In reply:

Abstract

We appreciate Dr. Swartz’s careful review of our article,1Farrukh S. Sivitz A.B. Onogul B. et al.The additive value of pelvic examinations to history in predicting sexually transmitted infections for young female patients with suspected cervicitis or pelvic inflammatory disease.Ann Emerg Med. 2018; 72: 703-712.e1Google Scholar but are unpersuaded by his argument. For our study, we used a composite score for cervicitis and pelvic inflammatory disease because we think the distinction between the former and early pelvic inflammatory disease is subtle. There were no patients in the study who received parenteral treatment, and in general hospitalization does not occur frequently for adolescents with pelvic inflammatory disease at our site. Our study suggests that the pelvic examination components of cervical motion tenderness, uterine tenderness, and adnexal tenderness are subjective, and although they might be present in pelvic inflammatory disease, they also might be present in cervicitis and in any patient who is anxious during the examination or has a lower pain threshold or intolerance for the examination. Conversely, some women with infection may be more stoic or familiar with the examination process, and pain will be less obvious on examination. There are other studies that also suggest that findings such as cervical, uterine, and adnexal tenderness are insensitive and nonspecific, and vary when different clinicians perform the examination.2Close R.J.H. Sachs C.J. Dyne P.L. Reliability of bimanual pelvic examinations performed in emergency departments.West J Med. 2001; 175: 240-244Google Scholar, 3Brown J. Aristizabal J. Fleming R. et al.Does pelvic exam in the emergency department add useful information? West.J Emerg Med. 2011; 12: 208-212Google Scholar, 4Padilla L.A. Radosevich D.M. Milad M.P. Accuracy of the pelvic examination in detecting adnexal masses.Obstet Gynecol. 2000; 96: 593-598Google Scholar, 5Breslin K. Tuchman L. Hayes K.L. et al.Sensitivity and specificity of empiric treatment for sexually transmitted infection in a pediatric emergency department.J Pediatr. 2017; 189: 48-53Google Scholar In the “Limitations” section of the study, we acknowledged that pelvic inflammatory disease can be attributed to other organisms such as Mycoplasma genitalium, herpes, and normal flora overgrowth. However, the antibiotic regimens that the Centers for Disease Control and Prevention suggests are targeted toward chlamydia, gonorrhea, and trichomonas. Visualization or palpation provided by the pelvic examination does not clarify which organism is involved or which antibiotic is needed. We agree with the concern for patients with negative test results for sexually transmitted infections and positive results for pelvic examinations, and the related risk of chronic complications because of untreated cases. In the article, we discuss a stepwise approach that begins with urine point-of-care testing for chlamydia, gonorrhea,6Gaydos 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: 1666-1672Google Scholar trichomonas, candida, and clue cells. For patients with negative urine testing results, we suggested the pelvic examination can be considered to aid diagnosis. Surveillance data show that rates of sexually transmitted infections and their subsequent complications are increasing every year, as is antibiotic resistance to gonorrhea. The current approach, which relies heavily on the pelvic examination, is proving unsuccessful at combating this epidemic. Empiric treatment of all patients with positive pelvic examination results, as Dr. Swartz points out, means that almost 60% of women are being treated with antibiotics that do not truly target the cause of their infection. This approach does not necessarily resolve the patient’s problem and creates resistance. The use of point-of-care sexually transmitted infection results and development of additional sensitive tests for other causes of cervicitis and pelvic inflammatory disease will aid in making a correct diagnosis. New treatment guidelines are imperative, and we encourage physicians who work in high-risk areas to repeat our study for external validity and assess whether it pertains primarily to cervicitis and not pelvic inflammatory disease. 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 Additive Value of Pelvic Examinations to HistoryAnnals of Emergency MedicineVol. 74Issue 1PreviewIn the study of sexually transmitted infections by Farrukh et al,1 the presented evidence is insufficient to justify the authors’ call to abandon the current Centers for Disease Control and Prevention (CDC) pelvic examination criteria for pelvic inflammatory disease diagnosis. Full-Text PDF