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graves-vag-speculum-lg-30-20-miltexWomen with undifferentiated abdominal pain and/or vaginal bleeding commonly present to the emergency department. Many textbooks advocate for the pelvic exam as an essential part of the history and physical exam. Performance of the pelvic exam is time consuming to the physician and uncomfortable for the patient. It is with great regularity that emergency physicians make clinical decisions, based on information derived from the pelvic examination, but is this information reliable and does it effect the clinical plan of patients?

How reliable is the pelvic exam?

Study
Year of Study
Number of Patients
What Was Evaluated
Results
Close RJH et al2003186Percentage agreement for cervical motion tenderness, uterine tenderness, adnexal tenderness, adnexal mass71 - 84% agreement of pelvic exam, but only
17 - 33% agreement of positive findings
Houry D et al200187Accuracy of pelvic exam for ovarian torsion29% of pts had no pain on exam, and 53% had no palpable mass
Padilla LA et al2000140Patients undergoing laparoscopy or laparotomy had pelvic exams performed under general anesthesiaAdnexal Mass Detection:
Sensitivity 15 - 36%,
Specificity 79 - 92%,
PPV 26 - 69%
Dart RG et al1999441History and physical exam findings predictive of ectopic pregnancy (EP)No constellation of findings could confirm or exclude EP
 

Is pelvic exam in the emergency department useful? [1]

What they did:

  • Prospective cohort study
  • 183 female patients with abdominal pain and/or vaginal bleeding prospectively evaluated
  • Providers were asked to predict the findings of the pelvic exam
  • Providers predictions were compared with actual findings of exam

Exclusion criteria:

  • Patients with suspected vaginal foreign body
  • Patients requiring pelvic exam for cultures
  • Patients whom the exam required visualizing products of conception

Results:

  • Pelvic exam findings were as predicted in 72% of cases
  • Pelvic exam findings were not as predicted in 22% of cases, but no change in clinical plan
  • Pelvic exam findings were not as predicted in 6% of cases but did change the clinical plan
    • 7 with normal exam
    • 1 not specified
    • 1 adenexal tenderness
    • 1 IUD requiring removal,
    • 1 less uterine bleeding than expected
    • 1 cervical motion tenderness

Limitations:

  • Management plans were not specified prior to completion of pelvic exam
  • The way in which unexpected findings changed plans was not documented
  • No objective criteria were used to determine need for cervical cultures and this group excluded from the analysis

Conclusion: In 94% of female patients with acute abdominal pain and/or vaginal bleeding, the results of the pelvic exam were predictable or had no effect on clinical plan.

Take Home Point

Although this is controversial and contrary to traditional teaching, this study suggests that basing decisions on female pelvic exams in the emergency department is not reliable and may not have any effect on the clinical plan.

References

  1. J. Brown, R. Fleming, J. Aristzabel, and R. Gishta, "Does pelvic exam in the emergency department add useful information?", The western journal of emergency medicine, 2011. http://www.ncbi.nlm.nih.gov/pubmed/21691528
Salim Rezaie, MD

Salim Rezaie, MD

ALiEM Associate Editor
Clinical Assistant Professor of EM and IM
University of Texas Health Science Center at San Antonio
Founder, Editor, Author of R.E.B.E.L. EM and REBEL Reviews