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1、SOGC COMMITTEE OPINIONNo.385,August 2019No.385-Indications for Pelvic ExaminationAbstractObjective:The primary objective of this document is to clarify theindications for pelvic examination.It is SOGC policy to review the content 5 years after publication,at which time the document may be re-affirme
2、d or revised to reflectemergent new evidence and changes in practice.This Committee Opinion has been prepared by the Society ofObstetricians and Gynaecologists of Canada(SOGC)s ClinicalPractice Gynaecology Committee,reviewed by the SOGCsFamily Physician Advisory;Canadian Paediatric and AdolescentGyn
3、aecology and the College of Family Physicians of Canada(CFPC)Maternal and Newborn Care Program Committee;andGuideline Management and Oversight Committees and approvedby the Board of the SOGC and the Society of GynecologicOncology of Canada(GOC).Devon Evans,MD,Winnipeg,MB(SOGC)Susan Goldstein,MD,Toro
4、nto,ON(SOGC/CFPC)Amanda Loewy,MD,Saskatoon,SK(CFPC)Alon D.Altman,MD,Winnipeg,MB(GOC)Clinical Practice Gynaecology Committee:Alaa Awadalla,MD,Winnipeg,MB;Annette Bullen,RN,Caledonia,ON;Devon,Evans,MD,Winnipeg,MB;Susan Goldstein,MD,Toronto,ON;Nicholas Leyland,MD,Hamilton,ON;Ally Murji,MD,Toronto,ON;Da
5、vid Rittenberg,MD,Halifax,NS(co-chair);Jackie Thurston,CHANGES IN PRACTICE1.Women undergoing cervical cytology screening may benefitfrom screening visual and bimanual exam.2.Women 70 years and older may be periodically screened forbenign or malignant vulvar disease.KEY MESSAGES1.Symptomatic gynaecol
6、ogic complaints must be investigatedwith pelvic exam.2.No study published to date has adequately evaluated thepelvic exam as a screening method.3.Current task force statements on pelvic exam should not beinterpreted to mean it is noncontributory to care.4.No pelvic exam is required before prescripti
7、on of hormonalcontraception for healthy women.MD,Calgary,AB;Wendy Wolfman,MD,Toronto,ON(co-chair);Grace Yeung,MD,Toronto,ON;Paul Yong,MD,Vancouver,BC;Andrew Zakhari,MD,Montreal,QCDisclosure statements have been received from all authors.Key Words:Pelvic examination,bimanual examination,speculum exam
8、ination,rectovaginal examination,periodic healthexamination,ovarian cancer screening,asymptomatic womenJ Obstet Gynaecol Can 2019;41(8):12211234https:/doi.org/10.1016/j.jogc.2018.12.007 2019 The Society of Obstetricians and Gynaecologists of Canada/LaSocit des obsttriciens et gyncologues du Canada.P
9、ublished byElsevier Inc.All rights reserved.This document reflects clinical and scientific consensus on the date issued and is subject to change.The information should not be construed asdictating an exclusive course of treatment or procedure to be followed.Local institutions can dictate amendments
10、to these opinions.They shouldbe well-documented if modified at the local level.None of these contents may be reproduced in any form without prior written permission of thepublisher.All people have the right and responsibility to make informed decisions about their care in partnership with their heal
11、th care providers.In order tofacilitate informed choice,patients should be provided with information and support that is evidence-based,culturally appropriate,and tailored totheir needs.This guideline was written using language that places women at the centre of care.The SOGC is committed to respect
12、ing the rights of allpeople including transgender,gender non-binary,and intersex people for whom the guideline may apply.We encourage health careproviders to engage in respectful conversation with patients regarding their gender identity and their preferred gender pronouns to be usedas a critical pa
13、rt of providing safe and appropriate care.The values,beliefs,and individual needs of each patient and their family should besought and the final decision about the care and treatment options chosen by the patient should be respected.AUGUST JOGC AOUT 2019?1221http:/ Users:Physicians,including gynaeco
14、logists,obstetricians,family physicians,and emergency physicians;nurses,includingregistered nurses and nurse practitioners;midwives,includingmidwives in clinical practice and midwifery trainees;medicaltrainees,including medical students,residents,and fellows;and allother health care providers who ca
15、re for women.Target Population:This publication provides evidence and expert-based recommendations for pelvic examination in adult women(18 years and older)both with and without gynaecologicsymptoms.Outcomes:This publication clarifies indications for pelvic examinationin the context of recently publ
16、ished national task force statementson the utility of pelvic examination.We aim to ensure that womenwho have clinical indications for examination receive proper clinicalinvestigation with minimal delays to diagnosis of treatable disease.Evidence:For this committee opinion,relevant studies were ident
17、ifiedin PubMed and Medline using the following terms,either alone or incombination,with the search limited to English-language materialsand human subjects and no publication date cut-off:pelvicexamination,bimanual examination,speculum examination,rectovaginal examination,ovarian cancer screening,asy
