Toward enhancing sexually transmitted infection clinic efficiency in an era of molecular diagnostics: the role of physical examination and risk stratification in men.

BACKGROUND: In an era of constrained resources, new molecular techniques may make it possible to detect common sexually transmitted infections (STIs) without physical examination in selected groups of men. Our objectives were to define the contribution of the physical examination in detecting clinically meaningful diagnoses that may not be identified by current laboratory methods and to identify characteristics that can stratify men into the appropriate risk category.

METHODS: A retrospective study from a database of all male visits to 2 urban STI clinics in Baltimore between 1990 and 2001 was conducted. Men were stratified on the basis of reason for visit. Proportions for diagnoses that would have been missed without physical examination were compared using the χ2 test. Logistic regression was used to assess which factors were most predictive of missed diagnoses.

RESULTS: A total of 58,073 of 140,052 records were included: 29,172 were asymptomatic, 23,972 were symptomatic, and 4929 were asymptomatic contacts of an infected partner. In addition, 2.7% of ASYM, 10.4% of symptomatic, and 4.5% of contact patients would have had missed diagnoses if no physical examination had been performed. For symptomatic patients, if those reporting rash, lesion, or genital itch were examined, the percent with missed diagnoses would drop to 3.7%.

CONCLUSIONS: Asymptomatic men may be candidates for accelerated STI testing, which includes the submission of genital and extragenital swabs as well as blood samples for HIV and syphilis testing without a physical examination. A significant proportion of symptomatic men would miss the opportunity for same-day treatment of gonococcal or nongonococcal urethritis.