EVIDENCE-TO-DECISION TABLE: LOWER ABDOMINAL PAIN

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Guidelines for the management of symptomatic sexually transmitted infections [Internet]. Geneva: World Health Organization; 2021 Jun.

Cover of Guidelines for the management of symptomatic sexually transmitted infections

Guidelines for the management of symptomatic sexually transmitted infections [Internet].

Show details

Contents

< Prev Next >

ANNEX 5EVIDENCE-TO-DECISION TABLE: LOWER ABDOMINAL PAIN

Should the current WHO syndromic management be recommended versus laboratory diagnosis, no treatment or treat all to identify pelvic inflammatory disease caused by STIs among women with lower abdominal pain?

Population

Women presenting with lower abdominal pain

Intervention and comparator

Intervention: current WHO syndromic approach versus comparison: laboratory diagnosis (or no treatment or treat all)

Purpose of the test

To identify women for treatment of STIs related to pelvic inflammatory disease

Linked treatments

Treatment for infections caused by C. trachomatis, N. gonorrhoeae, T. vaginalis and anaerobic infections

Anticipated outcomes

Number of people identified correctly as having or not having STI and/or pelvic inflammatory disease; number of people identified incorrectly as having or not having STI and/or pelvic inflammatory disease; consequences of appropriate or inappropriate treatment; patient and provider acceptability, feasibility, equity and resource use

Setting

Outpatient

Perspective

Population level

Subgroups

Pregnant women, sex workers and heterosexual women (general population).

Background

Syndromic management refers to a strategy for identifying and treating STIs based on specific syndromes (symptoms identified by a patient) and signs (clinically observed signs of infection) associated with clearly defined causes. Although etiological diagnosis is preferred, it is not always accessible or affordable.

Individuals presenting with lower abdominal pain syndrome could suggest the presence of acute pelvic inflammatory disease that requires immediate attention. Lower abdominal pain is a vague symptom and can be caused by myriad potential diseases, including pelvic inflammatory disease with consequent risk of chronic pelvic pain, tubal factor infertility and ectopic pregnancy. Pelvic inflammatory disease represents a spectrum of disease with a wide range of severity and results from an infection from the cervix or vagina entering into the endometrium, fallopian tubes and/or contiguous structures. Pelvic inflammatory disease is a polymicrobial infection and can be caused by an STI or by dysbiosis of the vaginal microbiome. The likely causes of lower abdominal pain could change depending on the age of the woman.

WHO published clinical guidelines for the syndromic management of lower abdominal pain syndrome in 2003 (Fig. A5.1).

Assessment

Download PDF (2.4M)

Summary of judgements

	Judgement
Problem	No	Probably no	Probably yes	Yes		Varies	Don’t know
Test accuracy	Very inaccurate	Inaccurate	Accurate	Very accurate		Varies	Don’t know
Desirable effects	Trivial	Small	Moderate	Large		Varies	Don’t know
Undesirable effects	Large	Moderate	Small	Trivial		Varies	Don’t know
Certainty of the evidence of test accuracy	Very low	Low	Moderate	High			No included studies
Certainty of the evidence of the effects of management	Very low	Low	Moderate	High			No included studies
Certainty of effects	Very low	Low	Moderate	High			No included studies
Values	Important uncertainty or variability	Possibly important uncertainty or variability	Probably no important uncertainty or variability	No important uncertainty or variability
Balance of effects	Favours the comparison	Probably favours the comparison	Does not favour either the intervention or the comparison	Probably favours the intervention	Favours the intervention	Varies	Don’t know
Resources required	Large costs	Moderate costs	Negligible costs and savings	Moderate savings	Large savings	Varies	Don’t know
Certainty of evidence of required resources	Very low	Low	Moderate	High			No included studies
Cost–effectiveness	Favours the comparison	Probably favours the comparison	Does not favour either the intervention or the comparison	Probably favours the intervention	Favours the intervention	Varies	No included studies
Equity	Reduced	Probably reduced	Probably no impact	Probably increased	Increased	Varies	Don’t know
Acceptability	No	Probably no	Probably yes	Yes		Varies	Don’t know
Feasibility	No	Probably no	Probably yes	Yes		Varies	Don’t know

Conclusions

Should the current WHO syndromic management be recommended versus laboratory diagnosis, no treatment or treat all to identify pelvic inflammatory disease caused by STIs among women with lower abdominal pain?

