What are the recommended diagnostic tests and treatment options for symptoms of vaginal discharge, odor, itching, post-intercourse pain, bleeding, and recurring infected lesions, potentially indicating a Sexually Transmitted Infection (STI)?

Diagnostic Testing and Treatment for Suspected STI with Vaginal Symptoms

Chelsea requires simultaneous nucleic acid amplification testing (NAAT) for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis, along with vaginal microscopy (Gram stain or wet mount) to evaluate for bacterial vaginosis and candidiasis, plus syphilis serology and HIV testing. 1

Immediate Diagnostic Testing Required

Core STI Panel

• Perform NAAT testing simultaneously for CT, GC, and Trichomonas - this triple testing is optimal for detecting the most common treatable STIs in female patients and is significantly more sensitive than culture-based methods 1, 2
• Obtain syphilis serology using the reverse algorithm (treponemal-specific test first via EIA/chemiluminescence, followed by RPR confirmation) 1
• HIV testing is mandatory for all sexually active patients aged 13-64 seeking STI evaluation 1

Vaginal Discharge Evaluation

• Collect vaginal pool samples for immediate microscopy including wet mount preparation and Gram stain - this is more specific than culture for bacterial vaginosis diagnosis 1
• Measure vaginal pH - elevated pH (>4.5) supports bacterial vaginosis or trichomoniasis 1
• Perform potassium hydroxide (KOH) preparation to identify Candida species, noting that 10-15% of recurrent vulvovaginal candidiasis cases involve resistant Candida species requiring culture and susceptibility testing 1

Additional Testing Based on Symptoms

• Cervical inspection during speculum exam - look for mucopurulent cervicitis (friability, hyperemia, purulent discharge), strawberry cervix (trichomoniasis), or cervical lesions 1, 3
• Consider Mycoplasma genitalium testing - this emerging pathogen causes cervicitis and is increasingly recognized as a cause of persistent symptoms 1, 2

Treatment Approach

For Bacterial Vaginosis (if diagnosed)

Metronidazole 500 mg orally twice daily for 7 days is the preferred first-line treatment 4, 5

Alternative regimens include:

• Metronidazole gel 0.75%, one full applicator (5g) intravaginally once daily for 5 days 4, 5
• Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days 4, 5

For Trichomoniasis (if diagnosed)

Metronidazole 2g orally as a single dose OR Tinidazole 2g orally as a single dose 4, 5

For Cervicitis in High-Risk Populations

Ceftriaxone 250mg IM single dose PLUS Doxycycline 100mg orally twice daily for 10 days - this covers both gonorrhea and chlamydia empirically while awaiting test results 4, 2

For Vulvar Symptoms with Negative Cultures

Clotrimazole cream applied to affected area for 7 days treats potential yeast infection despite negative initial testing 6

Critical Management Steps

Partner Notification and Treatment

• Sexual partners must be referred for evaluation and treatment simultaneously - failure to treat partners is the most common cause of persistent symptoms and positive tests after treatment 1
• Contact tracing should include all partners from 60 days preceding symptom onset 4, 7
• Patients must abstain from sexual intercourse until both they and their partners complete treatment and are symptom-free 7

Follow-Up Protocol

• Reevaluate if symptoms persist after 3 days of appropriate treatment - persistent symptoms may indicate resistant organisms, alternative diagnoses, or reinfection 4, 7
• Consider alternative diagnoses if no improvement occurs, including Mycoplasma genitalium, resistant Candida species, or non-infectious causes 1

Addressing the Facial Lesions

The recurring infected whiteheads with facial swelling require separate dermatologic evaluation, as these are unlikely related to genital STIs unless there is evidence of disseminated infection (rare). However, if facial lesions are vesicular or ulcerative, consider HSV testing via viral culture or PCR 1.

Common Pitfalls to Avoid

• Do not rely on clinical diagnosis alone - symptoms overlap significantly between different genital infections, and 25-40% of causes may not be identified without proper testing 1
• Do not treat based on symptoms without microscopic confirmation - this leads to misdiagnosis and inappropriate therapy 4
• Do not assume treatment failure means resistant organisms - reinfection from untreated partners is the most likely cause of persistent positive tests 1
• Do not delay partner treatment - asymptomatic partners are common sources of reinfection, and many infections are acquired from partners unaware of their infection status 1
• Recognize that 70% of HSV and trichomoniasis infections and 53-100% of extragenital gonorrhea/chlamydia are asymptomatic - partners may be infected without symptoms 2

Post-Coital Bleeding Consideration

Post-intercourse bleeding warrants cervical visualization to assess for cervicitis, ectropion (normal in adolescents), friability, or lesions that may indicate STI-related inflammation or other pathology requiring further evaluation 1, 3.