Is Pelvic Exam in the Emergency Department Useful?

Women 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

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