Type of recommendation

○

Strong recommendation against the intervention

○

Conditional recommendation against the intervention

○

Conditional recommendation for either the intervention or the comparison

○

Conditional recommendation for the intervention

●

Strong recommendation for the intervention

Recommendation

Recommendations for management of women with lower abdominal pain

For sexually active women with symptom of lower abdominal pain, we suggest assessing for pelvic inflammatory disease and treating syndromically.

Good practice includes:

taking a medical and sexual history and assessing the risk of STIs;
performing a physical examination, including abdominal and pelvic examination, to assess for pelvic inflammatory disease, surgical conditions or pregnancy and vulvovaginal examination to visualize any lesions, overt genital discharge, vulval erythema and excoriations;
performing a bimanual digital examination of the vagina to (1) assess for cervical motion tenderness or pain with palpation of the pelvic area to exclude pelvic inflammatory disease; and (2) assess for the presence of vaginal discharge and the colour and consistency of the discharge on the glove; and
offering HIV and syphilis testing and other preventive services as recommended in other guidelines.

For sexually active women with lower abdominal pain with either of the following features on clinical examination (bimanual palpation):

cervical motion tenderness; or
lower abdominal tenderness:

We suggest the following.

Treat for pelvic inflammatory disease on the same visit.
Test for infection with N. gonorrhoeae and C. trachomatis and, if available, M. genitalium, to support partner management when tests are available.
Schedule follow-up assessment in three days to assess for clinical improvement, and if the woman has not improved, refer for further assessment.

For women with lower abdominal pain with any of the following conditions, good practice includes referral to surgical or gynaecological assessment:

missed or overdue period;
recent delivery, abortion or miscarriage;
abdominal guarding and/or rebound tenderness;
abnormal vaginal bleeding in excess of spotting;
abdominal mass; and
detection of a suspected cervical lesion.

Justification

Managing people presenting with lower abdominal pain based on a syndromic approach results in moderate benefits and little harm compared with treating all or no treatment. The syndromic approach would be feasible and acceptable and would not negatively affect equity (in some settings it may increase equity) and incur negligible costs.

