Is PID a consideration for GPs, and what are their practices around diagnosis?

Problem

Pelvic Inflammatory Disease (PID) comprises a range of inflammatory disorders of the upper female genital tract and can lead to reproductive complications. Sexually transmissible infections (STIs) are often implicated as a cause. Diagnosing PID is challenging due to the wide variety of symptoms and severity. This can lead to under-diagnosis. Speculum and bimanual examinations are recommended to support PID diagnosis in women considered at risk and who report recent onset pelvic pain. There is limited evidence regarding general practitioner (GP) PID diagnosis practices. We investigated the PID diagnosis practices of GPs in Australia.

Approach

An online survey about chlamydia management was distributed in 2019 to GPs in Australia. It included Likert scale questions pertaining to investigating PID symptoms in women diagnosed with chlamydia, the frequency GPs conduct pelvic examinations for women reporting pelvic pain or dyspareunia, and a free-text question about barriers to performing pelvic examinations. From 323 respondents, 85.8% (n=277) responded to quantitative questions about PID and 74.6% (n=241) provided 452 comments regarding pelvic examination barriers. Adjusting for gender, age and additional sexual health training/education we used multivariable logistic regression to analyse factors associated with the frequency that GPs conducted pelvic examinations. Barriers to performing pelvic examinations were explored using thematic analysis.

Findings

Most GPs reported they frequently asked patients with an STI about symptoms suggestive of PID, including pelvic pain (86.2%), abnormal vaginal discharge (95.3%), dyspareunia (79.6%), and abnormal vaginal bleeding (89.5%). Over half reported they would frequently conduct speculum (69.0%) or bimanual (55.3%) examinations for women reporting pelvic pain. Multivariable analysis found female GPs were more likely to frequently perform speculum (adjusted odds ratio, AOR: 4.6, 95% CI 2.6-8.2) and bimanual examinations (AOR: 3.7, 95% CI 2.1-6.5). GPs with additional sexual health training/education were more likely to perform speculum (AOR: 2.2, 95% CI 1.1-4.2) and bimanual examinations (AOR: 2.1, 95% CI 1.2-3.7).Of the free-text comments, the most common barrier focused on was a lack of patient consent or desire to proceed with a pelvic examination, highlighting the need for further research into patient perspectives and expectations of pelvic examinations outside of cervical screening. Other barriers included GP gender, concerns about patient health, time pressures, and GP reluctance to perform examinations due to inexperience and/or a lack of certainty that an examination would add value to their assessment. This experience was not universal, however, with several GPs reporting that they did not face barriers to performing pelvic examinations.

Consequences

Under-diagnosis of PID is a global issue, and results in reproductive complications including chronic pain and infertility. While GPs typically ask about PID symptoms when managing patients with chlamydia, they are not consistently able or willing to perform pelvic examinations to support a diagnosis, potentially reducing capacity to diagnose PID.