TOP 22 - Do Pelvic Examinations in Adolescents Change Clinical Decision-Making in the Pediatric Emergency Department?

Publication Number: 4725.TOP 22

Payal M. Shah, Jacobi Medical Center, Hoboken, NJ, United States; Haamid Chamdawala, Albert Einstein College of Medicine, New York City, NY, United States; Fabliha Hussain, Albert Einstein College of Medicine, Bronx, NY, United States; Tanner W. Mercer, Albert Einstein College of Medicine, The Bronx, NY, United States

Background: American Academy of Pediatrics guidelines recommend performing a pelvic examination, defined as a bimanual and speculum examination, for an adolescent female with gynecologic or obstetric symptoms. Pelvic exams, however, are invasive, anxiety-provoking, and have low inter-rater reliability in the emergency department (ED). Noninvasive urine and self-collected vaginal-swab testing accurately detect sexually transmitted and non–sexually transmitted infections (STI), while ultrasonography and quantitative Beta-Human Chorionic Gonadotropin (β-hCG) assays aid in evaluating early pregnancy complications. Therefore, the clinical necessity of pelvic exams in the pediatric ED warrants reevaluation.

Objective: To assess the impact of pelvic examinations on diagnosis and treatment decisions for adolescent females presenting with gynecologic or obstetric complaints.

Design/Methods: This is an ongoing prospective observational study of clinicians in an urban pediatric ED caring for sexually active females aged 14–20 years who present with lower abdominal pain, vaginal discharge, or abnormal vaginal bleeding. Sexual assault cases are excluded. The study is IRB approved, and enrollment began in July 2025. Participants include pediatric emergency medicine (PEM) fellows and attendings, EM residents, and nurse practitioners (NPs). After obtaining a patient history and before performing a physical exam, clinicians complete a standardized questionnaire documenting patient demographics and presenting complaints. If available, point-of-care urinalysis and β-hCG results are recorded. Clinicians then rate, on a 1–10 Likert scale, the likelihood of specific diagnoses (i.e., cervicitis/vaginitis, pelvic inflammatory disease, pregnancy-related conditions, abnormal uterine bleeding, or urinary tract infection) and select diagnostic and treatment options from predefined lists. Performing a pelvic examination (speculum and/or bimanual) and ordering tests or treatments are at the clinician’s discretion. If the clinician performs either a speculum or bimanual exam, the same questionnaire and Likert scale are repeated after each exam. Electronic medical records are reviewed for STI results, and follow-up calls at 1–2 weeks assess persistent symptoms, treatment adherence, and revisits. The primary outcome is the percentage of encounters in which the clinician’s diagnosis or treatment changed after the pelvic exam. Secondary outcomes include assessing the appropriateness of diagnosis or treatment changes following pelvic examinations based on follow-up findings, and identifying factors associated with exam deferral.