A 37-year-old woman comes to the office for evaluation of abnormal vaginal discharge. She noticed increased clear, watery vaginal discharge 4 months ago and now has intermenstrual bleeding. She reports no pruritus or dysuria. The patient is sexually active with a male partner and uses condoms for contraception. She has had 5 lifetime sexual partners. She has no medical problems or previous surgeries. The patient has a 24-pack-year smoking history but does not use alcohol or illicit drugs. Blood pressure is 120/70 mm Hg and pulse is 88/min. On pelvic examination, a raised, ulcerative lesion is noted on the cervix, and clear discharge is present. The vaginal mucosa is not erythematous and has no lesions. The uterus is small, mobile, and anteverted, with no adnexal masses or cervical motion tenderness. No inguinal lymphadenopathy is present. Which of the following is the best next step in the diagnosis of this patient's condition?

Question

A 37-year-old woman comes to the office for evaluation of abnormal vaginal discharge.  She noticed increased clear, watery vaginal discharge 4 months ago and now has intermenstrual bleeding.  She reports no pruritus or dysuria.  The patient is sexually active with a male partner and uses condoms for contraception.  She has had 5 lifetime sexual partners.  She has no medical problems or previous surgeries.  The patient has a 24-pack-year smoking history but does not use alcohol or illicit drugs.  Blood pressure is 120/70 mm Hg and pulse is 88/min.  On pelvic examination, a raised, ulcerative lesion is noted on the cervix, and clear discharge is present.  The vaginal mucosa is not erythematous and has no lesions.  The uterus is small, mobile, and anteverted, with no adnexal masses or cervical motion tenderness.  No inguinal lymphadenopathy is present.  Which of the following is the best next step in the diagnosis of this patient's condition?

Quizplus · Accepted Answer

11ec25c8_d9ae_04cb_bc81_312bb4d6b662_MD0003_00 Cervical cancer is most commonly asymptomatic and detected only during screening. When symptoms do occur, as in this patient, they can include vaginal discharge, postcoital or intermenstrual bleeding, and a cervical lesion. Lesions suspicious for malignancy (eg, ulcerative, friable, raised), particularly in patients with risk factors (eg, long-term tobacco use), require a cervical biopsy. Advanced cervical cancer may present with symptoms of local invasion, including a large vascular cervical mass with heavy vaginal bleeding. (Choice B) Genital herpes typically presents as vesicular or ulcerating lesions on the vulva or vagina with tender lymphadenopathy; it is diagnosed using a herpes simplex viral culture. Cervical ulcers alone are not typical and suggest another etiology. (Choice C) Gonorrhea and chlamydia infections can present with purulent cervical discharge and cervical motion tenderness; they do not cause ulcerative, indurated cervical lesions, so nucleic acid amplification testing is not indicated in this patient. (Choice D) Pelvic ultrasonography may be used to evaluate the endometrium, uterine shape and size, and the adnexa. It is not indicated in the evaluation of a visible cervical lesion. (Choice E) Vaginal discharge is a nonspecific symptom, and a cervical lesion suggests an etiology other than vaginitis (eg, trichomoniasis, bacterial vaginosis). Wet mount is used to diagnosis vaginitis but is not indicated in this patient due to the visible cervical lesion. Educational objective: Cervical cancer may present with irregular bleeding, vaginal discharge, and a visible raised cervical lesion. Immediate biopsy is necessary to confirm the diagnosis. References: Locally advanced cervical cancer: what is the standard of care? (http://www.ncbi.nlm.nih.gov/pubmed/20473164)

A 37-Year-Old Woman Comes to the Office for Evaluation of Abnormal