The Additive Value of Pelvic Examinations to History in Predicting Sexually Transmitted Infections for Young Female Patients With Suspected Cervicitis or Pelvic Inflammatory Disease

Long-Acting Reversible Contraception Knowledge Among Female Adolescents Presenting to a Pediatric Emergency Department

OBJECTIVES

The objective of this study was to assess awareness and use of long-acting reversible contraception (LARC) among female adolescents presenting to a pediatric emergency department (PED).

STUDY DESIGN

During routine presentation to an urban PED in New Jersey, female adolescents, aged 15-19 years, were asked to voluntarily complete an electronic survey about sexual practices and contraception. The PED is in an urban teaching hospital, treating 35,000 children annually. Patients could schedule a follow-up appointment at the hospital's obstetrics/gynecology clinic. Data were collected over 13 months, and follow-up was monitored to determine if they attended an outpatient appointment, and if so, what the outcome was.

RESULTS

Data for 199 participants were analyzed. The median age of participants was 18 years, whereas 79% self-identified as Black, and 17.6% self-identified as Latina. Twenty-one percent of participants used a form of birth control during their first sexual encounter, the largest percentage being condoms (77.8%). Forty percent of participants reported some prior knowledge about contraceptive implants, and 20% had knowledge about intrauterine devices, whereas only 3 (1.5%) intrauterine devices and 2 (1%) arm implants had been previously used. Of the 78 participants that requested a follow-up, 14 (17.9%) completed their appointment. Of those, 2 (14%) were prescribed contraception (Depo-Provera shot and oral contraceptive pills).

CONCLUSIONS

Knowledge about LARC remains low in our PED, despite it being the most effective method of contraception. Even when interventions were made to link interested respondents to outpatient women's health services, follow-up attendance was poor, and no patients obtained LARC. There is a significant discrepancy between the consensus standard of contraception care across all relevant medical specialties and current utilization by high-risk populations. Future efforts must focus on how to close this gap, and the ED could be pivotal for improving both reproductive health education and intervention among adolescent patients.

[Pelvic exam in gynecology and obstetrics: Guidelines for clinical practice]

OBJECTIVE

To provide guidelines for the pelvic clinical exam in gynecology and obstetrics.

MATERIAL AND METHODS

A multidisciplinary experts consensus committee of 45 experts was formed, including representatives of patients' associations and users of the health system. The entire guidelines process was conducted independently of any funding. The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized.

METHODS

The committee studied 40 questions within 4 fields for symptomatic or asymptomatic women (emergency conditions, gynecological consultation, gynecological diseases, obstetrics, and pregnancy). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 27 recommendations. Among the formalized recommendations, 17 present a strong agreement, 7 a weak agreement and 3 an expert consensus agreement. Thirteen questions resulted in an absence of recommendation due to lack of evidence in the literature.

CONCLUSIONS

The need to perform clinical examination in gynecological and obstetrics patients was specified in 27 pre-defined situations based on scientific evidence. More research is required to investigate the benefit in other cases.

Clinical Evaluation of a New Molecular Test for the Detection of Organisms Causing Vaginitis and Vaginosis

In this prospective, observational, method comparison clinical study, the Xpert Xpress MVP test (MVP) was evaluated using both clinician-collected (CVS) and self-collected vaginal swabs (SVS) collected in a clinical setting. The study was conducted at 12 sites, including point-of-care (POC) settings, from geographically diverse locations in the United States. Participants were biologically female patients ≥ 14 years old with signs and/or symptoms of vaginitis/vaginosis. MVP test results for BV were compared to the BD MAX Vaginal Panel (BDVP). Results for Candida group and Candida glabrata and Candida krusei targets (species not differentiated) were assessed relative to yeast culture followed by mass spectrometry for species identification. Trichomonas vaginalis (TV) results were compared relative to a composite method that included results from the BDVP and InPouch TV culture. The investigational test demonstrated high positive percent agreement ranging from 93.6 to 99.0%, and negative percent agreement ranging from 92.1% to 99.8% for both CVS and SVS specimens, indicating it may be a valuable tool for the diagnosis of vaginitis/vaginosis in laboratory and POC settings.

