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Am Fam Physician. 1999;59(1):167-170

One fourth of sexually active adolescents will be infected each year with a sexually transmitted disease (STD). Early detection of STDs in female patients is critical in preventing sequelae such as pelvic inflammatory disease and infertility. Traditionally, evaluation for STDs required the patient to undergo a pelvic examination using a speculum, which may have been a deterrent for some patients. Urine-based nucleic acid amplification tests are able to diagnose chlamydial and gonorrheal infections without a speculum examination, leaving the question of whether such an examination is necessary for diagnosing other infections. Blake and colleagues studied this population to determine if various vaginal infections could be detected without the use of a speculum.

Female patients between 12 and 22 years of age who presented to a primary care clinic were included in the study if they required a pelvic examination during their visit. Information about the history of present illness was recorded, and the clinician performing the examination listed any positive vaginal or cervical findings. Before each speculum examination, a cotton swab was blindly inserted into the vaginal pool to collect vaginal secretions. Another swab was used to collect secretions along the anterior lateral vaginal wall and was then applied to phenaphthazine pH paper. During the speculum examination, standard specimens were collected for detection of trichomoniasis, bacterial vaginosis and vulvovaginal candidiasis. Another swab was used to collect vaginal pool secretions; this specimen was cultured for trichomoniasis. A final swab was used to collect a specimen from the anterior lateral vaginal wall and was evaluated for evidence of bacterial vaginosis by the Gram stain method.

For detection of trichomoniasis, the specimen collected by the speculum method was 75 percent sensitive and the specimen collected by the swab method was 77 percent sensitive. Of the 74 infections diagnosed by traditional speculum collection, 91 percent were also detected by the swab method. Sixty-seven of 99 patients had positive results by both methods. Similarly, sensitivity of detection of bacterial vaginosis was not significantly different for speculum and nonspeculum methods of collection. Again, the confidence interval was small enough to indicate that the speculum examination was unlikely to detect more infections than the swab method. For diagnosing vulvovaginal candidiasis, however, the authors found that although the difference between the speculum method and the swab method was not statistically significant, the speculum method may be more sensitive.

Previously undiagnosed cases of herpes or genital warts were not more likely to be detected using a speculum examination alone, since lesions characteristic of these conditions were found during external examination of the genitals. Also of note, the findings of cervical mucopus and cervical friability on speculum examination were not particularly sensitive or highly predictive in the diagnosis of cervicitis.

The authors conclude that evaluations for trichomoniasis, bacterial vaginosis and vulvo-vaginal candidiasis can be done reliably without a speculum examination. Once urine-based tests for gonorrheal and chlamydial infections are more widely available, it may be possible to perform routine STD evaluations without a speculum. Removal of obstacles to care (such as a pelvic examination) may be quite important in the early diagnosis and treatment of female patients with STDs.

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Copyright © 1999 by the American Academy of Family Physicians.

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