history and marked a 1st VAS score (visual analog scale). Then the provider did a pelvic exam and indicated a 2nd VAS score with information collected from a visual, speculum, and bimanual exam. This was then compared to a urine gonorrhea and chlamydia test.

Results:

Of the 848 laboratory tests ordered, 288 of those were enrolled in the study.

  1. 79 out of 288 had a positive urine, however, 123 patients were treated for cervicitis, 35 for PID, and 93 for vaginitis

  2. 166 out of 288 had a low 2nd VAS score, however, 36 patients were still treated

  3. after pelvic examination, management changed in 71 cases, of these 35 correlated with urine tests and 36 did not correlate

There were no significant differences between the 2 groups of patients (those with + infection and those with – infection) in terms of vaginal discharge, cervical motion tenderness, uterine tenderness, or adnexal tenderness.

After the pelvic exam, the 2nd VAS score did not show a decreasing trend in STD negative cases or an increasing trend in STD positive cases. There was also no statistical difference among provider groups.

The Takeaway: Pelvic exams may not be helpful in the diagnosis of cervicitis or PID in young, healthy women.

#ObstetricsGynecology