Cervical motion tenderness (CMT) is a gynecological finding that could indicate the presence of a peritoneal infection.

Cortes EG, Adamski JJ. Chandelier sign. StatPearls Publishing; 2022.

 

It is known colloquially as “chandelier sign” because patients with CMT experience intense pain during a bimanual pelvic exam, making them reach up towards the ceiling, as if to grab a chandelier.

 

Examining for chandelier sign

 

During a bimanual exam, providers can evaluate patients for CMT by inserting the index and middle finger into the vagina until the limit of the vaginal vault in the posterior fornix is reached.

The provider can then apply pressure to the abdominal wall with their other hand. This allows the provider to determine if there is any tenderness as they gauge the shape, size, position, and mobility of the cervix.

Pain upon manipulation of the uterine cervix is an indication of an inflammatory process of the pelvic organs. However, while CMT is typically associated with pelvic inflammatory disease (PID), it can also occur during ectopic pregnancy, endometriosis, ovarian torsion, appendicitis, and perforated abdominal viscus.

 

A closer look at pelvic inflammatory disease

 

PID is an upper genital tract infection that encompasses a range of diseases. It may affect the uterus, ovaries, fallopian tubes, and peritoneum.

Lewiss RE, Saul T, Goldflam K. Sonographic cervical motion tenderness: A sign found in a patient with pelvic inflammatory disease. Crit Ultrasound J. 2012;4(1):20.

While PID is often caused by multiple microbes, the most common pathogens responsible are N. gonorrhoeae and C. trachomatis.

 

Cases of PID often go undiagnosed, either due to a lack of symptoms or because patients present with mild or nonspecific symptoms such as bleeding and vaginal discharge. However, because women with asymptomatic or mild PID are at risk for infertility, it’s critical for healthcare providers (HCPs) to accurately diagnose this infection while maintaining a low threshold for diagnosis.

For sexually active women and women at risk for sexually transmitted infections, empiric antibiotic treatment for PID should be started under the following conditions:

1. If a patient has pelvic or lower abdominal pain and no other cause of illness is identified

2. If a patient presents with CMT, uterine tenderness, or adnexal tenderness during a pelvic exam; these are the three minimum clinical criteria for diagnosing PID.

 

How common is PID?

According to a 2017 Morbidity and Mortality Weekly Report that evaluated the incidence of PID in sexually active women in the US, the lifetime PID diagnosis was 4.4% among reproductive-aged women.

Kreisel K, Torrone E, Bernstein K, et al. Prevalence of pelvic inflammatory disease in sexually experienced women of reproductive age — United States, 2013–2014. MMWR Morb Mortal Wkly Rep. 2017;66(3):80–83.

 

This amounts to 2.5 million PID cases in women aged 18–44 years in the US.

Pelvic inflammatory disease (PID). CDC. Updated November 9, 2021.

 

 

Diagnosing PID

There is not a single physical, laboratory, historical, or imaging finding that demonstrates sensitivity and specificity for a PID diagnosis. While CMT is associated with PID, it can also be present in other diseases.

PID is usually diagnosed based on history and physical examination; however, laboratory and imaging studies are reserved for patients who have an uncertain diagnosis, are severely ill, or do not respond to initial therapy.

In these situations, HCPs can perform a trans-vaginal ultrasound in addition to sending cervical cultures to the laboratory and collecting vaginal secretions on a saline wet mount in the office to look for the presence of vaginal polymorphonuclear leukocytes.

During trans-vaginal ultrasound, the cervix is being directly visualized as pressure is applied with the ultrasound probe, and this can increase a provider’s confidence that a patient has CMT, ultimately aiding in the diagnosis of PID.

Grossman SH. The challenge of pelvic inflammatory disease. Am Fam Physician. 2006;73(5):859–864.

 

Classic symptoms of acute PID found on transvaginal ultrasound are fluid in the cul-de-sac, tubal wall thickness that’s greater than 5 mm, incomplete septae within the tube, and the cogwheel sign (a cogwheel appearance on the cross-section tubal view). However, not all non-OBGYN clinicians are well-versed in visualizing the absence or presence of these specific findings on ultrasound.