Identification of Symptoms that Indicate a Pelvic Examination is Necessary to Exclude PID in Adolescent Women

Abstract

Background: Diagnosis of chlamydia, gonorrhea, and vaginitis is now possible in adolescents using urine testing and vaginal swabs obtained by care provider or patient. However, a complete pelvic examination is necessary to diagnose pelvic inflammatory disease (PID). It is thus important to identify patients who might have pelvic inflammatory disease to assure complete gynecologic assessment of genitourinary symptoms. Purpose: To determine whether adolescent patients with pelvic inflammatory disease report predictable symptoms during the medical interview and to determine what proportion of patients diagnosed with PID report at least one predictor symptom. Methods: Design: Observational study. Settings: Hospital-based adolescent clinic and Job Corps health service. Patients: A convenience sample (n = 193) of adolescent and young adult women who had a pelvic examination performed to evaluate a wide range of genitourinary symptoms. Main outcome measure: Clinical diagnosis of pelvic inflammatory disease. Analysis: Sensitivity, specificity, and positive and negative predictive value of predictor symptoms for identifying patients given a diagnosis of pelvic inflammatory disease. Results: Twenty (10.4%) patients received a clinical diagnosis of PID. Lower abdominal pain was the most common symptom (90.0%) reported by these patients. All of the patients with PID reported either lower abdominal pain or dyspareunia in the medical history compared with 97 (56.1%) of those without PID. The presence of lower abdominal pain and/or dyspareunia in the clinical history yielded a sensitivity of 100%, specificity of 44%, and positive and negative predictive value of 17% and 100%, respectively, for identifying patients given a diagnosis of PID. Conclusion: This study identified two symptoms reported in the medical history (lower abdominal pain and dyspareunia) that were associated with a clinical diagnosis of pelvic inflammatory disease. If lack of these two symptoms was used as a criterion for omitting a pelvic examination, more than one third of the patients in this study could have been evaluated for cervical and vaginal infections with urine and directly obtained vaginal swabs. Although some of these patients might have required a pelvic examination to exclude other causes of abnormal vaginal bleeding, at least 30% of the total sample could have been evaluated without a speculum and bimanual examination. If further studies support these findings, patients with symptoms suggestive of uncomplicated genitourinary infection (e.g., vaginal discharge, vaginal pruritis, or dysuria) who deny lower abdominal pain and dyspareunia can be evaluated with urine and vaginal samples in place of a speculum and bimanual examination.