A 23-year-old woman comes to the office due to thick, yellow vaginal discharge for the past few days. She has had no fever or chills and has not recently changed personal hygiene items or sexual practices.
The patient takes oral contraceptives, does not use condoms, and has had the same male sexual partner for the past 3 years. Pap testing last year was normal.
On speculum examination, the cervix is erythematous and swollen and bleeds when touched with a cotton applicator. Pelvic examination reveals a small uterus with no cervical motion tenderness and no adnexal tenderness. The rest of the physical examination is normal.
Wet mount microscopy shows white blood cells, a few nonmotile bacteria, no clue cells, and no hyphae. A urine pregnancy test is negative.
Which of the following is the best next step in management of this patient?

Question

A 23-year-old woman comes to the office due to thick, yellow vaginal discharge for the past few days.  She has had no fever or chills and has not recently changed personal hygiene items or sexual practices.
The patient takes oral contraceptives, does not use condoms, and has had the same male sexual partner for the past 3 years.  Pap testing last year was normal.
On speculum examination, the cervix is erythematous and swollen and bleeds when touched with a cotton applicator.  Pelvic examination reveals a small uterus with no cervical motion tenderness and no adnexal tenderness.  The rest of the physical examination is normal.
Wet mount microscopy shows white blood cells, a few nonmotile bacteria, no clue cells, and no hyphae.  A urine pregnancy test is negative.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_97e3_d15c_853d_db68ad16bf0f_MD0002_00 This patient has acute cervicitis, likely due to an infectious etiology (eg, Chlamydia trachomatis, Neisseria gonorrhoeae). Untreated cervicitis can cause pelvic inflammatory disease (PID) with long-term sequelae (eg, infertility, ectopic pregnancy, chronic pelvic pain); in pregnant women with cervicitis, obstetrical (eg, spontaneous abortion, preterm prelabor rupture of membranes) or neonatal (eg, conjunctivitis) complications may occur. Patients can be asymptomatic (70%) or have purulent vaginal discharge, postcoital or intermenstrual bleeding, dysuria, dyspareunia, and vulvovaginal pruritus. The diagnosis is clinical based on pelvic examination showing purulent endocervical discharge and cervical friability (eg, bleeding due to mild trauma from a cotton swab). Patients with concomitant PID can also have cervical motion, uterine, or adnexal tenderness. Nucleic acid amplification testing (NAAT) is performed to confirm chlamydial or gonorrheal infection; patients also require testing for bacterial vaginosis and trichomoniasis (eg, wet mount microscopy). pelvic examination Current guidelines recommend empiric treatment (without waiting for test results) of the patient and sexual partners with ceftriaxone plus doxycycline to cover both chlamydia and gonorrhea. Fluoroquinolones (eg, ciprofloxacin) are avoided due to resistant gonococcus (Choice B). Repeat testing 3-6 months after treatment is recommended, particularly in patients with a high risk of recurrence (eg, >1 sexual partner). (Choice A) Cervical histopathology and cytology can be used to diagnose cervical dysplasia or cancer, which may present with cervical friability and vaginal discharge; however, a discrete cervical mass is typically present. In addition, this patient had normal Pap testing 1 year ago, making cervical cancer unlikely. (Choice D) Metronidazole can treat bacterial vaginosis and trichomoniasis. Bacterial vaginosis usually presents with thin, malodorous vaginal discharge and clue cells (ie, epithelial cells covered in bacteria) on wet mount microscopy. Trichomoniasis due to Trichomonas vaginalis infection can be asymptomatic or present with cervicitis/vaginitis (eg, frothy vaginal discharge, vulvar pruritus, cervical punctate hemorrhages) or urethritis. Wet mount microscopy usually shows motile organisms, but when it is nondiagnostic, NAAT can be used to confirm trichomoniasis. clue cells (Choice E) Cervical Gram stain is not recommended for evaluation of acute cervicitis due to low sensitivity (nearly 50%) for C trachomatis and N gonorrhoeae. Educational objective: Acute cervicitis typically presents with purulent cervical discharge and a friable cervix. Management includes nucleic acid amplification testing for chlamydia and gonorrhea as well as empiric treatment with ceftriaxone plus doxycycline. __________ References: Update to CDC's treatment guidelines for gonococcal infection, 2020. (http://www.ncbi.nlm.nih.gov/pubmed/33332296) Sexually transmitted diseases treatment guidelines, 2015. (http://www.ncbi.nlm.nih.gov/pubmed/26042815)

A 23-Year-Old Woman Comes to the Office Due to Thick