Diagnostic accuracy of pelvic examination in pelvic inflammatory disease: A meta‐analysis

Background

Pelvic inflammatory disease (PID) is not a mere transient infection. PID can lead to chronic pain, ectopic pregnancy, and infertility. Although the Centers for Disease Control and Prevention have established minimum diagnostic criteria, including pelvic examination, the diagnostic value of pelvic tenderness has recently garnered controversy. Our meta‐analysis aimed to confirm whether pelvic tenderness, cervical motion tenderness, and adnexal tenderness can help diagnose PID.

Methods

We searched for studies reporting the diagnostic test accuracy of pelvic tenderness, cervical motion tenderness, and adnexal tenderness among female patients at risk for PID, using MEDLINE, EMBASE, CENTRAL, CINAHL, Google, and Google Scholar through May 25th, 2022. After quality assessment using QUADAS‐2, we performed data synthesis using a bivariate random effect model and Bayesian hierarchical summary receiver operating characteristic model. We then conducted sensitivity analysis excluding studies with non‐PID cases.

Results

The literature search produced 6769 articles. After quality assessment, 14 studies and their 2808 participants were eligible for synthesis on pelvic tenderness. Laparoscopy, either alone or in combination, was the most frequent reference standard. The main results for pelvic tenderness sensitivity and specificity were 0.81, 95% confidence interval (CI) [0.67–0.90] and 0.40, 95% CI [0.25–0.57], respectively. Sensitivity and specificity were 0.72, 95% CI [0.57–0.83] and 0.50, 95% CI [0.34–0.66], for cervical motion tenderness, and 0.87 [0.64–0.96] and 0.27, 95% CI [0.12–0.52] for adnexal tenderness, respectively.

Conclusions

Our meta‐analysis suggests that pelvic tenderness assessed by pelvic examination may be useful for PID examination with moderate‐to‐high sensitivity, whereas clinicians should be aware of the diagnostic significance of pelvic tenderness.

Performance of a Vaginal Panel Assay Compared With the Clinical Diagnosis of Vaginitis

A vaginal panel assay could improve diagnostic accuracy for vaginitis and facilitate appropriate and timely treatment.

To compare the performance of vaginitis diagnosis based on clinical assessment to molecular detection of organisms associated with bacterial vaginosis, vulvovaginal candidiasis, and Trichomonas vaginalis using a vaginal panel assay.

Prediction model for gonorrhea, chlamydia, and trichomoniasis in the emergency department

OBJECTIVE

History and physical examination findings can be unreliable for prediction of genitourinary tract infections and differentiation of urinary tract infections from sexually transmitted infections (STIs). The study objective was to develop a prediction tool to more accurately identify patients with STIs.

METHODS

A retrospective review of 64,490 emergency department (ED) encounters between April 18, 2014, and March 7, 2017, where patients age 18 years or older had urinalysis and urine culture or testing for gonorrhea, chlamydia, or trichomonas, was used to develop a prediction model for men and women with Neisseria gonorrhoeae or Chlamydia trachomatis, or both, and for women with Trichomonas vaginalis. The data set was randomly divided into two-thirds discovery and one-third validation. Groups were assigned through a random number generator. Backward step regression modeling was used to identify the best model for each outcome.

RESULTS

With use of age, race, marital status, and findings from vaginal wet preparation (white blood cells [WBCs], clue cells, and yeast) and urinalysis (squamous epithelial cells, protein, leukocyte esterase, and WBCs), the models had areas under the receiver operating characteristic curve of 0.80 for men with N gonorrhoeae or C trachomatis, or both; 0.75 for women with N gonorrhoeae or C trachomatis, or both; and 0.73 for women with T vaginalis.

CONCLUSIONS

The model estimated likelihood of ED patients having STIs was reasonably accurate with a limited number of demographic and laboratory variables. In the absence of point-of-care STI testing, use of a prediction tool for STIs may improve antimicrobial stewardship.

