"To Pelvic or Not To Pelvic?" That Is The Question
Written by: Kevin Hon, DO; Edited by: Sumintra Wood, MD
Case:
A 21 year old female presents herself to your emergency department. She’s been complaining of generalized pelvic abdominal pain that has been worsening over the past 3 days. It’s dull, throbbing, non-radiating, constant. Despite taking tylenol, she hasn’t noticed any improvement in her symptoms. Fortunately, she has no fevers, chills, nausea, or vomiting.She’s noticed some new white, possibly yellow/green vaginal discharge. Oh, she’s also 18 weeks pregnant. And by the way, she recently found out her baby daddy also cheated on her and she had been sexually active with him up until the past month. Yikes.
So first things first, do you pelvic her???
We’ve all been there. Remember that time in medical school when you performed your first pelvic exam: complete with speculum and bimanual to assess for pelvic pathology? Remember the dread, awkwardness, and vulnerability explaining everything to your standardized patient? It was something I’d rather let my OB/GYN colleagues perform with poise and grace. How many times has OB/GYN asked you whether or not you performed this exam? If only you had the time between managing your other patients to grab a fellow chaperone and have the patient prepped and ready. Performing the pelvic exam can often feel like a burden when you could be doing so many other things.
Are ED physicians reliable in performing diagnostic pelvic exams? Though performed in 2001, Close et al, sought to answer this question by looking at ED senior residents and attending physicians in both private and community hospital settings and comparing their findings. Participants had only 33% agreement when an examiner noted uterine tenderness, 23% agreement when a pelvic mass was palpated, and 17% agreement when cervical motion tenderness was documented. Well what about the pros? OBGYN residents and attendings had less than 50% sensitivity for detecting adnexal masses by pelvic exam compared to their intra-operative findings in another study. Findings can be even more obfuscated in patients with large body habitus. While we have much stronger methods of visualizing pelvic pathology with ultrasound, performing the complete pelvic exam might not be the best use of your resources.
What about the pelvic complaints when we are considering STI, PID, or torsion? Current CDC guidelines already have a low threshold for empiric treatment of gonorrhea, chlamydia, and PID. While this has been primarily argued that such diagnosis would be made by performing the pelvic exam, some studies that compare pelvic exam findings to NAAT diagnosed STI like Farrukh et al. have shown that the pelvic exam is not as sensitive at catching a STI. Applying the blanket statement that pelvic exam is critical to this diagnosis would lead to approximately the same proportion of true negatives (8%) to false positives(8%) and true positives (4%) to false negatives (5%). Using other tests like NAAT whether it be endocervical versus vulvovaginal have been shown to be highly sensitive in diagnosing STI and are now standard of care. Plus, they have the benefit of the patient being able to perform and provide the sample for you in the ED, swab preferred but urine sample may suffice. Torsion patients on the other hand may have a physical exam limited by body habitus and may give a false sense of security as only 29% may have significant tenderness and nearly 47% may have a palpable mass. Regardless, don’t delay time to ultrasound to make a sonographic visual diagnosis if you’re especially concerned for torsion.
Do all vaginal bleeders need a pelvic? To start off, ACEP guidelines already suggest a pelvic ultrasound be performed in any pregnant patient presenting to an ED with vaginal bleeding or abdominal pain. While the pelvic may be useful in assessing for incomplete and inevitable miscarriage, ectopic can be limited in its diagnosis given the same limitations for assessing for torsion. Ultrasound images are better in quality and quantity of information.
So when is it really needed? The pelvic exam should be performed when it can alter the course of a patient's management. Namely, this occurs in the setting of trauma, hemodynamic instability from excessive vaginal bleeding, prolapsed organ, evaluation of PID, or foreign body removal. Granted, if your patient has a rash, please look at it. As described previously, more sensitive tests like NAAT can be used to diagnose STI and ultrasound should be primarily used to assess for torsion, ectopic, and stable vaginal bleeding. To perform blanket pelvic exams on all our female patients would be an inefficient use of our time and an unnecessary disservice to our patients.
And because CDC treatment guidelines were just updated in 2021. Here you go.
If Ceftriaxone is contraindicated, you can use Gentamicin 240mg IM + Azithro 2g PO or Cefixime 800mg PO x1. You’re less likely to see a Ceftriaxone allergy out there but if you do, Cefixime would be an easy swap so you avoid having to add more medications. After all, Azithromycin does have its share of GI upset symptoms.
Per the CDC, Expedited Partner Therapy (EPT) has been recommended since 2006 for heterosexual partners. Treat to cover both GC/CT. While it is preferred for a patient’s partner come in for evaluation to obtain Ceftriaxone IM, Cefixime 800mg is just as suitable. Check with your institution’s policy for prescribing such medication.
* Of note, there is an alternative to treat BV/Trichomonas with Metronidazole 2g PO once. While there can be the argument that you can give all the meds a patient needs upfront if you’re also giving Azithromycin, the multidose course reduced the proportion of women retesting positive at a 1-month test of cure visit by half, compared with women who received the 2g single dose.
PID is nastier and more infectious. Thus, your logic is to double the duration of the multi day antibiotics.