18、mptomaticwomen,periodic health examination.The search was performed inMay and June 2018.Relevant evidence was selected for inclusionin the following order:meta-analyses,systematic reviews,guidelines and national task force statements,randomizedcontrolled trials,prospective cohort studies,observation
19、al studies,non-systematic reviews,case series,and reports.Additional articleswere identified by cross-referencing the identified publications.Aformal systematic review was not conducted for all topics discusseddue to the paucity of evidence and number of different subtopicsdiscussed.The total number
20、 of publications included in this reviewwas 66.Validation Methods:The content and recommendations weredrafted and agreed upon by the principal authors.The Boards ofthe Society of Gynecologic Oncology of Canada(GOC),theCollege of Family Physicians of Canada(CFPC),and theSociety of Obstetricians and G
21、ynaecologists of Canada(SOGC)approved the final draft for publication after review by theirrespective representative committees.The quality of evidencewas rated using the criteria described in the Grading ofRecommendations Assessment,Development and Evaluation(GRADE)methodology framework(Tables 1 an
22、d 2).TheSummary of Findings is available upon request.Benefits,Harms,and Costs:This committee opinion should benefit allwomen with and without gynaecologic symptoms who present togynaecologists and primary care practitioners.It will help guidepractitioners in identifying indications for pelvic exami
23、nation toreduce unnecessary examination with related potential harm whilealso increasing indicated examination to reduce delays in diagnosisof treatable gynaecologic conditions.Guideline Update:This SOGC Committee Opinion will beautomatically reviewed 5 years after publication to determine if all or
24、part of the committee opinion should be updated.However,thisreview may be performed earlier if new high-impact research ispublished in the interim.SUMMARY STATEMENTS:1.National and international statements and guidelines on pelvicexamination should not be interpreted to suggest that the pelvicexamin
25、ation is irrelevant or noncontributory to physical assessmentor that the pelvic examination in symptomatic women should beomitted.2.Pelvic examination may include visual inspection,speculum exami-nation,bimanual examination,single digit examination,and/or rec-tovaginal examination depending on the i
26、ndication for examination.3.No study published to date has adequately evaluated any compo-nent of the pelvic examination as a screening method for any typeof malignant gynaecologic disease,except for the speculum exami-nation for cervical cancer cytology screening.As such,any univer-sal recommendati
27、ons for or against pelvic examinations for otherindications can only be made based on expert opinion and low-qual-ity evidence.4.In asymptomatic women at average risk for cervical cancer,cervicalcytology screening reduces both the incidence of,and mortalityfrom,cervical cancer by detecting pre-invas
28、ive,treatable lesions.5.In asymptomatic women at average risk of malignancy,a visual andbimanual examination at the time of obtaining cervical cytologysamples may add value to this screening manoeuvre:Women mightnot raise certain gynaecologic concerns until the time of pelvicexamination;the examinat
29、ion provides an opportunity for patienteducation and practitioner skill maintenance;and,although inade-quately studied to date,there may be positive effects on ovarianand vulvar malignancy that require further investigation.Thesepotential benefits should be weighed against potential harms likepatien
30、t discomfort and false positives/negatives that may result ininappropriate reassurance or unnecessary investigations/interven-tions.RECOMMENDATIONS:Symptomatic Women1.Any woman with gynaecologic complaints including,but not limitedto,vulvar complaints,vaginal discharge,abnormal premenopausalbleeding
31、,postmenopausal bleeding,infertility,pelvic organ prolapsesymptoms,urinary incontinence,new and unexplained gastrointes-tinal symptoms(abdominal pain,increased abdominal size/bloating,and difficulty eating/early satiety),pelvic pain,or dyspareuniashould undergo appropriate components of the pelvic e
32、xaminationto identify benign or malignant disease(strong,low).2.Health care providers may consider discussing the risks and bene-fits of performing a baseline pelvic examination including visual andbimanual examination prior to prescribing hormonal replacementtherapy/menopausal hormonal treatment(we
33、ak,very low).Asymptomatic Women3.Health care practitioners should perform cervical cytology cancerscreening in accordance with provincial/territorial guidelines(strong,strong).4.There is insufficient evidence to guide recommendations on screen-ing pelvic examination for noncervical gynaecologic mali