Vaginal leukocyte counts for predicting sexually transmitted infections in the emergency department

BACKGROUND

The use of vaginal white blood cell (WBC) counts to predict sexually transmitted infections (STIs) in the emergency department (ED) is incompletely characterized.

OBJECTIVES

Our objective was to assess the relationship between vaginal wet preparation WBC counts and STIs and to determine whether WBC counts of at least 11 WBCs per high-power field (HPF) could be useful for identifying STIs in women in the ED.

METHODS

Female ED patients 18 years or older who were evaluated in a single health system between April 18, 2014, and March 7, 2017, and had a genital wet preparation WBC result were retrospectively examined using univariable and multivariable analysis.

RESULTS

Vaginal wet preparation WBC counts were examined for 17,180 patient encounters. Vaginal WBC counts of at least 11 WBCs/HPF were associated with increased odds of having gonorrhea, chlamydia, or trichomoniasis. When this threshold was used for the diagnosis of each STI, sensitivity ranged from 48.2% to 53.9%, and specificity ranged from 67.2% to 68.8%.

CONCLUSION

Women with STIs are more likely to have higher vaginal WBC counts. However, higher vaginal wet preparation WBC counts in isolation have limited diagnostic utility for gonorrhea, chlamydia, and trichomoniasis. Incorporation of age, urine leukocyte esterase results, and vaginal WBC counts provided a better predictor of an STI than vaginal WBC counts alone.

[Pelvic Inflammatory Disease - Synergies between Family Practices and Gynaecological Specialised Assessment]

Pelvic Inflammatory Disease - Synergies between Family Practices and Gynaecological Specialised Assessment Abstract. The 'pelvic inflammatory disease' (PID) describes an ascending inflammation of the upper female genital tract, beginning with a local cervicitis and proceeding to endometritis and adnexitis. It is a common clinical picture with rising numbers in recent years, and it occurs both in gynaecological and general practice. The symptoms are often unspecific, discrete or althogehter lacking. In order to reduce long-term risks of chronic pelvic pain, sterility and/or ectopic pregnancies, rapid diagnosis followed by immediate therapy and a good interdisciplinary cooperation are necessary. Screening programs for chlamydia and gonococcus as the most common pathogens of PID have not yet been implemented in Switzerland so far.

History, Physical Examination, and Laboratory Findings Associated with Infection and the Empiric Treatment of Gonorrhea and Chlamydia of Women in the Emergency Department

Background Neisseria gonorrhea (NG), Chlamydia trachomatis (CT), and Trichomonas vaginalis (TV) are common sexually transmitted infections (STIs) treated in the emergency department (ED). Objectives To assess the history, physical examination, and laboratory findings associated with NG and CT infection and the decision to administer empiric antibiotic treatment for the diseases in the ED. Methods A retrospective review of 566 clinical encounters of adult female patients tested for STIs between January 1, 2013 and December 31, 2014. An analysis of patient- and provider-level variables was assessed to determine the characteristics associated with empiric antibiotic treatment in the ED and post-discharge laboratory confirmed NG or CT. Results Younger age and the presence of TV on vaginal wet prep had a higher association with being infected with NG or CT (p < 0.05). Subjective exam findings, such as vaginal discharge, abdominal pain, urinary urgency, urinary frequency, dysuria, objective vaginal discharge, cervical motion tenderness, adnexal tenderness, vaginal bleeding, as well as positive leukocyte esterase and nitrites on urinalysis were all not associated with NG or CT infection (p > 0.05). ED providers were more likely to treat subjects in the ED for NG and CT when there was subjective and objective vaginal discharge, cervical motion tenderness, adnexal tenderness, and vaginal bleeding, TV on wet prep, and leukocyte esterase on urinalysis (p < 0.05). Conclusions Only younger age women and the presence of TV on vaginal wet prep were associated with NG or CT infection. ED providers empirically over-treated with antibiotics ~20 patients uninfected with NG and CT by laboratory confirmation, for every one patient with a laboratory confirmed infection.