In reply:

Abstract

We appreciate the response from Mealy et al1Mealy K. Braverman P.K. Koenigs L.M.P. Why a pelvic exam is needed to diagnose cervicitis and pelvic inflammatory disease..Ann Emerg Med. 2019; 73: 424-425Google Scholar in regard to our 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.” We agree that not performing a pelvic examination during the evaluation of an adolescent with vaginal discharge and lower abdominal pain is a departure from the current recommendations put out by the Centers for Disease Control and Prevention, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics. However, important technologic advances have occurred in recent years, including the advent of urine sexually transmitted infection nucleic testing and the availability of urine point-of-care sexually transmitted infection testing.2Gaydos C.A. Pol B.V.D. Jett-Goheen M. et al.Performance of the Cepheid CT/NG Xpert rapid PCR test for detection of Chlamydia trachomatis and Neisseria gonorrhoeae.J Clin Microbiol. 2013; 51: 1666-1672Crossref PubMed Scopus (178) Google Scholar Without these tools, the pelvic examination was relied on to diagnose cervicitis and pelvic inflammatory disease, but our study and other publications indicate that the pelvic examination lacks the sensitivity, specificity, and interrater reliability found in current laboratory testing modalities.3Close R.J.H. Sachs C.J. Dyne P.L. Reliability of bimanual pelvic examinations performed in emergency departments.West J Med. 2001; 175: 240-244Crossref PubMed Google Scholar, 4Brown J. Aristizabal J. Fleming R. et al.Does pelvic exam in the emergency department add useful information?.West J Med. 2011; 12: 208-212Google Scholar Relying on these subjective examination findings may inappropriately dissuade a clinician or hospital from using highly accurate sexually transmitted infection testing and delay a diagnosis. Although the authors mention including vaginal fluid WBC counts for diagnosis, this is an operator-dependent test that has a low positive predictive value and is not routinely available in most clinical settings. Although there are other causes for cervicitis and pelvic inflammatory disease besides chlamydia, gonorrhea, and trichomonas, visualization on a pelvic examination will not distinguish one cause from another and therefore not guide toward a focused antibiotic choice. Current recommendations call for different treatments for cervicitis and pelvic inflammatory disease, but the pelvic examination findings of cervical motion tenderness and adnexal tenderness lack interrater reliability and do not correlate well with sexually transmitted infection tests.5Pattishall A.E. Rahman S.Y. Jain S. et al.Empiric treatment of sexually transmitted infections in a pediatric emergency department: are we making the right decisions?.Am J Emerg Med. 2012; 30: 1588-1590Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 6Breslin K. Tuchman L. Hayes K.L. et al.Sensitivity for sexually transmitted infections in a pediatric emergency department.J Pediatr. 2017; 189: 48-53Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar Finally, foreign bodies will be missed without the pelvic examination, but these are rare findings, and in our study the number of pelvic examinations needed to be performed to find 1 foreign body was 288. As physicians, we all believe in the physical examination, but we should acknowledge when the examination lacks sensitivity compared with more accurate diagnostic techniques. Other diseases for which testing or imaging has superseded the diagnostic accuracy of the clinical examination include pneumonia, group A streptococcal pharyngitis, adnexal masses, and appendicitis. Our study clearly demonstrates the lack of discriminative utility in the routine evaluation of adolescents with vaginal discharge and lower abdominal pain. Why a Pelvic Exam is Needed to Diagnose Cervicitis and Pelvic Inflammatory DiseaseAnnals of Emergency MedicineVol. 73Issue 4PreviewWe respectfully disagree with the conclusions by Farrukh et al1 that the pelvic examination may not be of added benefit in the evaluation of young female patients with suspected cervicitis or pelvic inflammatory disease. First, both cervicitis and pelvic inflammatory disease are clinical diagnoses that cannot be made without a pelvic examination. In accordance with the 2015 Centers for Disease Control and Prevention (CDC) sexually transmitted infection treatment guidelines, cervicitis is characterized by one or both of these major diagnostic signs: the presence of visible purulent or mucopurulent endocervical exudate or easily induced sustained endocervical bleeding. Full-Text PDF The Additive Value of Pelvic Examinations to History in Predicting Sexually Transmitted Infections for Young Female Patients With Suspected Cervicitis or Pelvic Inflammatory DiseaseAnnals of Emergency MedicineVol. 72Issue 6PreviewWe evaluate the additive value of pelvic examinations in predicting sexually transmitted infection for young female patients with suspected cervicitis or pelvic inflammatory disease in a pediatric emergency department (ED). Full-Text PDF