Grand Rounds

Does Pelvic Exam Provide Any Additional Benefit When Diagnosing STDs in Adolescents and Young Women?

BACKGROUND AND PURPOSE:

In the US, STDs caused by gonorrhea and chlamydia are highest in adolescents and young women 15-24 years of age
Farrukh et al. (Annals of Emergency Medicine, 2018) sought to determine the additive value of pelvic exam for predicting sexually transmitted infection (STI) with suspected cervicitis or pelvic inflammatory disease in a pediatric emergency department (ED)

Prospective observational study (blinded)
Participants
- Female patients 14 to 20 years
- Chief complaint of vaginal discharge or lower abdominal pain (regardless of pregnancy status)
- Exclusion: Pulse rate >110 bpm or systolic BP <90 mm Hg | Needs critical care management | Refuses testing | Never had a pelvic examination
Practioners
- Pediatric ED attending physician | Emergency medicine or pediatric resident | Pediatric ED fellow | Advanced practice provider
Urine sample obtained for chlamydia, gonorrhea, and trichomonas (genomic molecular test)
- Turnaround time for gonorrhea and chlamydia: 3 to 5 days
- Turnaround time for trichomonas: 1 to 3 hours
To assess for STI, practioners
- Obtained a standardized history and recorded the likelihood of cervicitis or pelvic inflammatory disease on a 100-mm visual analog scale (VAS) score (based on CDC criteria)
- Performed a pelvic examination and recorded a second VAS score
  - Score of ≥50 meant practioner thought patient had STI and should be treated
- Physical examination portion of the data form included
  - External genital visual inspection
  - Speculum exam
  - Bimanual exam
- Using the results of the urine STI tests, investigators calculated and compared the test characteristics of history alone and history with pelvic examination for the detection of STI

288 patients had complete urine tests and VAS scores
- STI rate of 27.4% based on urine tests
Prior to pelvic exam: 127 patients were thought to STD
After the pelvic examination
- Management changed in 71 cases
  - 35 of those cases had confirmed STI on urine test
  - 36 cases were not confirmed
History alone for the diagnosis of STI
- Sensitivity: 54.4% (95% CI, 42.8% to 65.5%)
- Specificity: 59.8% (95% CI 52.8% to 66.4%)
Pelvic examination included (2nd VAS)
- Sensitivity: 48.1% (95% CI 36.8% to 59.5%)
- Specificity: 60.7% (95% CI 53.8% to 67.3%)
Cervical motion tenderness, adnexal tenderness, and uterine tenderness were not significantly different between groups

Authors acknowledge potential limitations
- Urine test more sensitive for chlamydia but may be less sensitive for gonorrhea compared to cervical swabs
- ‘Convenience sample’ and not consecutive patients
- Other organisms can cause STI beyond the 3 tested for in this study
For young female patients with suspected cervicitis or PID that can be managed as an outpatient, pelvic examination does not increase quality of diagnosis for chlamydia, gonorrhea, or trichomonas

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