A 26-year-old woman comes to the office for an annual examination. The patient has regular menses with no intermenstrual spotting or abnormal vaginal discharge. Review of systems is negative. The patient is sexually active with her boyfriend of 1 year and uses combined oral contraceptives. She has no chronic medical conditions or previous surgeries. The patient's menstrual periods are regular, every 28 days with 3-4 days of light vaginal bleeding. Her last menstrual period ended 2 weeks ago. The patient's last Pap test, 3 years ago, was normal; the human papillomavirus vaccination series was completed at age 17. She has never had a sexually transmitted infection and has had 4 lifetime sexual partners. Family history is noncontributory. The patient does not use tobacco, alcohol, or illicit drugs. She has no known allergies. Temperature is 36.7 C (98.1 F), blood pressure is 134/88 mm Hg, and pulse is 76/min. BMI is 32 kg/m². Pelvic examination reveals normal external genitalia with no areas of inflammation. On speculum examination, the cervix has no lesions, is nonfriable, and has no discharge. The uterus is small and mobile and has no cervical motion tenderness. There are no adnexal masses. Pap testing is negative for intraepithelial lesions; however, multiple motile, flagellated organisms are visualized. Which of the following is the most appropriate next step in management of this patient?

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Quizplus · Accepted Answer

Explanation: 11ec2b69_bfcd_d1ef_8f63_c7ea0ba1d927_MD0005_00 Motile, flagellated organisms identified on a Pap test or wet mount are consistent with Trichomonas vaginalis, a protozoan parasite that is transmitted sexually. Clinical features in women include dysuria, urinary frequency, dyspareunia, vaginal pruritus, and a green, frothy discharge. Vaginal and cervical punctate hemorrhages ("strawberry cervix") are sometimes seen. However, vaginal trichomoniasis can also be asymptomatic in women and identified incidentally on routine cervical cytology, as in this patient. trichomoniasis Irritation and exposed bleeding areas in the vagina, as well as the presence of Trichomonas, can increase rates of HIV transmission. As a result, screening is recommended in HIV-positive patients and in women with a history of multiple sexually transmitted infections. Therefore, regardless of symptoms, both partners are treated with oral metronidazole to reduce the risk of reinfection and of HIV transmission (Choice C). Sexual partners should undergo clinical evaluation and testing for other sexually transmitted infections; however, expedited partner therapy (eg, prior to evaluation) is an appropriate initial step. (Choice A) Azithromycin is used to treat Chlamydia trachomatis, a bacterium causing a sexually transmitted infection that typically presents as asymptomatic cervicitis. Chlamydia is diagnosed via nucleic acid amplification testing and is not evident on microscopy or Pap test. (Choice D) Trichomoniasis should always be treated as symptoms may eventually develop and the presence of Trichomonas organisms can facilitate HIV transmission. (Choice E) Oral metronidazole has a significantly higher cure rate than vaginal metronidazole. It achieves higher therapeutic levels that eradicate reservoirs in the urethra and periurethral glands and thereby prevents recurrence. Educational objective: Trichomonas vaginalis, a flagellated, motile protozoan, causes trichomoniasis, a common sexually transmitted infection. Infected patients and their sexual partners are treated with oral metronidazole regardless of symptoms (or lack thereof) as untreated Trichomonas infection can increase the rates of HIV transmission. References: Trichomoniasis - are we giving the deserved attention to the most common non-viral sexually transmitted disease worldwide? (http://www.ncbi.nlm.nih.gov/pubmed/28357378) Challenges and persistent questions in the treatment of trichomoniasis. (http://www.ncbi.nlm.nih.gov/pubmed/27697044)

A 26-Year-Old Woman Comes to the Office for an Annual