Genitourinary Infections after a Routine Pelvic Exam

Abstract

Purpose: To determine if genitourinary problems are more common in women in the first 1 to 2 months after a routine pelvic examination.Methods: This was a historical cohort study in 2 family medicine teaching clinics at an urban university. Participants included all women who received a Papanicolaou smear during calendar year 2006. Subjects included all participants for weeks 1 to 7 after their Papanicolaou smear. Controls were all participants in weeks 8 to 52 after their Papanicolaou smear. The independent variable was time after Papanicolaou smear, and dependent variables included frequency of visits for urinary complaints, diagnosed urinary tract infections (UTIs), vaginal complaints, diagnosed vaginitis, and sexually transmitted diseases. Relative frequencies compared using 2-tailed t tests.Results: UTIs and urinary complaints were significantly more frequent during the first 7 weeks after a Papanicolaou smear compared with weeks 8 to 14, 8 to 48, and 8 to 52. The overall rate of UTIs was 7.33 per 100 person-years; the attributable risk during the first 7 weeks was 0.82 per 100 personyears, or 11% of observed UTIs. Combined Candidal and bacterial vaginitis was marginally more frequent during the first 7 weeks compared with weeks 8 to 48 and 8 to 52 only. The incidence of sexually transmitted diseases combined was 1.13 per 100 person-years, distributed evenly over the study period unrelated to time. Urinary tract infections (UTIs) are very common among adult women, accounting for more than 6 million physician office visits yearly in the United States. Sexual intercourse has long been recognized as one of the primary risk factors for female UTIs. 1Proposed mechanisms for this increased risk include propulsion of bacteria up the urethra into the bladder; microtrauma to the urethra and bladder mucosa, allowing bacterial adhesion; and alteration of normal flora. We postulated that the pelvic examination, including speculum insertion and bimanual examination, may increase the risk of UTIs by similar mechanisms. A small, retrospective, casecontrol study suggested such an association.2 A recent study has also demonstrated that symptoms of UTIs, namely dysuria and frequency, are more common in sexually active women in the 4 weeks after a screening pelvic examination.3 This study examined a larger cohort of women after a routine pelvic examination for the timing and frequency of genitourinary problems. MethodsThis was a historical cohort study performed by chart review. Participants were all women who had a Papanicolaou test at either of our 2 clinics during the calendar year 2006. Participants were identified through billing records, and a total of 1582 women were included. Participants were excluded only if they had no follow-up visit at our medical center since the initial Papanicolaou smear. The 2 clinics are university-based family medicine clinics in an urban setting, serving a diverse, large-city popula-

Urinary Tract Infections

“…Indwelling catheter and hospitalization: the most important risk factor for bacteriuria is the presence of a catheter 8 ; catheter-associated UTI is the most common nosocomial infection; hospitalized patients have a risk of 5% per day while an indwelling catheter is in place 8,9 Recent or frequent sexual intercourse 10,11 Recent spermicide use, particularly associated with increased risk of Staphylococcus saprophyticus UTI 10,12 History of previous UTI 10 Insertive anal intercourse 13 Lack of circumcision in men 13 Pelvic examinations and Pap smear 14 Urinary tract stent Intermittent bladder catheterization 8 Obstructive uropathy, including neurogenic bladder and nephrolithiasis Vesicoureteric reflux or other functional abnormalities Chemical or radiation injury of uroepithelium Recent urinary tract instrumentation 15 Polycystic renal disease 16 Renal transplantation Immunodeficiency or immunosuppression 15 MICROBIOLOGY Most UTIs are monomicrobial; the most common pathogen is Escherichia coli, accounting for 70% to 95% cases of acute uncomplicated cystitis. 5,17 The second most common pathogen is Staphylococcus saprophyticus, accounting for 5% to 15% of UTIs, and occurs mainly in young women.…”

Guest Family Physician Commentaries

“…In a follow up study, 11 Tiemstra's group evaluated 1582 women who had Papanicolaou testing at any time and their rates of urinary tract infections (UTIs) during the next year. They found that within the first 7 weeks after a Papanicolaou test, UTIs occurred at a rate of 12.7 per 100 person years versus 6.51 per 100 person-years in the subsequent 45 weeks.…”

Should the Annual Pelvic Examination Go the Way of Annual Cervical Cytology?

“…Fear of pain and embarrassment were identified as barriers to cervical cancer screening in a recently published survey study from Brazil [55]. A specific potential harm was illustrated by a study reporting higher rates of urinary tract infection in the 7 weeks after a routine pelvic examination with cervical cancer screening [56].…”

“…Fear of pain and embarrassment were identified as barriers to cervical cancer screening in a recently published survey study from Brazil [55]. A specific potential harm was illustrated by a study reporting higher rates of urinary tract infection in the 7 weeks after a routine pelvic examination with cervical cancer screening [56].Another potential disservice of performing a pelvic examination in asymptomatic women is providing false reassurance to the provider and the patient regarding the absence of gynecologic malignancy. This was demonstrated by Padilla et al's studies in which even under the most seemingly ideal circumstance for accuracy (patients were under general anesthesia), the ability to identify ovarian masses was poor and identification of uterine size and contour was also limited [12,13].…”