A 24-year-old woman comes to the office for an annual examination. The patient feels well and has no concerns. She has no chronic medical conditions and takes no daily medications. Her last Pap test was performed 3 years ago and was normal. She is sexually active with 1 partner and has no history of sexually transmitted infections. The patient had a progestin-containing intrauterine device placed 2 years ago and has been amenorrheic for the past year. Temperature is 36.1 C (97 F), blood pressure is 110/80 mm Hg, and pulse is 65/min. On pelvic examination, the uterus is small with no cervical motion or adnexal tenderness. On speculum examination, the intrauterine device strings are visible through the cervical os. There are no cervical lesions or abnormal discharge. A Pap test performed today indicates no evidence of cervical dysplasia but shows multiple Actinomyces organisms. Which of the following is the best next step in management of this patient?

Question

A 24-year-old woman comes to the office for an annual examination.  The patient feels well and has no concerns.  She has no chronic medical conditions and takes no daily medications.  Her last Pap test was performed 3 years ago and was normal.  She is sexually active with 1 partner and has no history of sexually transmitted infections.  The patient had a progestin-containing intrauterine device placed 2 years ago and has been amenorrheic for the past year.  Temperature is 36.1 C (97 F), blood pressure is 110/80 mm Hg, and pulse is 65/min.  On pelvic examination, the uterus is small with no cervical motion or adnexal tenderness.  On speculum examination, the intrauterine device strings are visible through the cervical os.  There are no cervical lesions or abnormal discharge.  A Pap test performed today indicates no evidence of cervical dysplasia but shows multiple Actinomyces organisms.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Actinomyces is a gram-positive facultative anaerobe common in the gastrointestinal microbiota. Because of the close proximity of the vagina and anus, it can colonize the genital tract in women. Actinomyces may ascend into the upper genital tract and cause severe pelvic inflammatory disease, particularly in the setting of long-term intrauterine device (IUD) use. However, because Actinomyces can be part of the normal vaginal flora, its presence does not necessarily indicate active pelvic infection. In addition, Pap testing has poor specificity for Actinomyces, with a high false-positive rate (eg, 50%), even in patients with an IUD. Therefore, patients with Actinomyces or Actinomyces-like organisms found incidentally on Pap testing require additional evaluation for symptoms (eg, pelvic pain, abnormal vaginal discharge). Asymptomatic patients, such as this one, have minimal risk of infection. Therefore, they can maintain their IUD and require no further management. (Choices B, D, and E) In contrast to this patient, those with Actinomyces on Pap testing who are symptomatic (eg, abnormal vaginal discharge, pelvic pain) require IUD removal and empiric broad-spectrum antibiotics for pelvic inflammatory disease. The IUD is sent for culture; those with positive Actinomyces cultures require additional targeted treatment with penicillin. Patients with severe pelvic actinomycosis may have systemic symptoms (eg, fever, weight loss) and a pelvic mass (ie, abscess). These patients require IUD removal and culture, pelvic ultrasound, and prolonged penicillin therapy (eg, 6-12 months). (Choice C) Cervical culture is typically not performed because a positive culture for Actinomyces may be due to asymptomatic colonization. Even in symptomatic patients, a culture from the IUD is preferred over a cervical culture. Educational objective: Actinomyces is normal gastrointestinal flora and may colonize the genital tract in women, sometimes causing severe pelvic inflammatory disease. However, incidental findings of Actinomyces on Pap testing in asymptomatic women does not indicate active pelvic infection and does not require treatment.

A 24-Year-Old Woman Comes to the Office for an Annual