Fig. A5.1Current WHO syndromic management guidelines for lower abdominal pain

References

1.: Peipert JF, Ness RB, Blume J, Soper DE, Holley R, Randall H et al. Clinical predictors of endometritis in women with symptoms and signs of pelvic inflammatory disease. Am J Obstet Gynecol. 2001;184:856–63. [PubMed: 11303192]
2.: Eggert J, Sundquist K, van Vuuren C, Fianu-Jonasson A. The clinical diagnosis of pelvic inflammatory disease – reuse of electronic medical record data from 189 patients visiting a Swedish university hospital emergency department. BMC Women’s Health. 2006;6:16. [PMC free article: PMC1624808] [PubMed: 17054801]
3.: Goller JL, De Livera AM, Fairley CK, Guy RJ, Bradshaw CS, Chen MY et al. Population attributable fraction of pelvic inflammatory disease associated with chlamydia and gonorrhoea: a cross-sectional analysis of Australian sexual health clinic data. Sex Transm Infect. 2016;92:525–31. [PubMed: 27091729]
4.: Sharma H, Tal R, Clark NA, Segars JH. Microbiota and pelvic inflammatory disease. Semin Reprod Med. 2014;32:43–9. [PMC free article: PMC4148456] [PubMed: 24390920]
5.: Wang Y, Zhang Y, Zhang Q, Chen H, Feng Y. Characterization of pelvic and cervical microbiotas from patients with pelvic inflammatory disease. J Med Microbiol. 2018;67:1519–26. [PubMed: 30113305]
6.: Ness RB, Hillier SL, Kip KE, Soper DE, Stamm CA, McGregor JA et al. Bacterial vaginosis and risk of pelvic inflammatory disease. Obstet Gynecol. 2004;104:761–9. [PubMed: 15458899]
7.: Ness RB, Kip KE, Hillier SL, Soper DE, Stamm CA, Sweet RL et al. A cluster analysis of bacterial vaginosis–associated microflora and pelvic inflammatory disease. Am J Epidemiol. 2005;162:585–90. [PubMed: 16093289]
8.: Aghaizu A, Adams EJ, Turner K, Kerry S, Hay P, Simms I et al. What is the cost of pelvic inflammatory disease and how much could be prevented by screening for Chlamydia trachomatis? Cost analysis of the Prevention of Pelvic Infection (POPI) trial. Sex Transm Infect. 2011;87:312–7. [PubMed: 21444333]
9.: Yeh JM, Hook EW 3rd, Goldie SJ. A refined estimate of the average lifetime cost of pelvic inflammatory disease. Sex Transm Dis. 2003;30:369–78. [PubMed: 12916126]
10.: Adams EJ, Garcia PJ, Garnett GP, Edmunds WJ, Holmes KK. The cost–effectiveness of syndromic management in pharmacies in Lima, Peru. Sex Transm Dis. 2003;30:379–87. [PubMed: 12916127]
11.: Llata E, Bernstein KT, Kerani RP, Pathela P, Schwebke JR, Schumacher C et al. Management of pelvic inflammatory disease in selected U.S. sexually transmitted disease clinics: Sexually Transmitted Disease Surveillance Network, January 2010–December 2011. Sex Transm Dis. 2015;42:429–33. [PMC free article: PMC6740322] [PubMed: 26165434]
12.: Garcia P, Hughes J, Carcamo C, Holmes KK. Training pharmacy workers in recognition, management and prevention of, STDs: district-randomized controlled trial. Bull World Health Organ. 2003;81:806–14. [PMC free article: PMC2572366] [PubMed: 14758407]
13.: Wilkinson D, Sturm AW. Value of clinical algorithms to screen for gonococcal and chlamydial infection among women attending antenatal and family planning clinics. S Afr Med J. 1998;88(7 Suppl. 1):900–5.
14.: Alary M, Laga M, Vuylsteke B, Nzila N, Piot P. Signs and symptoms of prevalent and incident cases of gonorrhea and genital chlamydial infection among female prostitutes in Kinshasa, Zaire. Clin Infect Dis. 1996;22:477–84. [PubMed: 8852966]
15.: Meda N, Sangaré L, Lankoandé S, Sanou PT, Compaoré PI, Catraye J et al. Pattern of sexually transmitted diseases among pregnant women in Burkina Faso, west Africa: potential for a clinical management based on simple approaches. Genitourin Med. 1997;73:188–93. [PMC free article: PMC1195819] [PubMed: 9306899]
16.: Piper JM, Korte JE, Holden AE, Shain RN, Perdue S, Champion JD, Newton ER. Development of composite symptom variables for quantitative analysis of genitourinary symptomatology in women. Int J STD AIDS. 2005;16:128–32. [PubMed: 15807940]
17.: Vallely LM, Toliman P, Ryan C, Rai G, Wapling J, Gabuzzi J et al. Performance of syndromic management for the detection and treatment of genital Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis among women attending antenatal, well woman and sexual health clinics in Papua New Guinea: a cross-sectional study. BMJ Open. 2017;7:e018630. [PMC free article: PMC5778337] [PubMed: 29288183]
18.: Wiesenfeld HC, Hillier SL, Krohn MA, Amortegui AJ, Heine RP, Landers DV et al. Lower genital tract infection and endometritis: insight into subclinical pelvic inflammatory disease. Obstet Gynecol. 2002;100:456–63. [PubMed: 12220764]
19.: Woods JL, Scurlock AM, Hensel DJ. Pelvic inflammatory disease in the adolescent: understanding diagnosis and treatment as a health care provider. Pediatr Emerg Care. 2013;29:720–5. [PubMed: 23714759]
20.: Cohen CR, Manhart LE, Bukusi EA, Astete S, Brunham RC, Holmes KK et al. Association between Mycoplasma genitalium and acute endometritis. Lancet. 2002;359:765–6. [PubMed: 11888591]
21.: Grio R, Latino MA, Leotta E, Smirne C, Lanza A, Spagnolo E et al. Sexually transmitted diseases and pelvic inflammatory disease. Minerva Ginecolog. 2004;56:141–7. [PubMed: 15258543]

