Journal Club April 2017 - Pelvic Inflammatory Disease

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Urinary complaints in females are an incredibly common reason for visits to emergency departments. We are often left to make the decision of whether to treat for infection on a fairly equivocal urinalysis (UA) results without the help of a definitive culture. Muddying the waters is the risk of sexually transmitted infections (STI's) which can cause similar if not more benign symptomatology (even at times completely asymptomatic). Can the history help? Do reported symptoms correlate with a diagnosis? As the treatment regimens and potential long-term sequelae differ this can become a very important decision in patients that overall are non-toxic in appearance. In this journal club, we chose articles that aimed to clarify the distinction between two entities (UTI vs. STI) that are incredibly frequent in sexually active women.

ARTICLES REVIEWED

1. Huppert, et al. Urinary Symptoms in Adolescent Females: STI or UTI? Journal of Adolescent Health 40 (2007) 418-424.

2. Tomas, et al. Overdiagnosis of Urinary Tract Infection and Underdiagnsis of Sexually Transmitted Infection in Adult Women Presenting to an Emergency Department. Journal of Clinical Microbiology August 2015 Volume 53 Number 8.

3. Schoeman, et al. Assessment of best single sample for finding chlamydia in women with and without symptoms: a diagnostic test study. PMCID: PMC3520545.

4. Bugg, et al. Pelvic Inflammatory Disease: Diagnosis and Treatment in the Emergency Department. Emergency Medicine Practice December 2016 Volume 18, Number 12.

HUPPERT ET AL:

This was a prospective, cross-sectional study aiming to determining whether urinary symptoms or UTI's are associated with STI's and which history, clinical, and lab findings can distinguish these infections. The authors did not find that urinary symptoms increased the risk of UTI or that UTI and STI frequently coexisted (only 6% overlap). Of patients that had urinary symptoms, 52% had UTI, and they were more likely to have the presence of a UTI, concomitant vaginal symptoms, and a history of both UTI and STI. There was a non-significant trend toward higher prevalence of STI than UTI in women with urinary or vaginal symptoms (p = 0.06). Some secondary findings were interesting and relevant to clinical practice. In those with urinary symptoms but without UTI, trichomonas was 2.5 X more prevalent. Interestingly, while the strongest predictor of UTI was the presence of nitrites, proteinuria and a history of STI were the 2nd and 3rd strongest predictors of UTI, respectively. Leukocytes or blood on the UA were associated with an increased risk of STI. No other history or lab findings, including the presence of vaginal symptoms, were predictive of the presence of either UTI or STI. Some take home points:

Consider vaginal and urinary symptoms to be basically equivalent in adolescent females
Self reported UTI symptoms are basically a coin flip
In adolescent females with urinary symptoms, consider testing for trichomonas if the UA is negative
A vaginal self swab is a reasonable alternative method, as many of these patients will defer a full pelvic exam

TOMAS ET AL:

The purpose of this observational cohort study was to determine the accuracy of using clinical diagnosis of UTI & STI in adult women presenting with genitourinary symptoms or diagnosed with GU infection. A urinarlysis was sent on all women aged 18-65 who presented to the ED with GU symptoms or abdominal pain. Every patient had a UA and was cultured and tested for gonorrhea, chlamydia, and trichomonas. Conclusions made by the authors:

Over diagnosis of UTI is common (52%)
Under diagnosis of STI is common (37%)
Over diagnosis of UTI causes unnecessary antibiotics use AND under diagnosis of STI
Despite some literature and common practice, empiric treatment of women based on symptoms and suspicion alone and without additional testing, especially if ED has a high rate of STI, leads to over-prescribing of antibiotics

SCHOEMAN ET AL:

The purpose of this study was to compare vulvovaginal (Vv) swabs with endocervical (Ec) swabs as optimal diagnostic sample for detection of Chlamydia trachomitis infection. Over 3973 women >16 years old requesting testing for STI were included. They concluded Vv swabs (Aptima Combo-2 assay) were better than Ec swabs at detecting Chlamydia trachomitis infections in both symptomatic and asymptomatic patients (97% sens for Vv, 88% for Ec; Ec would miss 1/11 infections). For women without symptoms or do not need a speculum exam, a self taken vulvovaginal swab is appropriate for both gonorrhea and chlamydia testing.

Summary

Evaluation and treatment of women presenting with genitourinary complaints is complex. From these articles, it is imperative to consider STI (sexually transmitted infections) more routinely. We have learned that reported symptoms (dysuria, urgency, etc) do not necessarily correlate with urinalysis findings. ED and urgent care practitioners routinely over-diagnose UTI's and under-diagnose STI's. This leads to inappropriate antibiotic usage and potential complications. Lastly, self-taken vulvovaginal swabs perform comparatively well to endocervical swabs for the diagnosis of STI's. This provides a potentially less invasive and more comfortable form of screening in selected patient populations.

Written by Peter Croft, MD

Edited and Posted by Jeffrey A. Holmes, MD

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