Questioning the Utility of the ER Pelvic Exam
I hate doing pelvic exams because in the ER setting, they are:
1) time consuming
2) labor-intensive (requiring an assistant)
3) low yield
Women commonly require pelvic examinations in the ER for three reasons: bleeding, discharge, and pelvic pain. It's rare that the pelvic exam findings change my management. Occasionally the woman with vaginal discharge will have an unsuspected retained tampon. Usually, they know.
Every woman who complains of heavy periods comes in saying she's bleeding A LOT; maybe one in 20 really are. The sensitivity and specificity of diagnosing anything from a bimanual exam are not much better than flipping a coin.
If we think she has ovarian torsion or if she is pregnant with bleeding/pain, she gets an ultrasound automatically. If we think she might have appendicitis, we're going to order a CT scan anyway. If we think she has PID, we're going to empirically treat with antibiotics. Endometriosis? Who cares.
We don't get the STD panel back before the patient leaves the department; it takes a couple of days. The wet prep could be made obsolete by just adding Flagyl and Diflucan to the standard STD cocktail. Probably some of us do that already.
With vaginal bleeding all we really need are the CBC, urine pregnancy test, and maybe orthostatic vital signs. If the patient isn't going to be transfused, the ER treatment is the same: it's megahormones or nothing.
For such a useless procedure, there is an unreasonable amount of emphasis placed on its performance by our consultants, probably a vestigial remnant from the olden days when CT scans, ultrasounds, and antibiotics were not as powerful or widely available. Don't get me wrong, I still do pelvic exams as often as historically indicated. But it's sort of like checking the control on a hemoccult slide. Yeah, we're supposed to do it and document it thoroughly. But how often does it really matter?
1) time consuming
2) labor-intensive (requiring an assistant)
3) low yield
Women commonly require pelvic examinations in the ER for three reasons: bleeding, discharge, and pelvic pain. It's rare that the pelvic exam findings change my management. Occasionally the woman with vaginal discharge will have an unsuspected retained tampon. Usually, they know.
Every woman who complains of heavy periods comes in saying she's bleeding A LOT; maybe one in 20 really are. The sensitivity and specificity of diagnosing anything from a bimanual exam are not much better than flipping a coin.
If we think she has ovarian torsion or if she is pregnant with bleeding/pain, she gets an ultrasound automatically. If we think she might have appendicitis, we're going to order a CT scan anyway. If we think she has PID, we're going to empirically treat with antibiotics. Endometriosis? Who cares.
We don't get the STD panel back before the patient leaves the department; it takes a couple of days. The wet prep could be made obsolete by just adding Flagyl and Diflucan to the standard STD cocktail. Probably some of us do that already.
With vaginal bleeding all we really need are the CBC, urine pregnancy test, and maybe orthostatic vital signs. If the patient isn't going to be transfused, the ER treatment is the same: it's megahormones or nothing.
For such a useless procedure, there is an unreasonable amount of emphasis placed on its performance by our consultants, probably a vestigial remnant from the olden days when CT scans, ultrasounds, and antibiotics were not as powerful or widely available. Don't get me wrong, I still do pelvic exams as often as historically indicated. But it's sort of like checking the control on a hemoccult slide. Yeah, we're supposed to do it and document it thoroughly. But how often does it really matter?
Labels: pelvic exams, questioning authority
posted by scalpel at 2:53 PM
30 Comments:
Pelvics and the trauma rectal need to be relegated to the dustbin of medically near-useless procedures. Oh, I do them, too, but often question why.
GruntDoc
agreed! We were just discussing (with non-medical family members) the utility of the DRE in most patients. In how many abdominal pain patients does it really change your management?
Same with the pelvic...although I have found on occasion that some nice cervical motion tenderness (I'm talking "chandelier sign" tender, not "ow, that's uncomfortable") and purulent discharge help me dispo some a lot quicker.
I suggest to evaluate for PID that perhaps a simple bimanual exam to check for CMT/adnexal fullness is sufficient. That could be followed by smearing the glove on the Q-tips for the wet prep and STD panel tests.
