What is ‘chandelier sign’—and how can you treat it?

By Samar Mahmoud, PhD | Medically reviewed by Kristen Fuller, MD
Published August 12, 2022

Key Takeaways

  • Chandelier sign is the colloquial term used to refer to cervical motion tenderness, a pelvic exam finding that is indicative of a peritoneal infection.

  • Pain during manipulation of the cervix is associated with pelvic inflammatory disease but can also be present during ectopic pregnancy, endometriosis, ovarian torsion, appendicitis, and perforated abdominal viscus.

  • Pelvic inflammatory disease can often go undiagnosed which may put affected women at increased risk for infertility.

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

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.

It may be helpful for physicians to learn more about this infection—its symptoms, causes, and how to properly diagnose it.

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.[] While PID is often caused by multiple microbes, the most common pathogens responsible are N. gonorrhoeae 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

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 odor.

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.[]

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.

What this means for you 

Patients with PID may present with CMT, colloquially known as chandelier sign, during a pelvic examination. CMT can also be a sign of other conditions, including appendicitis and ectopic pregnancy. It’s essential that HCPs accurately diagnose PID, as even asymptomatic or mild PID can lead to fertility problems. To avoid this, providers should maintain a low threshold for PID diagnosis, commencing treatment if a patient presents with CMT or uterine tenderness or adnexal tenderness during a pelvic exam, or if a patient has pelvic pain with no discernible cause.

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