Patients with Pelvic Inflammatory Disease PID may present with CMT, colloquially known as chandelier sign, during the pelvic examination. This article explains the diagnosis of PID along with the examination of the chandelier sign.

Cervical motion tenderness (CMT) is a gynaecological finding that could indicate the presence of a peritoneal infection. It is known colloquially as the “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 the 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. While PID is often caused by multiple microbes, the most common pathogens responsible are N. gonorrhoea and C. trachomatis.

It is important to note that although the majority of PID cases are caused by sexually transmitted diseases, about 10% of cases are not.

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.

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

Diagnosing PID

1. Symptoms of PID include lower abdominal pain, dyspareunia, fever, back pain, and vomiting, as well as symptoms of lower genital tract infection such as abnormal vaginal discharge or bleeding, itching, and odour.
2. 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.
3. 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.
4. 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.
5. During a transvaginal ultrasound, the cervix is directly visualised 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.

Classic signs of acute PID found on transvaginal ultrasound are as follows: 

• Fluid in the cul-de-sac
• Tubal wall thickness that’s greater than 5 mm
• Incomplete septae within the tube
• The cogwheel sign (a cogwheel appearance on the cross-section tubal view)

However, not all non-OBGYN clinicians are well-versed in visualising the absence or presence of these specific findings on ultrasound.

This story is contributed by Samar Mahmoud and is a part of our Global Content Initiative, where we feature selected stories from our Global network which we believe would be most useful and informative to our doctor members.