Questioning the Utility of the ER Pelvic Exam
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?