Perhaps the speculum exam is unnecessary in that situation. Omitting it would certainly save a couple of minutes.
Since so many women replied to the last post, let me ask them this: would it seem creepy if your doctor just plowed right into the bimanual exam without performing the speculum exam first? Or would you be relieved to omit the stirrups and speculum if we felt it wasn't necesssary?
Totally agree - they really are useless. All I really care about is the dx. tests except I do add a beta-hcg quantitative to pregos.
But, once, I did strike it rich doing a pelvic. The patient had forgotten that she stashed a roll of money in a zip lock bag deep in her veegee.
Scalpel -I would feel cheated, like something was missing if I didn't get to use the stirrups and feel the speculum!
Yeah, that and I'd love to have a big ureteral stent placed in me sans medication!
NO! NO! and NO! I doubt any woman WANTS to have that done and yes I know I would be relieved that it was one less thing I had to endure to establish a dx.
Of course, you could have some women think/say,"What...no speculum, etc...?" because that is what is "always" done. You know...kind of like the people that want x-rays after an mvc that are totally unnecessary.
I think as long as you explain what your doing and why prior to the exam (you all do anyway) that should be just fine.
Of course then pt goes home and her husband's brother's girlfriend tells her "BUT SHE had a speculum exam and the ER doc must've done it wrong!"
Simplify, simplify whenever possible!
P.S. Not common (I hope)but what is different with the rape exam?
Ouch! I had endometriosis during my infertile days but cleared up after my 1st son was born. Never went to the ER for it though.
No I am lying because I ended up in the ER with it in the fall of 99 but that wasn't the dx. Periods can be difficult and it was an autoimmune doc in 2003 that diagnosed it and he didn't even have to run any tests, just listened to what I said about it. It is worse this time around then when I was in my 20's. But like Russian roulette and not consistent.
My thoughts on the rape exam.
Another beef is that once you start the process, nobody is supposed to come in or out of the room until the exam is completed. I can't justify dedicating a significant amount of uninterrupted time to ANY non-life-threatening process.
That's interesting Scalpel...I will have to come back to read the comments/comment.
I actually think that the pelvic is important. Most of the ER docs in my area can't do one very well.
I hate being the doc that has to follow up on the ER visit. Far too many are diagnosed and treated for PID that they don't have. Pain without fever or an elevated white count is not PID.
Too, too many are diagnosed with an ovarian cyst. Every menstruating female will have some cysts on their ovaries. Unless they're complex or greater than 5 cm in diameter or torsed, they probably don't cause pain. But every patient comes to the office afraid of her follicular cysts.
Even more are diagnosed with the dreaded ruptured ovarian cyst, because there is a small amount of physiologic fluid in their cul de sac.
The following is a true story. Got a call from the ER to come in and due a D&C on a patient with an SAB who was bleeding. I asked how much and the doc couldn't tell me because he had not done a pelvic. I asked her H&H, it wasn't back yet. I asked about the U/S result, not done yet. So I asked how he knew she needed a D&C, and he said it was because she was pregnant and bleeding. So I went to see her and did a pelvic. I got a bunch of blood out of her vagina and pulled a sac out from the os and the bleeding stopped, she felt better and went home. No surgery needed. Why didn't the ER doc do that.
If you do a good pelvic you can tell whether the pain is in the bladder, the uterus, the ovaries or in the myofascia of the pelvis.
Sorry for the rant. But the ER docs in my area seem to know very little gynecology and they deathly afraid of pregnant women.
Amen, brother.
I do omit the pelvic in carefully selected cases. Pregnant and bleeding gets a bedside ultrasound first -- hey, it's an exam tool like a stethoscope, right? If the US is clearly normal, there's no real need for the speculum. If I'm using the endovag probe, it gives me as much or more info than a bimanual does.
Chronic pelvic pain also typically does not benefit from a pelvic, either (as long as they don't have a discharge and don't present suggestive of PID. It helps that many of the frequent ED visitors for pelvic pain have been recently seen and tested for GC/Ch, further obviating the need for a pelvic.