34、gnancy orany benign gynaecologic disease in healthy,asymptomatic womenwith average risk of malignancy.However,health care practitionersmay consider performing a screening pelvic examination includingvisual,speculum,and bimanual examinations in concert with cervi-cal cytology sampling intervals as re
35、commended by provincial/terri-torial guidelines.This practice may identify clinically importantbenign or malignant disease not recognized or reported by thepatient(weak,very low).5.In women over age 70 who no longer require screening with cervicalcytology,health care practitioners should consider co
36、ntinuing periodicscreening of asymptomatic women for vulvar disease with inspectionof the vulva,perineum,and anus to identify benign or malignant dis-ease unrecognized by this population.There is insufficient evidence toguide recommendations on frequency of this examination(weak,low).6.Women with a
37、personal history of gynaecologic malignancy,agenetic diagnosis that increases gynaecologic malignancy risk,or ahistory of in utero diethylstilbestrol exposure may benefit from moreSOGC COMMITTEE OPINION1222?AUGUST JOGC AOUT 2019http:/ screening pelvic examinations to identify early primary,recurrent
38、,or metastatic malignancy in the absence of symptoms.Because there is inadequate evidence to define these screeningintervals,they should be in accordance with provincial/territorialguidelines and expert opinion(weak,very low).7.Non-invasive and self-collection screening options for chlamydiaand gono
39、rrhea are acceptable in asymptomatic women,but pelvicexamination,including visual inspection,speculum examination,and bimanual examination,is required in the presence of symptomsto rule out pelvic inflammatory disease or tubo-ovarian abscess(strong,low).8.No pelvic examination is required prior to p
40、rescription of hormonalcontraception in a healthy woman with no gynaecologic symptoms(strong,low).Table 2.Judgement and interpretation of strong and conditional recommendationsJudgement/interpretationStrong recommendation“We recommend.”Conditional recommendation“We suggest.”Judgement by guideline pa
41、nelIt is clear to the panel that the net desirable con-sequences of a strategy outweighed the con-sequences of the alternative strategy.It is less clear to the panel whether the net desir-able consequences of a strategy outweighedthe alternative strategy.Implications for patientsMost individuals in
42、this situation would want therecommended course of action,and only asmall proportion would not.Most individuals in this situation would want thesuggested course of action,but many wouldnot.Implications for cliniciansMost individuals should receive the intervention.Adherence to this recommendation ac
43、cordingto the guideline could be used as a quality cri-terion or performance indicator.Clinicians should recognize that differentchoices will be appropriate for each individualand that clinicians must help each individual toarrive at a management decision consistentwith his or her values and prefere
44、nces.Implications for policy makersThe recommendation can be adopted as policyin most situations.Policy making will require substantial debateand involvement of various stakeholders.From Sch unemann et al.13Table 1.Key to Grading of Recommendations,Assessment,Development and Evaluation(GRADE)Strengt
45、h of therecommendationDefinitionStrongHighly confident of the balance between desirable and undesirable consequences(i.e.,desirable consequencesoutweigh the undesirable consequences;or undesirable consequences outweigh the desirable consequences).Conditional(weak)aLess confident of the balance betwe
46、en desirable and undesirable consequences.Quality level of a bodyof evidenceDefinitionHighj+We are very confident that the true effect lies close to that of the estimate of the effect.Moderatej+0We are moderately confident in the effect estimate:The true effect is likely to be close to the estimate
47、of the effect,but there is a possibility that it is substantially different.Lowj+00Our confidence in the effect estimate is limited.The true effect may be substantially different from the estimate ofthe effect.Very lowj+000We have very little confidence in the effect estimate:The true effect is like
48、ly to be substantially different from theestimate of effect.aConditional(weak)recommendations should not be misinterpreted as weak evidence or uncertainty of the recommendation.From Sch unemann et al.13No.385-Indications for Pelvic ExaminationAUGUST JOGC AOUT 2019?1223http:/ female pelvic examinatio
49、n has been an integralcomponent of the periodic health examination forasymptomatic,healthy women at average risk of malig-nancy for decades.1Components of the examination,which may include visual inspection of the perineum/vulva/vagina/urethral meatus/anus;speculum examina-tion of the vagina and cer
50、vix;bimanual assessment of thevagina,cervix,uterus,and adnexa;single digit examinationof the pelvic muscles and viscera;and rectovaginal exami-nation,are also often performed to investigate commonsymptoms of infectious,inflammatory,and other benignand malignant diseases.These examinations may be per