We are no stranger to controversial subjects here at TOTAL EM, but one that already has a significant division in emergency medicine is the use of pelvic exams. Most people fall into one of two camps: to do one, or not to do one in the event of vaginal bleeding. The big factor in more recent medical history has been with the availability of ultrasound to supplement or fully replace the pelvic exam. Michelle Perkins, who has co-authored some of our most well visited posts, joins us in this discussion.
As a quick note, information is grouped not only in the way it was presented in the podcast but also by the papers cited. Please see the link at the beginning of each set for more information.
Medical myth: Bimanual pelvic examination is a reliable decision aid in the investigation of acute abdominal pain or vaginal bleeding.
1. Bimanual pelvic examination has been long considered necessary both in pregnant and non-pregnant women with abdominal pain or vaginal bleeding. It has been assumed to have benefit to help identify abnormal pregnancy, potential abortion, ovarian torsion, pelvic inflammatory disease, (PID), or pelvic abscess along with other non-pelvic causes such as appendicitis and pyelonephritis.
2. The bimanual exam is unreliable and insensitive with a number of variables including cervical motion tenderness (CMT), adnexal or uterine tenderness, and adnexal mass.
3. No combination of historical or physical exam findings can reliably rule out ectopic pregnancy.
4. An open cervical os is not diagnostic for an abnormal pregnancy.
5. The pelvic exam is not something that is easy to define normal versus abnormal. There is generally poor agreement between clinicians on what defines a normal versus abnormal exam based on findings present which can lead to a variation in decision making. In certain studies 2/3 of surgically identified masses were missed on exam and 3/4 of patients thought to have a mass were misdiagnosed.
6. No matter the level of experience, examination of the female pelvis is not sufficient to base clinical decisions.
Vaginal examination does not improve diagnostic accuracy in early pregnancy bleeding.
1. Even a positive examination for abnormal findings does not ensure a diagnosis but only helps raise suspicion. The same suspicion that can usually be obtained via other means especially ultrasound.
2. A negative examination does not rule out pathology and more definitive studies such as ultrasound is more appropriate.
3. Pelvic examination in the emergency department (ED) is invasive, distressing (during an already unpleasant time), uncomfortable, resource heavy, and time consuming. Routine vaginal examination is not necessary in the stable first trimester bleeding patient during their ED assessment. Examination is unlikely to influence management in any meaningful way.
Pelvic examination is unnecessary in pregnant patients with a normal bedside ultrasound.
1. Those patients with an ultrasound confirmed viable pregnancy will not find benefit in the addition of a pelvic exam when it comes to immediate obstetric management. A pelvic examination only provides indirect information about the pregnancy and is not reliable.
2. Even if a cervical os is found to be open, watchful waiting is usually the first step until the patient has specialist follow-up.
3. Point of care ultrasound (POCUS) is sufficient and has been using to risk stratify patients in lieu of a pelvic exam by both physicians and physician assistants at up to 20 weeks in pregnancy.
4. Although the pelvic exam can be skipped, if there is concern for sexually transmitted infections urine testing can be performed such as those that are commercially available in many countries.
Review article: The use of pelvic examination within the emergency department in the assessment of early pregnancy bleeding.
1. Multiple studies have demonstrated the benefits of ultrasound, but add in beta human chorionic gonadotropin (beta hCG) assays and this is considered sufficient in most cases to avoid the need of pelvic examination including via bimanual and speculum.
2. This is important since ectopic pregnancy cannot be identified by clinical examination alone. For example, the classic triad of pain, vaginal bleeding, and adnexal mass is actually more common in miscarriage.
3. Although POCUS can be performed, transvaginal ultrasound (TVUS) in conjunction with beta hCG has proven to be much more sensitive and specific in detection of ectopic pregnancy. It is worth mentioning that no beta hCG is sufficient to rule out ectopic pregnancy.
4. Speculum examination may be beneficial in those with severe bleeding or hypotension as it can be crucial in both diagnosis and management. If part of the concern is for cervical cancer or other lesions, specialists are more beneficial to evaluate this issue. Either way, those who are at highest risk would benefit more from specialist evaluation.
5. Overall though, risk stratification is not effective to help differentiate patients. Again, it appears that ultrasound and beta hCG appear to be more accurate measures than a pelvic exam. This is true for a number of obstetric complaints including ectopic pregnancy, diagnosis of miscarriage versus viable pregnancy, and identification of other causes of early pregnancy bleeding.
Is the pelvic examination still crucial in patients presenting to the emergency department with vaginal bleeding or abdominal pain when an intrauterine pregnancy is identified on ultrasonography? A randomized controlled trial.
1. The largest randomized controlled trial (RCT) to date was performed in the United States and further supported the benefits of ultrasound. Foregoing the pelvic exam did not result in increase morbidity but led to increased patient satisfaction.
2. An interesting side note, most patients who refused to enter the study for a specific reason did so because they did not want a pelvic exam performed.
3. At this stage, pelvic examination should not be a routine part of the management of patients with vaginal bleeding or lower abdominal pain. The exceptions are for those who do not have access to ultrasound, beta hCG testing, or there are specific clinical concerns (cancer, trauma, or infection).
Also make sure to check out the ACEP clinical policy regarding this subject with some additional key points such as when to avoid a pelvic exam for risk of complications.
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