Is Pelvic Exam in the Emergency Department Useful?

30 Jan
January 30, 2014

Pelvic Exam SpeculumWomen 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 this portion of the exam is time consuming to the physician and uncomfortable for the patient. It is with great regularity that emergency medicine physicians make clinical decisions based on information derived from it, but is this information reliable and does it effect the clinical plan of patients?

How reliable is the pelvic exam?

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

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. Brown J et al. Does Pelvic Exam in the Emergency Department Add Useful Information? WJEM 2011. PMID: 21691528
  2. Close RJ et al. Reliability of Bimanual Pelvic Examinations Performed in Emergency Departments. WJEM 2001. PMID: 11577050
  3. Houry D et al. Ovarian torsion: A Fifteen-Year Review. Ann emergency Med 2001. PMID: 11468611
  4. Padilla LA et al. Accuracy of the Pelvic Examination in Detecting Adnexal Masses. Obstet Gynecol 2000. PMID: 11004365
  5. Dart RG et al. Predictive Value of History and Physical Examination in Patients with Suspected Ectopic Pregnancy. Ann Emerg Med 1999. PMID: 10036342
The following two tabs change content below.

Salim Rezaie

Emergency Physician at Greater San Antonio Emergency Physicians (GSEP)
Creator & Founder of R.E.B.E.L. EM
Tags:
2 replies
  1. Chris Bond says:

    Hey Salim,

    This is always a hot topic, thanks for the post.

    I agree it’s uncomfortable and the utility is questionable in most circumstances. Aside from foreign body, when are you doing pelvics in your regular practice?

    The G+C cultures can be obtained from urine, and I also seem to recall a study that having patients perform their own BV/yeast/trichomonas swabs resulted in superior swabbing and less discomfort than having a physician do it. I’ll see if I can find the reference for this, but it obviates the need for doing any swabs.

    One final word: Always ask the nurse to set-up the tray with the smallest (pediatric) speculum rather than the standard one. Many of my patients have thanked me for this, and I can see the os just fine 99% of the time with the small speculum. I’m still blown away that we default to the average size (green) one.

    Cheers and keep up the great work,

    Chris

    Reply

Trackbacks & Pingbacks

  1. […] EM takes a look at the utility of the pelvic exam in the ED – perhaps may not be as useful as we […]

Leave a Reply

Want to join the discussion?
Feel free to contribute!

Leave a Reply

Your email address will not be published. Required fields are marked *

Time limit is exhausted. Please reload CAPTCHA.