Table A5.1Detection of any STIs for lower abdominal pain syndrome

Algorithm	Year of study	Country	Country income level	Sample size	Where recruited	Sub-population	How a positive case is defined	Pathogen, diagnostic	True positive	False negative	False positive	True negative
Wilkinson & Sturm (13)	1998	South Africa	Upper middle	268	Antenatal clinic	100% pregnant women	Symptoms only	C. trachomatis and N. gonorrhoeae C. trachomatis = direct immunofluorescence N. gonorrhoeae = culture	13	38	48	170
Wilkinson & Sturm (13)	1998	South Africa	Upper middle	190	Family planning clinic	100% women	Symptoms only	C. trachomatis and N. gonorrhoeae C. trachomatis = direct immunofluorescence N. gonorrhoeae = culture	3	18	5	163
Alary et al. (14)	1988–1991	Zaire	Low	771	Unclear	100% female sex workers	Symptoms only	C. trachomatis and N. gonorrhoeae C. trachomatis = enzyme immunoassay N. gonorrhoeae = culture	100	125	217	329
Meda et al. (15)	1994	Burkina Faso	Low	397	Antenatal care	100% pregnant women	Symptoms only	C. trachomatis and N. gonorrhoeae C. trachomatis = enzyme immunoassay N. gonorrhoeae = culture	8	22	113	254
Piper et al. (16)	Unclear	United States	High	518	Public health clinic	100% ethnic minority women	Symptoms only	C. trachomatis, and N. gonorrhoeae and T. vaginalis C. trachomatis and N. gonorrhoeae = NAAT (GenProbe) T. vaginalis = culture	106	279	20	113
Vallely et al. (17)	2011–2015	Papua New Guinea	Lower middle	765	Antenatal clinic	100% pregnant women	Symptoms only	C. trachomatis, N. gonorrhoeae and T. vaginalis NAAT	60	267	106	332
Vallely et al. (17)	2011–2015	Papua New Guinea	Lower middle	614	Well-woman clinic	100% women	Symptoms only	C. trachomatis, N. gonorrhoeae and T. vaginalis NAAT	46	108	154	306
Vallely et al. (17)	2011–2015	Papua New Guinea	Lower middle	385	Sexual health clinic	100% women	Symptoms only	C. trachomatis, N. gonorrhoeae and T. vaginalis NAAT	109	36	173	67

Table A5.2Detection of gonorrhoea for lower abdominal pain syndrome

Study	Year of study	Country	Country income level	Sample size	Where recruited	Subpopulation	How a positive case is defined	Diagnostic	True positive	False negative	False positive	True negative
Wiesenfeld et al. (18)	1998–2000	United States	High	427	Hospital, sexual health clinic, ambulatory care sites	Excluded acute pelvic inflammatory disease	Subclinical pelvic inflammatory disease (endometrial biopsy)	Culture	15	26	57	329
Woods et al (19)	2013	United States	High	150	General practice, emergency department	100% diagnosed with pelvic inflammatory disease	Pelvic inflammatory disease diagnosis according to ICD criteria (symptoms + examination)	Unclear	19	6	98	27
Vallely et al. (17)	2011–2015	Papua New Guinea	Lower middle	765	Antenatal clinic	100% pregnant women	Symptoms only	PCR	15	94	151	505
Vallely et al. (17)	2011–2015	Papua New Guinea	Lower middle	614	Well-woman clinic	100% women	Symptoms only	PCR	15	34	185	380
Vallely et al. (17)	2011–2015	Papua New Guinea	Lower middle	385	Sexual health clinic	100% women	Symptoms only	PCR	46	17	236	86
Cohen et al. (20)	Unclear	Kenya	Lower middle	115	Sexual health clinic	100% had pelvic pain (14 days or less)	Endometritis (endometrial biopsy)	PCR	9	4	49	53

Table A5.3Detection of chlamydia for lower abdominal pain syndrome

Study	Year of study	Country	Country income level	Sample size	Where recruited	Subpopulation	How a positive case is defined	Diagnostic	True positive	False negative	False positive	True negative
Wiesenfeld et al. (18)	1998–2000	United States	High	403	Hospital, sexual health clinic, ambulatory care sites	Excluded acute pelvic inflammatory disease	Subclinical pelvic inflammatory disease (endometrial biopsy)	PCR	27	44	46	286
Woods et al. (19)	2013	United States	High	150	General practice, emergency department	100% diagnosed with pelvic inflammatory disease	Pelvic inflammatory disease diagnosis according to ICD criteria (symptoms + examination)	Unclear	31	14	86	19
Vallely et al. (17)	2011–2015	Papua New Guinea	Lower middle	765	Antenatal clinic	100% pregnant women	Symptoms only	PCR	30	145	136	454
Vallely et al. (17)	2011–2015	Papua New Guinea	Lower middle	614	Well-woman clinic	100% women	Symptoms only	PCR	19	27	181	387
Vallely et al. (17)	2011–2015	Papua New Guinea	Lower middle	385	Sexual health clinic	100% women	Symptoms only	PCR	62	16	220	87
Cohen et al. (20)	Unclear	Kenya	Lower middle	115	Sexual health clinic	100% had pelvic pain (14 days or less)	Pelvic inflammatory disease (endometrial biopsy)		4	2	54	55
Grio et al. (21)	1997–2001	Italy	High	5026	Hospital		Symptomatic for pelvic inflammatory disease	LCR using Abbot LCx system	49	38	1505	3434