Anything acute, anything with a discharge, then you're pretty well stuck doing the exam. And I have never had anybody object to a bimanual only, when appropriate.
As a Gyn, I have to say, most doctors are so scared of the vagina that they do crappy exams.
BUT...it still needs to be done. My management may vary if you tell me vault filled with blood for someone c/o vag bleeding. Hell, I'll admit that my sense of urgency will vary. You will likely get a faster all-important dispo, whether I end up admitting her or taking her to the OR...just don't be like one ER doc who called me last Feb to "look at a little bleeding". No labs back, no pelvic "Because you're just going to do one." He's lucky I was in the hospital grabbing lunch, so I went to see her before doing that - pt had ~1 liter worth of clots/blood in her vault and her hgb ended up at 3.1 on admission.
And as an aside, please let those women in the ER know that they are NOT getting a "pap." Now you and I know what a pap is, but most women think a speculum in her hoo-ha means she got a pap. ;)
OK, I think I'm done bitching. :)
True story. I was once assisting an ER doc doing a pelvic (in a hospital, far far away....)
And somehow a fly had gotten into the ER.
I was dutifully helping the doc with the pelvic by handing off the various swabs he needed for the pelvic when, unbeknownst to the him, I spotted the damn fly. It was hovering just over the doc's head, and it looked like it was going to go towards the woman's hoo-hoo.
I kept thinking "Please don't land THERE, please don't land THERE...."----and then suddenly that stupid fly dive-bombed towards THERE....
And so I swatted at it, which caused all the swabs I had in my hand to fly across the room.
The doc simply said: "Bo, do you mind telling me why you just threw my wet prep across the room?"
First a comment to a prior poster -
Technically, the diagnosis of PID (per the CDC case definition) does not require a fever or a white count. It only requires abdominal pain and a tender uterus and adnexae, and no other good reason for the pain. That's all. So, Scalpel, you DO have to do a pelvic to diagnose it - I bet your DNA probe isn't validated for "glove discharge" - and the CDC wants us all - ER and OB alike - to wildly overdiagnose it to preserve fertility, since there's nothing specific otherwise to diagnose it except laparoscopy. They know they're making us overdiagnose it, and the literature supports that - better to give some unnecessary antibiotics than cause unnecessary chronic pelvic pain and infertility. The fact that it drives the follow-up gynecologist crazy (I know - I'm one of them) is beside the point, from the CDC's perspective.
So, score one for typical ER management there - but I have my own grumpy-consultant things about ERs and pelvics.
First, I don't want ER docs putting q-tips up the os and then telling me that she "has an open os" when ruling out miscarriage. Every multiparous os can allow passage of a q-tip, miscarriage or no. An open os in my book has to pass a 8 to 10 French without pressure. However, physical diagnosis of an open os and tissue passage _makes_ the diagnosis of incomplete miscarriage, no tech necessary. There's one good use for the pelvic exam. And, sorry, sono alone is not enough to reassure me. I've seen positive FHR with widely dilated cervices and membranes outside the os. You can't be sending them home without checking the cervix digitally, at a minimum. That's use number 2 for a pelvic. Sure, an experienced sonographer can do a cervical length transabdominally. Are you that experienced? Are all your ER colleages that experienced? Do the physical exam, if not.
Gynecologists don't always do speculum exams. There are plenty of occasions when they are not required, but a digital exam is still useful. If you aren't considering a diagnosis which requires looking for vaginal or cervical lesions or discharge, ruptured membranes, or STDs, you can probably get away without a spec exam.
Agree with the previous poster that you can't tell if it's a lot of blood or not without looking. I mean, would you consult a cardiologist without listening to the heart yourself first, however briefly? No? Well, then...
I have seen several cases of patients admitted to general surgery or medicine service for abdominal symptoms where I was consulted, the next day, because the CT scan showed a large pelvic mass. Which could have been diagnosed on a friggen rectal if anyone did them any more, not to mention a pelvic, and the patient admitted to the correct service. I know that ER doesn't care - much - as long as the patient who needs admission gets admitted, but it saves time and money to admit them to the right service.
