SOLVing the swab dilemma

OK, I have a confession to make.  I am a truly appalling gynaecologist!  I know, I claim to be a generalist – one who loves it all – but when it comes to the non-pregnant women I admit that I am sometimes less than enthusiastic.

Now this is not such a dilemma as I work in an ED, and there are not a lot of non-pregnant Gynae emergencies that I cannot sort out with a quick US and examination.  But here is my dilemma [maybe you share this one?]:  I have trouble finding the cervix on spec exam.  I know if I practiced more and got good at it I would be an ace cervix-locator. But….  I do i so infrequently and poorly that I just never really got there.

So, why worry?  Well I work in an area where STIs are rampant – we need to get good Micro samples and sort out who has go what.  And my training was to get an endocervical swab to prove (or disprove) these diagnoses.  I have always been told that clinican-obtained swabs were the gold-standard.  Accept no less.  In the last few years there has been a trend towards SOLVS (self-obtained lower vaginal swabs) for STI testing.  And I have been of the belief that they were the poor cousin to my fumbling attempts to swab the cervical canal.

BUT, wait!  News just in….  SOLVS might actually be better than my swabbing samples.  2 recent papers that I have seen looking at the diagnosis of Chlamydia and Gonorrhea indicate that the patients are better than me at getting a diagnostic sample.

This Paper from Stewart et al in BMJ Dec 2012 compared SOLVS to clinician-endocervical swabs for the screening of asymptomatic women for chlamydia.  In summary the SOLVS had a sensitivity of 97%, compared to the endocervical swabs 88% (P – significant) with narrow CI.

So I think it is fair to say that SOLVS is at least non-inferior to clinician-obtained swabs.  And I would go further to state that SOLVS is definitely superior to Doc-swabs when the Doc happens to be me!

Now, one last word of caution.  This does NOT mean that clinical examination is useless.  It would be tempting to say that we can manage a PV discharge or pain without having to get the patient undressed and have a look.  This is not the case.

I can recall countless cases where I have seen women either self-diagnose or be “diagnosed” blindly and empirically treated for what was thought to be thrush or bacterial vaginosis.  They eventually get a proper examination and it is clear that the culprit is something else – herpes, trichomonas etc.

So by all means get the patient to do a SOLVS – but you still need to have a look, to ensure you are not missing anything.  Although I think when we are prely screening for STI or other micro in an asymptomatic woman, then a SOLVS alone should suffice.

Now – not sure if this is news to anyone else?  BUt would love to hear your comments.  More Women’s health coming all month.

Casey