Table A5.4Detection of trichomoniasis for lower abdominal pain syndrome

Study	Year of study	Country	Country income level	Sample size	Where recruited	Subpopulation	How a positive case is defined	Diagnostic	True positive	False negative	False positive	True negative
Wiesenfeld et al. (18)	1998–2000	United States	High	428	Hospital, sexual health clinic, ambulatory care sites	Excluded acute pelvic inflammatory disease Women 15–30 years old	Subclinical pelvic inflammatory disease (endometrial biopsy)	Culture	14	35	60	319
Vallely et al. (17)	2011–2015	Papua New Guinea	Lower middle	765	Antenatal clinic	100% pregnant women	Symptoms only		29	142	137	457
Vallely et al. (17)	2011–2015	Papua New Guinea	Lower middle	614	Well-woman clinic	100% women	Symptoms only		24	68	176	346
Vallely et al. (17)	2011–2015	Papua New Guinea	Lower middle	385	Sexual health clinic	100% women	Symptoms only		40	14	242	89
Grio et al. (21)	1997–2001	Italy	High	5516	Hospital	100% women	Symptomatic for pelvic inflammatory disease	LCR using Abbot LCx system	23	22	1697	3774

Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing.

Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user.

Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”.

Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization (http://www.wipo.int/amc/en/mediation/rules/).

Bookshelf ID: NBK572651

Contents

< Prev Next >

PubReader
Print View
Cite this Page
Guidelines for the management of symptomatic sexually transmitted infections [Internet]. Geneva: World Health Organization; 2021 Jun. ANNEX 5, EVIDENCE-TO-DECISION TABLE: LOWER ABDOMINAL PAIN.
PDF version of this title (5.5M)

In this Page

Should the current WHO syndromic management be recommended versus laboratory diagnosis, no treatment or treat all to identify pelvic inflammatory disease caused by STIs among women with lower abdominal pain?
Assessment
Summary of judgements
Conclusions

Other titles in this collection

WHO Guidelines Approved by the Guidelines Review Committee

Related information

PMC
PubMed Central citations
PubMed
Links to PubMed

Recent Activity

Clear Turn Off Turn On

EVIDENCE-TO-DECISION TABLE: LOWER ABDOMINAL PAIN - Guidelines for the management...
EVIDENCE-TO-DECISION TABLE: LOWER ABDOMINAL PAIN - Guidelines for the management of symptomatic sexually transmitted infections

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

Bookshelf

Guidelines for the management of symptomatic sexually transmitted infections [Internet].

ANNEX 5EVIDENCE-TO-DECISION TABLE: LOWER ABDOMINAL PAIN

Should the current WHO syndromic management be recommended versus laboratory diagnosis, no treatment or treat all to identify pelvic inflammatory disease caused by STIs among women with lower abdominal pain?

Population

Intervention and comparator

Purpose of the test

Linked treatments

Anticipated outcomes

Setting

Perspective

Subgroups

Background

Assessment

Summary of judgements

Conclusions

Should the current WHO syndromic management be recommended versus laboratory diagnosis, no treatment or treat all to identify pelvic inflammatory disease caused by STIs among women with lower abdominal pain?

Fig. A5.1Current WHO syndromic management guidelines for lower abdominal pain

References

Table A5.1Detection of any STIs for lower abdominal pain syndrome

Table A5.2Detection of gonorrhoea for lower abdominal pain syndrome

Table A5.3Detection of chlamydia for lower abdominal pain syndrome

Table A5.4Detection of trichomoniasis for lower abdominal pain syndrome

Views

In this Page

Other titles in this collection

Related information

Recent Activity