whither the pelvic, again


BMJ had a recent systemic review and meta-analysis of urinary screening for HPV (see hpv urine screen bmj 2014 in dropbox, or  doi: 10.1136/bmj.g5264), including 14 studies with 1443 women, comparing urine HPV DNA screen with cervical DNA screen. findings:

--urine detection of HPV had a pooled sensitivity of 87% (CI: 78-92%), and specificity of 94% (CI: 82-98%)
--urine detection of high risk HPV (15 serotypes assessed) had a pooled sensitivity of 77% (CI: 68-84%), and specificity of 88% (CI: 58-97%)
--urine detection of HPV 16/18 (the worst of the high-risk) had a pooled sensitivity of 73% (CI: 56-86%), and specificity of 98% (CI: 91-100%)
--translation of above: the high specificity suggests that positive test results are 15 times more likely to occur in HPV positive women; the less-high sensitivity suggests that a negative test results would happen only 7 times more frequently in non-infected women. for those with HPV​ 16/18, positive test results are 37 times more likely to occur in HPV positive women and negative test results would happen only 4 times more frequently in non-infected women.
--sensitivity for urinary HPV testing increased with first void urine, on meta-regression analysis
so, we have moved away from annual pelvic exams for pap smears and gc/ct (gonorrhea/chlamydia) screening of yore to much less frequent pap smears (beginning later, at age 21, and with frequency of every 3-5 years depending on age and HPV testing, and with several European countries currently assessing doing only HPV testing without cytology). and now perhaps we are moving to just doing urine testing for HPV in the future, maybe even as a sole initial screen. And we have transitioned from cervical gc/ct screening to urine gc/ct tests. in addition, women with vaginal discharges are often appropriately self-treating (eg for yeast) or getting medications for various infections without pelvic exams (eg, urine testing for trichomonas, or simply empiric therapy for bacterial vaginosis/BV). as a result, as clinicians we certainly are doing many fewer pelvic exams now as compared to a couple of years ago. though, clearly, pelvic exams are invasive, uncomfortable procedures that many women would love to avoid, i do have one caveat. i have seen several episodes where a woman has potential PID and the clinician is comfortable with just sending a urine for GC/chlamydia. the issue here is that GC and chlamydia are not the only culprits (the data are a bit murky here, since there are so many potentially infectious pathogens in the vagina, but it is likely that PID is caused by mycoplasmas, ureoplasmas, BV, and, very often, mixed organisms - both aerobic and anaerobic). and there can be other causes of acute pelvic pain besides PID (eg, ovarian cysts, appendicitis, endometriosis, assorted GI problems including bowel obstruction and constipation...). again, i think it is great that we clinicians need to do fewer pelvic exams. my concern is that this mind-set may lead to not doing one when it is clinically indicated.

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