Oh, and another use: vaginal bleeding in pregnancy is sometimes caused by a friable exocervix, or a bleeding polyp. If that's all they've got, you can reassure the heck out of them, and send them on their way. It's not a threatened miscarriage at all, at all. Only a speculum exam will tell you this.
And finally, I can't count the number of women who have told me that their last pap was done by the ER, and look at me like I'm crazy when I explain that the ER does not do pap smears. I know ER's too busy to explain it, but I wish they could. Agree with all previous gyn posters on that point.
That said, I've also seen some marvelous physical diagnosis done in the ER - the doc who looked at a patient for maybe 5 minutes including a quick bimanual, called ultrasound and lab stat, told the nurse to notify the OR, and called me to meet the patient in ultrasound in 10 minutes, telling me she probably had an ectopic. Sho 'nuff. He's the one that saved her life - I'm only the one that did the surgery. So hats off to the ER docs who come through when it counts. Even though you drive us crazy at times...
- Anon OB
I appreciate your comments and perspective. As you undoubtedly know, we ER docs have no reservations about overdiagnosing PID. We don't need a chandelier sign, elevated WBC, or even a significant vaginal discharge. In fact, any woman with lower abdominal pain who isn't absent-mindedly chewing gum and bemusedly watching Fresh Prince of Bel-Air reruns while I work her cervix over like a speed bag is going to get treated for PID anyway, so I doubt the questionably decreased sensitivity of a glove-fomited cervical discharge sample is going to make as much difference as you suspect.
I agree that direct visualization of the cervix is mandatory in threatened miscarriage, but I am less inclined to agree that the difference in visualization between a moderate amount of blood or a lot of blood in the vault is going to change either of our managements much in a nonpregnant patient with a normal hemoglobin and vital signs. Are you really going to come personally evaluate an uninsured no-doc patient at 2 am because I tell you that she has a "lot" of blood in the vault even if her Hgb is 12?
I didn't think so. You'll be happy to see her in the office in a couple of days though.
That's funny BRN! :)
Most of these pts sound like they should be going to the womens clinic or the gyn doc so I see the frustration. Also pelvic pain, is that a bit like diffuse abdominal pain?
I still think men should have one full year of painful hemorrhagic periods (on a 21 day cycle of course) for a better understanding of what that feels like!
Oh yeah, I wouldn't mind skipping the speculum.
As a medical student I've got to day that discussions like these are why I love the medical blogosphere. It's like sitting in a doctor's lounge at lunch listening to a bunch of docs talking.
Just wanted to add my 2ยข:
As a medical student it was interesting to see hibgia say:
We were just discussing (with non-medical family members) the utility of the DRE in most patients. In how many abdominal pain patients does it really change your management?
I just finished my GI unit and we were strictly told to always, always do a rectal.
In fact, one doc told us the only two reasons to NOT do a rectal are if 1) you don't have a finger or 2) the patient doesn't have a rectum.
I actually just got home from a hospital stay for appendicitis; while in the ER for my initial evaluation, I heard an older doctor tell a younger one to do a pelvic exam because 'we always do it for females with pelvic pain'. The younger doctors refused, saying that my blood work and physical exam were indicative of appendicitis and he was sending me for a CT (for the record, I never ended up needing the pelvic).
I'm not a healthcare professional, but from a patient perspective I've always found pelvic exams in the ER both stressful (for the patient) and low yield in terms of results, for the reasons you outlined. Sometimes they do need to be done, but having it as a default procedure for females with pelvic pain doesn't fly with me.
