How good is the pelvic examination, and is it being upstaged by newer technologies?

Abstract

Close and colleagues measured the reliability of the bimanual examination performed by emergency department physicians. As they point out, such a study of reliability has never been published before. There was poor agreement (17%-32%) between physicians as to whether there was a positive examination finding—cervical motion tenderness, uterine tenderness, adnexal tenderness, or adnexal mass. The unreliability of the pelvic examination is worrying because these positive findings are important in making a clinical diagnosis of pelvic inflammatory disease. Pelvic inflammatory disease is the most common reproductive health problem of young women, and it increases the risk of subsequent ectopic pregnancy and tubal infertility. The poor validity of the pelvic examination in diagnosing pelvic inflammatory disease was shown in a 1969 Swedish study.1 Women were examined by trained gynecologists and then underwent laparoscopy by examiners who were blind to the original clinician's diagnosis. At laparoscopy, the clinicians were found to have made a correct diagnosis in less than two thirds of cases. Before dismissing the pelvic examination altogether, we note that the current study had 4 important limitations. First, there was no objective clinical outcome measure, such as laparoscopy or testing for sexually transmitted infections, and so the clinical meaning and implications of the findings are unclear. Second, many relatively inexperienced clinical trainees were used in the study. Third, sexually active teenagers, who are most at risk for pelvic inflammatory disease, were not included in the study. Finally, apart from the clinician's assessment of uterine size and the presence of an adnexal mass, the variables measured involved the subjective perceptions of pain by the woman being examined. Despite the limitations, the study cautions against relying solely on the pelvic examination in an emergency situation. Examination findings must be combined with the patient's history (particularly risk factors for urgent conditions such as pregnancy, especially ectopic pregnancy, and sexually transmitted infections) and appropriate laboratory tests and procedures. Great strides have been made in developing noninvasive, highly sensitive urine-based tests for pregnancy and sexually transmitted infections that can assist in making a diagnosis in the acute care setting. Urinalysis can now be used as a screening test for common infections related to pelvic inflammatory disease, such as chlamydia and gonorrhea. The Food and Drug Administration will shortly approve the use of self-administered vaginal swabs for diagnosing sexually transmitted infections. The evidence is accumulating that physicians cannot always make clinical judgments based on the often inaccurate and insensitive pelvic examination. But additional and evolving adjunctive tests and procedures are now available to help with acute care quandaries. The pelvic examination may not be the final determining step in the diagnosis of acute pelvic conditions because of its inherent insensitivity and the evolution of better diagnostic tools. The accuracy of diagnostic imaging, for example, will continue to improve and will determine more accurately than the bimanual pelvic examination the presence of pelvic disease. For most asymptomatic young women in need of sexually transmitted infection screening, urine-based sexually transmitted infection screening for chlamydia appears sufficient.2,3 The future will bring rapid bedside tests for other bacterial and viral agents. More broad-based sexually transmitted infection screening is at hand with the development of self-administered tests of urine and vaginal specimens. Home testing for sexually transmitted infection similar to the current urine-based pregnancy tests is likely not far in the future. Finally, clinical algorithms will continue to be developed to help determine what factor or factors are most important in specific clinical diagnoses. Clearly, the role of the pelvic examination in clinical practice is changing with the evolution and application of new technologies.