Identification of symptoms that indicate a pelvic examination is necessary to exclude PID in adolescent women

[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.

A Primary Care Approach to Abdominal Pain in Adults

Abdominal pain is a common presenting problem with multiple aetiologies that often pose diagnostic and therapeutic dilemmas for primary care practitioners. The vague symptomatology and difficult correlation to specific organ pathology obscures clinical findings leading to incorrect diagnoses. Although most presentations of abdominal pain are benign, a significant number of patients have life-threatening conditions that require a meticulous approach to management in order to prevent morbidity and mortality. The skill in assessing patients presenting with abdominal pain is fundamental for all primary care doctors. This review will discuss an approach to the assessment and diagnosis of abdominal pain in the primary care setting.

[Diagnosis of pelvic inflammatory disease: Clinical, paraclinical, imaging and laparoscopy criteria. CNGOF and SPILF Pelvic Inflammatory Diseases Guidelines]

The objective of this literature review is to update the recommendations for clinical practice about the diagnosis of pelvic inflammatory disease (PID), microbiologic diagnosis excluded. An adnexal pain or cervical motion tenderness are the signs that allow a positive diagnosis of PID (LE2). Associated signs (fever, leucorrhoea, metrorrhagia) reinforce clinical diagnosis (LE2). In a woman consulting for symptoms compatible with PID, a pelvic clinical examination is recommended (grade B). In cases of suspected PID, hyperleukocytosis associated with a high C-reactive protein suggests a complicated PID or a differential diagnosis such as acute appendicitis (LE3). The absence of hyperleukocytosis or normal CRP does not rule out the diagnosis of PID (LE1). When PID is suspected, a blood test with a blood count and a CRP test is recommended (grade C). Pelvic ultrasound scan does not contribute to the positive diagnosis of uncomplicated PID because it is insensitive and unspecific (LE3). However, ultrasound scan is recommended to look for signs of complicated PID (polymorphic collection) or differential diagnosis (grade C). Waiting for an ultrasound scan to be performed should not delay the start-up of antibiotic therapy. In case of diagnostic uncertainty, an abdominal-pelvic CT scan with contrast injection is useful for differential diagnosis of urinary, digestive or gynaecological origin (LE2). Laparoscopy is not recommended for the unique purpose of the positive diagnosis of PID (grade B).

RNA Biosignatures in Adolescent Patients in a Pediatric Emergency Department With Pelvic Inflammatory Disease

BACKGROUND

Adolescents are at high risk for pelvic inflammatory disease (PID). Because accurate diagnosis of PID is difficult, and complications of untreated PID are significant, novel methods to improve diagnosis are essential.

OBJECTIVES

To determine if patients with PID have unique RNA expression patterns compared to controls.

METHODS

Peripheral blood was collected from adolescent females with PID in the emergency department, and from control patients in the operating room. RNA was isolated, and microarray analysis was performed. Initial analysis involved a training set of 18 patients (9 PID patients with either Neisseria gonorrhoeae or Chlamydia trachomatis infection and 9 control patients). Supervised and unsupervised cluster analyses were performed, followed by network analysis. The training set was used to classify a set of 15 additional PID patients and 2 controls.

RESULTS

Supervised cluster analysis of the training set revealed 170 genes which were differentially expressed in PID patients versus controls. Network analysis indicated that several differentially expressed genes are involved in immune activation. Analysis of additional PID patients based on the training set findings revealed that patients with positive testing for Trichomonas vaginalis partitioned with the PID group, whereas patients with no organism identified partitioned with both groups.

CONCLUSIONS

RNA sample collection from adolescents in the emergency department is feasible. Genes were identified which were differentially expressed in PID patients versus controls, many of which are involved in inflammation. Future studies should confirm the training set findings on a larger sample and may lead to improved accuracy of PID diagnosis.

Symptomatic presentation with cervical cancer in Uganda: a qualitative study assessing the pathways to diagnosis in a low-income country

Background

Symptomatic cervical cancer patients in low- and middle-income countries usually present with late stage disease and have poor survival. We explored the views of cervical cancer patients on their symptom appraisal and interpretations, and their help-seeking including lay consultations.

