Diagnosis of pelvic inflammatory disease and barriers to conducting pelvic examinations in Australian general practice: findings from an online survey

Abstract

Background Pelvic inflammatory disease (PID) is under-diagnosed globally, particularly in primary care, and if untreated may cause reproductive complications. This paper investigates PID diagnosis by Australian general practitioners (GPs) and barriers to their conducting a pelvic examination. Methods: An online survey investigating Australian GPs’ chlamydia management, including PID diagnosis, was conducted in 2019. From 323 respondents, 85.8% (n = 277) answered multiple-choice questions about PID and 74.6% (n = 241) answered a free-text question about barriers to conducting pelvic examinations. Using multivariable logistic regression, we identified factors associated with conducting pelvic examinations. Barriers to performing pelvic examinations were explored using thematic analysis. Results: Most GPs indicated that they routinely ask female patients with a sexually transmissible infection about PID symptoms, including pelvic pain (86.2%), abnormal vaginal discharge (95.3%), abnormal vaginal bleeding (89.5%), and dyspareunia (79.6%). Over half reported routinely conducting speculum (69.0%) and bimanual pelvic (55.3%) examinations for women reporting pelvic pain. Female GPs were more likely to perform speculum [adjusted odds ratio (AOR) 4.6; 95%CI: 2.6–8.2] and bimanual pelvic examinations (AOR 3.7; 95%CI: 2.1–6.5). GPs with additional sexual health training were more likely to routinely perform speculum (AOR 2.2; 95%CI: 1.1–4.2) and bimanual pelvic examinations (AOR 2.1; 95%CI: 1.2–3.7). Barriers to pelvic examinations were patient unwillingness and/or refusal, GP gender, patient health-related factors, time pressures, and GP reluctance. Conclusion: Although 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.

Is there a place for a molecular diagnostic test for pelvic inflammatory disease in primary care? An exploratory qualitative study

“…All clinicians acknowledged that there is a degree of uncertainty when diagnosing PID, and some considered how diagnosis can be especially challenging for clinicians with less experience. This perception is reflected in other literature; some Australian clinicians who infrequently perform bimanual pelvic examinations have reported low levels of confidence in interpreting findings, [ 9 ] and less experienced clinicians have demonstrated lower levels of diagnostic ability for PID [ 8 ].…”

“…This is unsurprising, as clinicians who responded to the study advertisement are likely to have been interested in sexual and reproductive health. We interviewed only one male clinician and it is clear that male GPs face additional barriers to conducting pelvic examinations; our previous research found male GPs less likely to perform pelvic examinations on symptomatic women than female GPs [ 9 ]. Our findings are therefore not generalisable to all Australian primary care clinicians, and we were not able to explore the perspectives of clinicians working in a wide range of clinical settings.…”

“…Furthermore, findings from UK-based research suggest that variability may be related to clinician experience; inexperienced clinicians were found to have lower levels of diagnostic acumen, both under and over-diagnosing PID [ 8 ]. Our recent research also suggests that some Australian general practitioners (GPs) lack experience and confidence with interpreting findings from bimanual pelvic examinations, an important component of the clinical diagnosis [ 9 ].…”

Chlamydia prevention and management in Australia: reducing the burden of disease

“…PID is predominantly diagnosed according to clinical signs and symptoms; however, clinical diagnosis can be challenging due to the diverse range of clinical presentations. A more definitive investigation such as laparoscopy is considered a more invasive and resource‐intensive test, and usually not requested in general practice unless for more complicated infections with poor treatment response 17 . Further, many general practitioners cite that the need for a pelvic examination can be a barrier to diagnosis 17 …”

Management of Chlamydia Cases in Australia (MoCCA): protocol for a non-randomised implementation and feasibility trial

“… 9 20 While acknowledging the risk for PID is likely to be higher for women attending sexual health clinics, other Australian data show general practitioners (GPs) have expressed hesitancy in conducting pelvic examinations to support a PID diagnosis, potentially reducing their capacity to diagnose PID. 21 Interventions for strengthening chlamydia management (eg, mailed specimen kits, links to partner notification websites in chlamydia test results) have improved retesting and uptake of partner notification discussions in specialist sexual health and family planning clinics. 22 23 Patient-delivered partner therapy (PDPT), a method of expediting partner treatment, has been shown to be effective at reducing reinfection and acceptable to patients and partners.…”