As a patient with endometriosis, pelvic exams suck for the patient. Trust me, we would rather go without. Out of 4 ER visits in 2 years (1 for uterine infection and ecoli, 2 for endometriosis, and 1 for ruptured cyst), the only one that yielded anything was the one for the uterine infection. 5 days pp and I had very heavy bleeding, fever, abdominal pain, and chills. The nurse was not very helpful, till I brought him a urine sample full of blood. That changed his mind a bit. All of a sudden I was getting tons of workups. The ER dr removed a bunch of clots from the cervix (can't remember if it was just outside or just inside). He removed an enormous one and even the nurse's eyes got big. I ended up having a d&c three days later. You would have thought after removing all those clots, the doc would have done an US but he didn't. My obgyn ordered one on followup and I was in emergency surgery an hour after the US. The last time I was in the ER for endo, the doc told me he had to do one for "liability" reasons. Great.
scalpel.
hadn't thought much about this before because it was beaten in to me.
i have quit doing recaal exams with some obvious exceptions but was taught, 'there's only two reasons not to do a rectal exam... 1. you have no fingers 2. the patient does not have an asshole.'
your reasoning is sound. i have already moved more to the bedside bimanual exam when i can justify not doing cultures.
cheers.
Sometimes it can be valuable to re-examine our habits. Just because we've always been taught something doesn't make it right.
Here's an analogy...
Would you feel it is necessary to do a digital rectal examination on a patient who comes to the ER every month with rectal bleeding from well-documented intestinal AVMs when he obviously has bloody stool in his diaper?
Why the heck would you? You know he has a condition that makes him bleed. You know where it's probably coming from. You can see the blood in the diaper. The important issues are the hemoglobin and vital signs. Sticking your finger up his ass isn't going to change your management. And you certainly don't need to use an anoscope.
Same with menorrhagia patients, except for the different orifice.
Most of the Dr's I assist with pelvic exams also order GC/CT culture and wet prep. I guess you can't do that without a speculum. I know scalpel suggested getting the specimens from the gloves used in the bimanual exam, but I don't know if any tests have been done to show it was just as accurate as doing it the traditional way.
Our lab is pretty particular about how they get their specimens. I sent down one spec with both little swabs in and they sent it back because they said, 'One swab is to wipe the cervix first and the second to collect the specimen.' I kid you not.
"I agree that direct visualization of the cervix is mandatory in threatened miscarriage."
Completely agree. Although I think I've seen enough of these patients now to know who is incomplete and who is just threatened prior to the pelvic. There's just a different posture and affect to the ones that are in the middle of a miscarriage.
Otherwise, I can remember 2 times that the speculum exam was worthwhile:
-a lady with lower abd pain who had pus flowing from her cervix
-a perimenopausal lady with daily bleeding who had a giant fungating mass on her cervix.
That's out of hundreds of exams. So I don't know, really low yield but I'm glad I did it in those two cases.
On a same...yet oh so different note. When is the last time you guys have used the anoscope in the ER? I've only had a Doc ask for it once...that was two weeks ago.
When I was a resident on surgical service, I was called to ER to see a woman with painful rectal mass and fever. It was her cervix ,not a mass, felt through anterior rectal wall with pretty good CMT...Why would anyone do a rectal and not a pelvic in a case like that is beyond me.
Bottom line is, it's a judgment call. Always--that's what being the doc is about--making the judgment call, I think you agree. The PE has got to be focused, problem oriented and we decide what the focus is. Protocols only take you so far and provide a general standard.
You sound like an uncaring asshole!
Multiple studies have shown the inaccuracy of pelvic examinations in women, even under controlled conditions such as anaesthesia.
The deep anatomical location of the ovaries in the abdomen precludes easy examination and reduces examination sensitivity. This is particularly the case in the US, which has been labelled the "fattest country in the world".
Even so, the majority of pelvic masses found are either benign, or if malignant, advanced.
As far as DRE's are concerned a study by Campbell and Shaughnessy (1998) found that out of 272 rectal exams ZERO diagnostic findings were made. They did however discover incidental findings in seven patients (hemorrhoids, stool in rectum - fancy that!, and vaginal scar), and one confirmatory finding of colitis.
They concluded that a digital rectal examination should not be included as part of a routine gynecological examination unless a SPECIFIC diagnosis or condition is suspected.
There is also no scientific evidence to support the use of 'routine' vaginal examination during pregnancy. Clinical pelvimetry is not a valid means of predicting the outcome of labour.
Additionally, there is no scientific evidence that it reduces the risk of preterm labour, and nor does it have any effect on pregnancy outcome.