Methods

We conducted an in-depth interview study in two northern Ugandan hospitals. Theoretical models underpinned the study guide for data collection and analysis. We used thematic analysis techniques, informed by the theoretical concepts in the Model of Pathways to Treatment. Sub-themes and themes were identified through consensus among investigators.

Results

Eighteen women aged 35–56 years, recently diagnosed with cervical cancer were interviewed. Their first symptoms included abnormal vaginal bleeding, offensive vaginal discharge and lower abdominal pain. Most participants did not perceive themselves to be at risk for cervical cancer and they usually attributed the initial symptoms to normal bodily changes or common illnesses such as sexually transmitted diseases. Lay consultations with husbands, relatives and friends were common and often influenced decisions and timing for seeking care. Prompt help-seeking was frequently triggered by perceived life threatening symptoms such as heavy vaginal bleeding or lower abdominal pain; symptom burden sufficient to interfere with patients’ work routines; and persistence of symptoms in spite of home-based treatments. Participants did not promptly seek care when they perceived symptoms as mild; interpreted symptoms as due to normal bodily changes e.g. menopause; and attributed symptoms to common illnesses they could self-manage. Their cancer diagnosis was often further delayed by long help-seeking processes including repeated consultations. Some healthcare professionals at private clinics and lower level health facilities failed to recognize symptoms of cervical cancer promptly therefore delayed referring women to the tertiary hospitals for diagnosis and treatment.

Conclusion

Ugandan patients with symptomatic cervical cancer often misattribute their gynaecological symptoms, and experience long appraisal and help-seeking intervals. These findings can inform targeted interventions including community awareness campaigns about cervical cancer symptoms, and promote prompt help-seeking in Uganda and other low- and middle-income countries with high incidence and mortality from cervical cancer.

Trends in illness severity and length of stay in inner-city adolescents hospitalized for pelvic inflammatory disease

BACKGROUND

In 1998, the Centers for Disease Control and Prevention (CDC) changed their guidelines for treatment of adolescents with pelvic inflammatory disease (PID), no longer recommending hospitalization of all teenagers.

STUDY OBJECTIVES

(1) To determine the proportion of adolescents with PID who were admitted for failed outpatient treatment after the CDC guideline change. (2) To determine if adolescents admitted for PID after the guideline change needed longer hospital stays and/or were more likely to be "very ill" [as measured by inflammation markers, e.g. fever] or to have tubo-ovarian abscess (TOA) than those admitted before the change.

DESIGN

Retrospective chart review

SETTING/PARTICIPANTS

All 12-21-year-old females with the diagnosis of PID admitted to an adolescent inpatient unit in an inner-city teaching hospital during a two-year period before [T1=1995-1997 (54 cases)] and after [T2=1998-2000 (91 cases)] the CDC guideline change.

INTERVENTIONS

None

MAIN OUTCOME MEASURES

Reason for admission (failed outpatient treatment; TOA; or admission at the time of diagnosis of PID); clinical toxicity at admission, and length of hospital stay (LOS).

RESULTS

During T2, 22% of PID admissions were for failure of outpatient therapy. However, those admitted after failure of outpatient therapy (n=20) in T2 were less likely to be "very ill" than those who were admitted at the time of PID diagnosis in either T1 or T2 (n=123) [RR:0.30; 95% CI:0.09-0.94]. Mean LOS for females admitted to the adolescent unit with all diagnoses other than PID did not change between T1 and T2 but mean LOS for those diagnosed with PID decreased significantly from 6.3 +/- 3.7 days to 4.7 +/- 2.7 days, respectively (P = 0.002). LOS for PID was longer for younger (<16 years; 8.20 +/- 4.5 days) than older (> or =16 years; 5.0 +/- 2.8 days) girls (P = 0.02) and for adolescents with TOA (7.9 +/- 5.0 days) than for those without (5.3 +/- 2.9 days) (P = 0.05).

