Observer Agreement With Laparoscopic Diagnosis of Pelvic Inflammatory Disease Using Photographs Pontus Molander, MD, Patrik Finne, MD, PhD, Jari Sjöberg, MD, PhD, John Sellors, MD, PhD, and Jorma Paavonen, MD, PhD OBJECTIVE: To test the intraobserver (are observers likely to agree between themselves?) and interobserver (are observ- ers likely to agree with other observers?) reproducibility and the overall diagnostic accuracy of laparoscopic diagno- sis of pelvic inflammatory disease (PID). METHODS: Three senior consultants and three residents in training in obstetrics and gynecology scored the four lapa- roscopic images (adnexa, cul-de-sac, and pelvic panoramic view) from each of 40 patients and repeated the process 2 days later after the order of presentation had been random- ized. A standardized predesigned scoring form was used. Histopathologically proven PID was used as the gold stan- dard. RESULTS: The overall accuracy of the laparoscopic diagno- sis of PID was 78%, the sensitivity was 27%, and the speci- ficity was 92%. The overall intraobserver reproducibility of the diagnosis of PID was only fair (  0.58), and it was clearly better among the consultants than among the resi- dents (  0.76 and 0.39, respectively). The overall inter- observer reproducibility was poor to fair (  0.43), and it was again better among the consultants than among the residents (  0.48 and 0.38, respectively). When specific diagnostic features (including tubal erythema, edema, ad- hesions, cul-de-sac fluid) were separately analyzed, the results were no different suggesting only poor-to-fair repro- ducibility. CONCLUSION: Based on photographic images, the observer reproducibility and the overall diagnostic accuracy of the laparoscopic diagnosis of PID are unsatisfactory when his- topathologically proven PID is used as the gold standard. (Obstet Gynecol 2003;101:875– 80. © 2003 by The Amer- ican College of Obstetricians and Gynecologists.) Laparoscopy has been recognized as the gold standard for the diagnosis of pelvic inflammatory disease (PID). 1 Many studies have been performed on the correlation between the clinical and the laparoscopic diagnosis of PID. Most studies have demonstrated a relatively low sensitivity for the clinical diagnosis usually in the range of 60 –70%. 2–4 Similarly, laboratory criteria seem to have a low sensitivity in the diagnosis of PID. 2 Several other diagnostic modalities including transvaginal ultra- sound, 5 magnetic resonance imaging, 6 endometrial biop- sy, 7 and evidence of lower genital tract infection 8 have also been compared with laparoscopy in the diagnosis of PID. Laparoscopic criteria for the diagnosis of PID include tubal erythema, tubal edema, and the presence of puru- lent exudate. 1,9 In some studies, the acute salpingitis score has been derived to improve laparoscopic diagno- sis and also to determine the severity of PID. 10 However, uniform classification systems for the laparoscopic diag- nosis of PID have been difficult to develop and imple- ment. In fact, laparoscopy has never been properly vali- dated as the gold standard in the diagnosis of PID. An expectation bias by the laparoscopist can be a major problem. 11 Sellors et al 11 demonstrated that laparoscopy was no better than chance in the diagnosis of salpingitis when fimbrial minibiopsy showing histopathologic evi- dence of salpingitis was used as the gold standard. This study clearly demonstrated the inaccuracy of the laparo- scopic diagnosis of PID. Surprisingly, only few studies have tested observer reproducibility of specific laparo- scopic findings. 12–15 Thus, there is a growing concern about the use of laparoscopy as the gold standard. Therefore, we decided to perform a systematic study of the observer reproducibility and diagnostic accuracy of the laparoscopic diagnosis of PID among unselected patients referred for acute pelvic pain. We used the histopathologic diagnosis of PID as the gold standard. MATERIALS AND METHODS Three senior consultants (experience in laparoscopic surgery 6 –15 years, mean 12 years) and three residents in training (third-year residents undergoing rotation in gynecologic surgery) from the Department of Obstetrics From the Departments of Obstetrics and Gynecology and Clinical Chemistry, University of Helsinki, Helsinki, Finland; and Program for Appropriate Technol- ogy in Health, Seattle, Washington. This study was supported by grants from the Helsinki University Research Funds, K. Albin Johansson Funds, and Medical Society of Finland. 875 VOL. 101, NO. 5, PART 1, MAY 2003 0029-7844/03/$30.00 © 2003 by The American College of Obstetricians and Gynecologists. Published by Elsevier. doi:10.1016/S0029-7844(03)00013-9