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Pelvic exam not needed to identify high likelihood of cervicitis or pelvic inflammatory disease
Clinical Question
Does a pelvic examination improve clinicians' diagnostic accuracy when evaluating adolescent women with vaginal discharge or lower abdominal pain?
Bottom line
Rely on your history-taking skills to identify adolescents at high risk of cervicitis or pelvic inflammatory disease. Although counterintuitive to omit, a pelvic examination does not increase the sensitivity or specificity compared with taking a history alone in adolescents at high likelihood (> 25%) of having a sexually transmitted infection. After good history-taking, a pelvic examination can cause you to change your mind, and the new diagnosis will be incorrect for approximately half the women. 3b
Reference
Study design: Cohort (prospective)
Funding: Self-funded or unfunded
Setting: Emergency department
Synopsis
The investigators enrolled 288 adolescent women who presented to an urban emergency department (while the researchers were present) with vaginal discharge or lower abdominal pain; 27.4% would subsequently be given a diagnosis of chlamydia, gonorrhea, or trichomonas infection. Prior to this determination of infection (via urine sample), a clinician obtained a standardized history to assess for cervicitis or pelvic inflammatory disease, and then recorded their impression of the likelihood of either. Then, the clinicians performed a pelvic examination and again recorded their impression. The sensitivity of history alone was 54.4% and the specificity was 59.8%; after the pelvic examination, the sensitivity dropped slightly and the specificity remained about the same. The addition of the pelvic examination, without urine testing, would have correctly identified an additional 35 women with infection and falsely identified 36 who did not.
Reviewer
Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA
Comments
Incorrect diagnosis of PID
PID is caused by more then the three pathogens used in this study. This study design is flawed by this fact and therefore comes to an incorrect conclusion. PID is diagnosed by history and physical exam features. The testing of STIs is important but complimentary. There are many pathogens that we cannot test for. PID is already considered underrecognized and this study will only further worsen the problem. PID can have unfortunate complications for women. This infopoem should be re-evaluated. Please check out the canadian guideline for sexually transmitted disease. They are execellent.
I’m confused.
Urine testing was the gold standard in this study (sample size 288) for chlamydia, gonorrhea or trichomonas infection and detected 79 cases for an incidence of 27.4%.
The sensitivity of history alone is stated as 54.4% or 43 cases.
Pelvic exam reportedly correctly identified an additional 35 cases or 78 in total (98.7% of all cases).
But the synopsis states that the sensitivity dropped slightly.
So ... what’s up doc?