CONCLUSION

At our medical center, after the CDC guideline change many adolescents with PID were admitted because of failure of outpatient therapy but they were not sicker than those admitted at the time of diagnosis and overall LOS for PID was shorter. These findings are reassuring because they suggest that an initial trial of outpatient therapy for PID is unlikely to harm adolescents and may lead to significant cost savings.

Cost-effectiveness of screening strategies for Chlamydia trachomatis using cervical swabs, urine, and self-obtained vaginal swabs in a sexually transmitted disease clinic setting

BACKGROUND

We evaluated the cost-effectiveness of Chlamydia screening strategies that use different methods of specimen collection: cervical swabs, urines, and self-obtained vaginal swabs.

METHODS

A decision analysis was modeled for a hypothetical cohort of 10,000 per year of women attending sexually transmitted disease (STD) clinics. Incremental cost-effectiveness of 4 screening strategies were compared: 1) Endocervical DNA probe test (PACE2, Gen-Probe), 2) Endocervical AC2 (Aptima Combo 2, Gen-Probe), 3) Self-Obtained Vaginal AC2, and 4) Urine AC2. Sensitivities of the vaginal, urine, and cervical AC2 tests were derived from 324 women attending STD clinics. The primary outcome was cases of pelvic inflammatory disease prevented. The model incorporated programmatic screening and treatment costs and medical cost savings from sequelae prevented.

RESULTS

Chlamydia prevalence in the sampled population was 11.1%. Sensitivities of vaginal, urine, and cervical AC2 were 97.2%, 91.7%, and 91.7%, respectively. The sensitivity of the DNA probe was derived from the literature and estimated at 68.8%. The self-obtained vaginal AC2 strategy was the least expensive and the most cost-effective, preventing 17 more cases of pelvic inflammatory disease than the next least expensive strategy.

CONCLUSIONS

Use of a vaginal swab to detect Chlamydia in this STD clinic population was cost-saving and cost-effective.

Pelvic Inflammatory Disease in Adolescents

Pelvic inflammatory disease (PID) is a polymicrobial infection typically occurring in sexually active females. It occurs when microorganisms ascend from the lower genital tract into the upper genital tract. The clinical presentation varies in severity, with most patients presenting with mild disease. Complications include tubo-ovarian abscess, ectopic pregnancy, infertility, and chronic pain. The newly revised criteria issued by the Centers for Disease Control and Prevention now include either cervical motion tenderness or adnexal tenderness with unchanged additional criteria.

Management of pelvic inflammatory disease in adolescents

Pelvic inflammatory disease (PID) is highly prevalent among sexually active adolescent females. The major organisms are N gonorrhoeae and C trachomatis. Diagnosis is based on historical information and clinical findings. Early diagnosis and treatment effectively reduce the incidence of complications associated with PID. Highly effective treatment regimens are available and main antimicrobials used include quinolones, cephalosporins, metronidazole, doxycycline, and azithromycin. Delay or inadequate treatment is associated with long term sequelae including tubal infertility and chronic pelvic pain. Prevention efforts should be directed towards routine screening and treatment for sexually transmissible infections, public education and provision of resources for treatment and follow-up.

Can the diagnosis of pelvic inflammatory disease be excluded without a bimanual examination?

Now that urine-based tests are available for detection of Chlamydia and gonorrhea, we sought to determine whether history alone could be used to exclude pelvic inflammatory disease (PID) and thus preclude a bimanual examination. The study design was a retrospective chart review. The study population included females aged 15-24 years diagnosed with PID. Outcome measures were documentation of screening symptoms (abdominal pain, dyspareunia, or abnormal vaginal bleeding) in the medical record. Our primary analysis was sensitivity of screening symptoms for identifying patients with PID. At least 1 of the 3 screening symptoms was reported by 93% of the PID group. If absence of all 3 screening symptoms were used as a screening instrument to exclude a bimanual examination, many women with lower genital tract symptoms could be evaluated noninvasively. However, this approach could result in delayed diagnosis of PID in a small number of patients. Before this strategy is adopted, a large prospective study is needed.