Pelvic inflammatory disease--an evidence-based approach to diagnosis

MRI versus laparoscopy to diagnose the main causes of chronic pelvic pain in women: a test-accuracy study and economic evaluation

BACKGROUND

Chronic pelvic pain (CPP) symptoms in women are variable and non-specific; establishing a differential diagnosis can be hard. A diagnostic laparoscopy is often performed, although a prior magnetic resonance imaging (MRI) scan may beneficial.

OBJECTIVES

To estimate the accuracy and added value of MRI in making diagnoses of (1) idiopathic CPP and (2) the main gynaecological causes of CPP. To quantify the impact MRI can have on decision-making with respect to triaging for therapeutic laparoscopy and to conduct an economic evaluation.

DESIGN

Comparative test-accuracy study with cost-effectiveness modelling.

SETTING

Twenty-six UK-based hospitals.

PARTICIPANTS

A total of 291 women with CPP.

METHODS

Pre-index information concerning the patient's medical history, previous pelvic examinations and ultrasound scans was collected. Women reported symptoms and quality of life at baseline and 6 months. MRI scans and diagnostic laparoscopy (undertaken and interpreted blind to each other) were the index tests. For each potential cause of CPP, gynaecologists indicated their level of certainty that the condition was causing the pelvic pain. The analysis considered both diagnostic laparoscopy as a reference standard for observing structural gynaecological causes and consensus from a two-stage expert independent panel for ascertaining the cause of CPP. The stage 1 consensus was based on pre-index, laparoscopy and follow-up data; for stage 2, the MRI scan report was also provided. The primary analysis involved calculations of sensitivity and specificity for the presence or absence of each structural gynaecological cause of pain. A decision-analytic model was developed, with a 6-month time horizon. Two strategies, laparoscopy or MRI, were considered and populated with study data.

RESULTS

Using reference standards of laparoscopic and expert panel diagnoses, MRI scans had high specificity but poor sensitivity for observing deep-infiltrating endometriosis, endometrioma, adhesions and ovarian cysts. MRI scans correctly identified 56% [95% confidence interval (CI) 48% to 64%] of women judged to have idiopathic CPP, but missed 46% (95% CI 37% to 55%) of those considered to have a gynaecological structural cause of CPP. MRI added significant value, over and above the pre-index information, in identifying deep-infiltrating endometriosis (p = 0.006) and endometrioma (p = 0.02) as the cause of pain, but not for other gynaecological structural causes or for identifying idiopathic CPP (p = 0.08). Laparoscopy was significantly more accurate than MRI in diagnosing idiopathic CPP (p < 0.0001), superficial peritoneal endometriosis (p < 0.0001), deep-infiltrating endometriosis (p < 0.0001) and endometrioma of the ovary (p = 0.02) as the cause of pelvic pain. The accuracy of laparoscopy appeared to be able to rule in these diagnoses. Using MRI to identify women who require therapeutic laparoscopy would lead to 369 women in a cohort of 1000 receiving laparoscopy unnecessarily, and 136 women who required laparoscopy not receiving it. The economic analysis highlighted the importance of the time horizon, the prevalence of CPP and the cut-off values to inform the sensitivity and specificity of MRI and laparoscopy on the model results. MRI was not found to be a cost-effective diagnostic approach in any scenario.

CONCLUSIONS

MRI was dominated by laparoscopy in differential diagnosis of women presenting to gynaecology clinics with CPP. It did not add value to information already gained from history, examination and ultrasound about idiopathic CPP and various gynaecological conditions.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN13028601.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 40. See the NIHR Journals Library website for further project information.

Improving adherence to guidelines for the diagnosis and management of pelvic inflammatory disease: a systematic review

BACKGROUND

Evidence suggests adherence to clinical guidelines for pelvic inflammatory disease (PID) diagnosis and management is suboptimal. We systematically reviewed the literature for studies describing strategies to improve the adherence to PID clinical guidelines.

