COMMENTARY

Choosing to Do--or Not Do--a Genital Exam

Choosing Wisely Recommendations From AAFP

Kenneth W. Lin, MD, MPH

Disclosures

September 17, 2018

Editorial Collaboration

Medscape &

Hello, everyone. I'm Dr Kenny Lin, a family physician at Georgetown University Medical Center in Washington, DC, and I blog at Common Sense Family Doctor.

After a 5-year hiatus, the American Academy of Family Physicians (AAFP) recently added five new recommendations to its Choosing Wisely list of medical tests and interventions that patients and physicians should question, and withdrew a previous recommendation, bringing its total of active recommendations to 19. Today I will discuss three of the five additions that emphasized the lack of benefits of genital examinations or testing for genital herpes simplex in asymptomatic patients.

Because genital exams have long been considered part of a complete physical exam, there may be some resistance to skipping them. When, in 2014, the American College of Physicians first recommended not performing screening pelvic examinations in asymptomatic, nonpregnant adult women,[1] the American College of Obstetricians and Gynecologists responded by reaffirming their existing guidance on well-woman exams,[2] which states that "a pelvic examination [should] be performed on an annual basis in all patients aged 21 years and older." For what purpose is not clear.

Screening for chlamydia and gonorrhea in women can be performed on urine samples with nucleic acid amplification tests.[3] A systematic review of the bimanual pelvic examination found that it is highly inaccurate as a screening test for ovarian cancer, with a positive predictive value of only 1% in a typical screening population.[4]

Although the US Preventive Services Task Force (USPSTF) found insufficient evidence to assess the balance of benefits and harms of screening pelvic examinations,[5] the AAFP has concluded that these exams are not warranted in nonpregnant women unless necessary for guideline-appropriate screening for cervical cancer.

Turning to men, the AAFP recommended not screening for testicular cancer in asymptomatic adolescents and adults. As a colleague and I concluded in a review performed for the USPSTF's 2011 recommendation against routine testicular exams,[6] the low incidence and the high cure rates of testicular cancer make any theoretical benefits of screening unlikely to outweigh harms of false-positive tests and unnecessary procedures.

Incidentally, though not included in their most recent set of Choosing Wisely recommendations, the AAFP continues to recommend against routinely screening for prostate cancer using a digital rectal exam. A recent systematic review of studies of digital rectal exam screening in primary care[7] found that the test has low sensitivity and specificity, and could lead to considerable overdiagnosis and overtreatment.

Finally, the AAFP recommended against serologic screening for genital herpes in asymptomatic adults, including pregnant women. Many adults with detectable antibodies to HSV-1 or HSV-2 will never develop genital symptoms, and "a positive test can cause considerable anxiety and disruption of personal relationships." When a patient without genital lesions asks to be tested for sexually transmitted infections, this is a test to leave off the laboratory order.

Although genital examinations can seem harmless, and these Choosing Wisely recommendations may contradict what we learned in training, family physicians do patients no favors by performing tests that are more likely to make their health worse rather than better.

This has been Dr Kenny Lin for Medscape Family Medicine. Thank you for listening.

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