There is no scientific evidence to support the use of rectal exams as a means of assessing the cervix during pregnancy.
So as Allen said, lets relegate these to the dust bin...
Why is anyone performing a pelvic for suspected STD's? Just collect a 1st catch urine PCR GC/CT. Also, the patient can self collect a swab of any discharge, you don't need to be doing that for them.
A lot less invasive for the patient, and a hell of a lot quicker...
I was disturbed by American doctors.
I was astounded that women were brainwashed to believe their reproductive organs and breasts needed constant surveillance.
The fear, pain & harm these "routine" exams cause is awful.
I saw terribly distressed women returning from their first brutal gyn exam, one almost suicidal...yet not one woman was sympathetic, it was basically, get used to it, it's part of being a woman.
I was shocked with the dishonesty of doctors, openly lying to women.
Fact: No asymptomatic woman needs routine gyn exams EVER. It is inhuman to put women through invasive and harmful exams without a sound clinical reason. The clinical evidence for these exams is not there, they are of low/poor value in the absence of symptoms. Even virgins are included in this madness.
I was also dismayed to see the negligent over-screening of women for cervical cancer.
The clinical evidence is clear - screening is unsafe and unreliable in women under 25 (our doctors say 30)...all you do is cause harm sending most women for invasive, painful and harmful treatments.
The excess is so extreme in the States, I concluded this was an unethical use of all women to generate big profits. Many of these women are left with health problems after false positives and over-treatment. (infertility, miscarriages, problems during pregnancy, more c-sections, premature delivery/babies and psych problems)
This means 95% of US women will in their lifetime have an abnormal smear and be referred...this is with annual screening.
Two yearly - 77%...
(See Richard DeMay article at Dr Joel Sherman's medical privacy blog under women's privacy issues)
Dr Sherman is also the author of "Informed consent is missing from cervical screening" at the Kevin MD site.
Even responsible programs like Finland and the Netherlands that recommend 5 yearly smears from 30 - 5 to 7 tests in total - send 30%-55% of women for colposcopy and usually some sort of biopsy.
Around 95% of all referrals are for false positives.
Dr A Raffle, UK expert tells us 1000 women need regular screening for 35 years to save ONE woman from cervical cancer. (BMJ, 2003)
This testing MUST be used responsibly and with the woman's informed consent.
Your Dr's even use coercion to force these exams...they routinely deny women the Pill UNTIL they submit.
Birth control and cancer screening are unrelated...this is a paternalistic tactic to avoid informed consent.
With no screening at all, 1% of women would get this cancer.
Even with screening, one third of the 1% still get cancer (false negatives)...but women in the States (and elsewhere) are led to believe it's an epidemic and that abnormal smears mean cancer - they VERY rarely mean cancer.
Few women make their own healthcare decisions in the States, it's a militant, arrogant, paternalistic and very harmful business, totally devoid of medical ethics.
Misleading & scaring women and making money is the aim...if you hurt most of your patients, no problem....
The use of stirrups and the demands for routine unnecessary gyn exams shows a complete lack of respect for women.
No wonder your women have more hysterectomies than any other women in the world (600,000 every year) and huge numbers of gyn procedures. I lost count of the number of young women having LEEP, cone biopsies and other things...all completely unnecessary. Sometimes women of 23 were on their 3rd or 4th procedure. These women would not even be offered testing in my country.
The evidence is there, but your doctors choose to ignore it for their own benefit.
I have never had a routine pelvic exam, nor routine breast exam (they don't help, but cause biopsies) and have made an informed decision not to have cervical screening. (my risk is near zero, even responsible screening carries a high risk of a false positive and over-treatment)
It is shameful what is being done to American women and to call it women's healthcare is a cruel joke.
Please, get informed and fight back....
Went in to the er last sunday night from bleeding. Followed by feeling dizzy almost fainting sick to my stomach. They did an exam and took blood. Know would they be testing for stds? They didn't really say. The er dr just came back in and the test were all good know infections. Know by infections does he mean stds?
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