METHODS

The databases MEDLINE and EMBASE, and reference lists of review articles were searched from January 2000 to April 2012. Only studies with a control group were included.

RESULTS

An interrupted time-series study and two randomised controlled trials (RCTs) were included. The interrupted time-series found that following a multifaceted patient and practitioner intervention (practice protocol, provision of antibiotics on-site, written instructions for patients, and active followup), more patients received the recommended antibiotics and attended for followup. One RCT found a patient video on PID self-care did not improve medication compliance and followup. Another RCT found an abbreviated PID treatment guideline for health-practitioners improved their management of PID in hypothetical case scenarios but not their diagnosis of PID.

CONCLUSION

There is limited research on what strategies can improve practitioner and patient adherence to PID diagnosis and management guidelines. Interventions that make managing PID more convenient, such as summary guidelines and provision of treatment on-site, appear to lead to better adherence but further empirical evidence is necessary.

Mycoplasma genitalium in cervicitis and pelvic inflammatory disease among women at a gynecologic outpatient service

OBJECTIVE

We sought to analyze the prevalence and clinical manifestations of Mycoplasma genitalium infection in a heterogeneous population of women.

STUDY DESIGN

The study was designed as a cross-sectional case-control study. Women attending a gynecological outpatient service from 2003 through 2008 were invited to participate.

RESULTS

The prevalence of M genitalium was 2.1% and of Chlamydia trachomatis was 2.8% among 5519 tested women. A total of 679 women were included. Both pelvic inflammatory disease (PID) and cervicitis were independently associated with M genitalium (odds ratio, 9.00; 95% confidence interval, 1.62-49.89 and odds ratio, 3.80; 95% confidence interval, 2.06-7.03, respectively). Women with C trachomatis had a higher frequency of both PID (18.3% vs 4.9%, P < .001) and cervicitis (33.4% vs 22.3%, P < .001) than women with M genitalium.

CONCLUSION

M genitalium was an independent and strong risk factor for both cervicitis and PID although, compared to C trachomatis, clinical manifestations were less frequent.

Prevalence and characteristics of chronic pelvic pain among women in Alexandria, Egypt

BACKGROUND

Chronic pelvic pain (CPP) is widespread among women with a significant impact on their health. The nature and severity of pain varies between different women and areas.

OBJECTIVES

To estimate the prevalence CPP and associated dysmenorrhea, and dyspareunia among women attending Family Health Centers in Alexandria, Egypt and to describe the nature and severity of pain as reported by women.

MATERIALS AND METHODS

A cross-sectional study was performed on a sample of 900 ever-married women aged (18-59) years attending three Family Health Centers in Alexandria, Egypt (2007-2008). Personal, social, reproductive, and medical data were collected using a modified Oxfordshire questionnaire. Severity of pain was assessed using both the Verbal Rating Scale and the Visual Analogue Scale.

RESULTS

Prevalence of CPP was 26.6%, dysmenorrhea was 55.3%, and dyspareunia was 40.5%. The three types overlapped. Most women (92%) had CPP of intermittent type and 46.9% had this pain for more than 1 year (1-5 years). Pain was perceived as severe in approximately one third of them (32.2%). Their mean Visual Analog Scale for pain severity was 6.5±2.1. The most frequently mentioned types of pain were moderate cramping pain and moderate heaviness (40%). Factors that increase their pain were mainly full bladder, sexual intercourse, and loaded colon (60, 46.4, and 40%, respectively). Relieving factors were urination and sleep/rest (46.9 and 46.4%, respectively) and use of medications (40%).

CONCLUSION AND RECOMMENDATIONS

The three types of pain were highly prevalent and overlapping among the women studied. CPP was perceived as severe and intermittent by many women. Pelvic pain should receive greater attention both in public education and in clinical practice. Primary care physicians should be prepared to initiate pain management to alleviate women's stress and disability. Women should be educated regarding the importance of seeking medical treatment early.

