What is the recommended evaluation and treatment for a 33-year-old female with 1 month of vaginal discharge and dyspareunia (painful intercourse)?

Evaluation and Treatment of Vaginal Discharge with Dyspareunia in a 33-Year-Old Woman

This patient requires immediate pelvic examination with vaginal pH testing, wet mount microscopy, and nucleic acid amplification testing (NAAT) for gonorrhea and chlamydia, followed by empiric treatment based on clinical findings while awaiting test results. 1, 2

Diagnostic Evaluation

Essential Physical Examination Findings

A speculum examination is mandatory and cannot be replaced by self-obtained swabs or history alone, as studies show that eliminating speculum examination results in missing 32% of bacterial vaginosis cases, 48% of candidiasis cases, and 34% of trichomoniasis cases. 3

During examination, assess for:

• Cervical motion tenderness, uterine tenderness, or adnexal tenderness - these findings indicate possible pelvic inflammatory disease (PID) and require immediate empiric antibiotic therapy 1, 2
• Mucopurulent cervical discharge - suggests cervicitis from gonorrhea or chlamydia 1
• Vaginal discharge characteristics - homogeneous white discharge (bacterial vaginosis), thick white cottage cheese-like discharge (candidiasis), or yellow-green frothy discharge (trichomoniasis) 1, 4

Point-of-Care Testing

Perform vaginal pH testing and wet mount microscopy immediately during the examination - these simple tests provide diagnostic information within minutes and guide empiric treatment. 1, 5

• pH >4.5 indicates bacterial vaginosis or trichomoniasis 1, 5
• pH ≤4.5 suggests vulvovaginal candidiasis 5
• Whiff test (fishy odor with 10% KOH) indicates bacterial vaginosis or trichomoniasis 1, 5
• Saline wet mount - look for clue cells (bacterial vaginosis) or motile trichomonads 1, 5
• KOH preparation - identifies yeast or pseudohyphae of Candida species 1

Laboratory Testing

Order NAAT for Chlamydia trachomatis and Neisseria gonorrhoeae on cervical or urine samples - these are the preferred diagnostic tests and should be obtained in all sexually active women under 25 years or those with risk factors (new/multiple partners, unprotected sex). 1, 6, 7

Culture for Trichomonas vaginalis should be obtained if wet mount is negative but symptoms suggest trichomoniasis, as microscopy has only 50% sensitivity. 1

Treatment Approach

Cervicitis (Mucopurulent Cervical Discharge)

If cervicitis is present or the patient is at high risk for STIs (age <25, new/multiple partners), initiate presumptive treatment immediately without waiting for test results:

• Doxycycline 100 mg orally twice daily for 7 days (preferred for chlamydia) 1, 6, 7
• Alternative: Azithromycin 1 g orally as a single dose (use only if adherence concerns exist) 1, 7
• Add ceftriaxone for gonorrhea if prevalence >5% in your patient population or if gonorrhea is suspected: ceftriaxone 500 mg IM for patients weighing <150 kg, or 1 g IM for patients ≥150 kg 6, 7

Bacterial Vaginosis

If three of four Amsel criteria are present (homogeneous white discharge, clue cells, pH >4.5, positive whiff test), treat with metronidazole 500 mg orally twice daily for 7 days. 1, 8, 5

• This 7-day regimen achieves 95% cure rate compared to 84% for single-dose therapy 8
• Warn patients to avoid alcohol during treatment and for 24 hours after completion due to disulfiram-like reaction risk 1, 8, 9
• Partner treatment is not indicated as it does not prevent recurrence 1, 8

Vulvovaginal Candidiasis

If pruritus with white discharge and pH ≤4.5 with yeast/pseudohyphae on microscopy:

• Fluconazole 150 mg orally as a single dose (preferred for convenience) 1, 5, 10
• Alternative: Topical azoles (clotrimazole, miconazole, terconazole) for 3-7 days 1, 5
• Partner treatment is not routinely needed unless recurrent infections occur 1

Trichomoniasis

If motile trichomonads are seen on wet mount or culture is positive:

• Metronidazole 500 mg orally twice daily for 7 days (preferred regimen per 2021 CDC guidelines) 1, 5, 6
• Alternative: Metronidazole 2 g orally as a single dose (90-95% cure rate) 1, 5, 9
• Partner treatment is mandatory - treat all sexual contacts within 60 days 1, 5

Pelvic Inflammatory Disease

If cervical motion tenderness, uterine tenderness, or adnexal tenderness is present, initiate empiric PID treatment immediately:

• Ceftriaxone 500 mg IM (or 1 g if ≥150 kg) as a single dose 6, 7
• PLUS doxycycline 100 mg orally twice daily for 14 days 1
• PLUS metronidazole 500 mg orally twice daily for 14 days 1, 6

Hospitalization is indicated if: patient is pregnant, unable to tolerate oral therapy, has tubo-ovarian abscess, or fails to improve within 72 hours of outpatient therapy. 1

Critical Clinical Pitfalls

Do not wait for test results to initiate treatment in high-risk patients - the one-month duration of symptoms increases risk for ascending infection and PID complications including infertility, ectopic pregnancy, and chronic pelvic pain. 1, 2

Dyspareunia (painful intercourse) is a red flag symptom that may indicate cervicitis or early PID, warranting lower threshold for empiric antibiotic treatment. 1, 2

Laboratory testing fails to identify a cause in a substantial minority of women - if symptoms persist despite negative initial testing, consider culture for Trichomonas (more sensitive than microscopy) and reevaluation for cervicitis or PID. 1

Partner Management and Follow-Up

Sexual partners must be evaluated and treated if gonorrhea, chlamydia, or trichomoniasis is identified or suspected. 1, 5

Patients should abstain from sexual intercourse until they and their partners complete therapy (7 days after single-dose regimen or after completion of multi-day regimen). 1

Follow-up examination is required only if symptoms persist or worsen - routine test-of-cure is not needed for most vaginitis cases but is recommended for pharyngeal gonorrhea and rectal chlamydia treated with azithromycin. 1, 6