Clinical Inquiries

Do annual pelvic exams benefit asymptomatic women who receive regular Pap smears?

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References

EVIDENCE-BASED ANSWER:

No evidence exists to support a clinical benefit from annual pelvic examinations for asymptomatic women who receive Pap smears every 3 to 5 years. However, the American College of Obstetricians and Gynecologists (ACOG) committee on gynecologic practice recommends annual pelvic exams (strength of recommendation [SOR]: C, expert opinion).

Urine testing alone reliably diagnoses gonorrhea and chlamydia (SOR: A, systematic review of cohort studies).

Pelvic examinations unreliably detect adnexal masses (SOR: B, single cohort study); pelvic exams accompanied by ultrasound fail to affect outcomes in ovarian cancer screening (SOR: B, cohort studies).

Pelvic exams aren’t necessary before prescribing oral contraceptive pills (OCPs) (SOR: C, expert opinion).

Vulvar carcinoma has a low prevalence and is usually symptomatic (SOR: B, ecologic study and a case series).

EVIDENCE SUMMARY

A systematic review and meta-analysis included 29 studies that compared the sensitivity and specificity of nucleic acid amplification tests on specimens collected invasively from the cervix or urethra with noninvasively collected urine specimens.1 Studies included both asymptomatic and symptomatic patients. Reference standards varied and included cervical culture, enzyme immunoassay, direct fluorescent antibody, ligase chain reaction, and positive results on 2 of 3 nucleic acid amplification assays.

The sensitivity and specificity of chlamydia and gonorrhea detection didn’t differ between urine and cervical specimens. The pooled sensitivity and specificity for polymerase chain reaction urine samples were 83.3% (95% confidence interval [CI], 77.7%-88.9%) and 99.5% (CI, 99.3%-99.8%), respectively, and for cervical samples 85.5% (CI, 80.3%-90.6%) and 99.6% (CI, 99.4%-99.8%), respectively.1

Pelvic exams detect adnexal masses, but not reliably

A prospective cohort of 127 women undergoing pelvic surgery had preoperative bimanual exams under anesthesia to detect an adnexal mass.2 The gold standard for detection was findings at surgery. The woman had a high prevalence (20%) of ovarian masses. Indications for surgery included diagnosis, sterilization, and suspected malignancy.

When the preoperative bimanual examination detected a left adnexal mass, the odds of finding one at surgery increased 2.8 times, whereas when the exam was normal the odds decreased by 0.8 (positive predictive value [PPV]=0.64; 95% CI, 0.45-0.83). Conversely, the preoperative examination failed to correctly predict a right adnexal mass regardless of the result; the likelihood ratio for both normal and abnormal right adnexal examinations was 1 (PPV=0.26; 95% CI, 0.12-0.47).

Evidence-based answers from the Family Physicians Inquiries Network

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