Characteristics of women at low risk of STI presenting with pelvic inflammatory disease

OBJECTIVE

To investigate the background and reproductive history of women who are considered at low risk of sexually transmitted infection (STI) presenting with acute pelvic inflammatory disease (PID).

METHODS

Case-control study, investigating 51 women admitted to hospital with a diagnosis of acute PID and 50 healthy women attending for routine gynecological checkup.

RESULTS

Women with PID were older (p = 0.003) and more often unemployed (p = 0.008), and had a lower educational level (p = 0.000003). Healthy women reported more regular routine attendance to gynecologists (p = 0.0008) and were less often smokers (p = 0.0009). There was no difference between groups regarding age at first sexual intercourse, number of sex partners during life, duration of current sexual partnership, and frequency of sexual intercourse, total number of deliveries, spontaneous abortions, ectopic pregnancies and outcome of last pregnancy. The number of induced abortions was significantly higher in the PID group (p = 0.0004). There were no differences between the groups with regard to previous episodes of PID. Healthy controls more often reported a history of STI (p = 0.00007). IUD was the most commonly reported current contraceptive method in both groups, and there was no difference in contraceptive practices between groups.

CONCLUSION

Women with PID differed from healthy controls only with regard to socio-demographic characteristics and not with regard to common risk factors for PID.

Emergency gynaecology

The management of gynaecological emergencies is directed at the preservation of life, health, sexual function and the perpetuation of fertility. Ectopic pregnancy (EP), pelvic inflammatory disease (PID) and miscarriages are common gynaecological emergencies and early recognition and appropriate treatment is essential to avoid unwanted sequelae. Controversy will always exist in clinical medicine because management is mainly based on uncontrolled studies, expert opinion and personal experiences. It is estimated that only 10% of clinical treatments have been validated by prospective, randomised trials. Recent advances have led to earlier diagnosis and more conservative treatment on an outpatient or day care basis in EP and miscarriages.

Diagnosis of pelvic inflammatory disease: time for a rethink

OBJECTIVES

To critically evaluate the available evidence base concerned with the diagnosis of pelvic inflammatory disease (PID) based on clinical presentation, and to investigate the relation between signs and symptoms and the presence of laparoscopically diagnosed PID using the largest available dataset.

METHODS

The evidence base was critically evaluated and data collected by Lund University between 1960 and 1969 were used to compare clinical presentation with the results of laparoscopic investigation. Three techniques were used in this investigation-sensitivity and specificity, likelihood ratios, and discriminant analysis.

RESULTS

None of the variables (abnormal vaginal discharge, fever >38 degrees C, vomiting, menstrual irregularity, ongoing bleeding, symptoms of urethritis, rectal temperature >38 degrees C, marked tenderness of pelvic organs on bimanual examination, adnexal mass, and erythrocyte sedimentation rate >or=15 mm in the first hour) had both high specificity and sensitivity-most had low specificity and sensitivity. There was little variation in either the likelihood ratios or the post-test probabilities between the variables. The lowest likelihood ratio (0.97) produced a post-test probability of 78% (95% CI: 74% to 81%) whereas the highest (1.73) had a post-test probability of 84% (95% CI: 81% to 87%). The pretest probability of having PID based on the presence of lower abdominal pain was 79% (95% CI: 76% to 82%). The discriminant analysis indicated that three variables significantly influenced the prediction of the presence of PID: erythrocyte sedimentation rate (p<0.0001), fever (p<0.0001), and adnexal tenderness (p<0.0001). These variables correctly classified 65% of patients with laparoscopically diagnosed PID (95% CI: 61% to 69%).

CONCLUSION

There is insufficient evidence to support existing diagnostic criteria, which have been based on a combination of empirical data and expert opinion. A new evidence base is urgently needed but this will require either a new investigation of the association between clinical presentation and PID based on a laparoscopic "gold standard" or the development of new diagnostic techniques.