The End of the “Emergency” Pelvic Exam

Enthusiasm, as measured by time-to-provider, for performing a pelvic examination in the Emergency Department is low. The logistics of a comfortable, adequate examination can be time consuming and detract from patient throughput. The yield of such examination is thought to be poor – enough so many providers, even absent sufficient evidence, choose to forgo the examination whenever reasonable, and depend on symptoms or advanced imaging to complete the evaluation.

This study aims to determine the acceptableness of the practice of forgoing the pelvic examination in a subset of vaginal complaints, those presenting with vaginal bleeding or abdominal pain in early pregnancy. From an ED standpoint, the typical most worrisome consideration is an ectopic pregnancy, with other diagnostic considerations important, but less salient. These authors developed a protocol in which women of fewer than 16 weeks gestation could be randomized to assessment with pelvic examination omitted or not. Their primary outcome was a composite pregnancy morbidity and utilization outcome at 30 days, with the trial designed to evaluate statistical equivalence between the two strategies.

Unfortunately, we have to give this trial a grade of “incomplete” for its ability to answer the research question – not the least because they under-enrolled their study cohort by over 500 patients. Of a planned enrollment of 720, they were only able to capture 202 due to slow enrollment due to a variety of factors. Furthermore, even if they had met their enrollment, I’m uncertain whether their composite outcome – chosen, almost certainly, to reduce the sample size needed to detect already rare outcomes – is clinically meaningful. Some elements of their composite morbidity outcome – unscheduled ED visits, hospital admissions, procedures relating to pregnancy – are of uncertain relationship to the decision to provide or withhold a pelvic examination at the time of first encounter. The most relevant of their composite is undoubtedly the identification of an alternative symptom source, but, again, this would require additional enrollment to detect a difference in such an infrequent outcome. Of the 202 patients included, 2 of 100 in the pelvic examination cohort had an alternative source for symptoms identified, but these are not specifically commented upon in the text.

Secondary outcomes relating to ED throughput and patient satisfaction favored the cohort omitting the pelvic examination, only ED length of stay suggests a potentially meaningful difference of approximately 20 minutes (not reaching statistical significance). Patient perceptions and concerns over embarrassment were not consistent across measures and assessment and probably not reliable.

Generally speaking, this study probably provides evidence supporting a strategy in which pelvic examinations are omitted, but this evidence is quite weak. The clinical significance of the information gleaned from a pelvic examination is unlikely to be of substantial clinical interested except in rare cases, and I would suggest the next steps in observational research to be to evaluate the clinical features of patients whose diagnosis or plan of care is changed by the pelvic examination.

“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”
http://www.annemergmed.com/article/S0196-0644(17)31387-2/fulltext

 

3 thoughts on “The End of the “Emergency” Pelvic Exam”

  1. It’s like we’ll do whatever we can to get out of the pelvic exam. I get it–I really do. It takes time to marshal the RN or tech “chaperone,” nobody can ever find the pelvic light, and there’s probably few things as off-putting to the patient as me covering an upside-down bedpan with a sheet and shoving it underneath them. And this study seems to recognize those things, with a signal that the pelvic exam contributes to patients reporting feeling uncomfortable or embarrassed versus those who get poorer care (oh, wait, my bias slipped out there).

    But for so many of my patients, I’m the only step along the path between the pregnancy test and the delivery room. It’s terrible and awful, and I’m a worse OB/GYN than I am a pediatrician, but I think until that time when next-day obstetrics appointments and walk-in GYN clinics become the norm, I’m still going to need my speculum holster. How could I justify allowing that Trich to end a pregnancy early, just because my patient never made it to a first trimester OB visit? What if I can save even one kid from being born with chlamydia? Doesn’t an open os lead to a different conversation with the patient than a closed one?

    I don’t fault anyone for omitting it, and I know that I stand on shaky and biased ground when I hold them up as my “standard.” But in the end, I’m just a guy trying to give everyone the best care in the best way I know how, and I think until we have better data (or until we have more information on features suggesting increased utility of the exam, as you say), that will still include the pelvic exam.

    1. Great perspective, Rick. These data definitely don’t generalize to every patient in every situation – and, you’re absolutely correct the calculus changes if you’re the only “OB” the patient will see.

Leave a Reply

Your email address will not be published. Required fields are marked *