What work‑up and treatment should I initiate for a female patient with blood‑colored vaginal discharge, left lower abdominal pain, urinary‑tract‑like tenderness, fatigue, perinephric swelling, who requests a comprehensive sexual‑health panel (including Mycoplasma genitalium) and evaluation of the kidney, liver, and spleen?

Comprehensive Work-Up and Management for Suspected Pelvic Inflammatory Disease with Sexual Health Concerns

This patient requires immediate comprehensive STI testing including nucleic acid amplification tests (NAATs) for gonorrhea, chlamydia, and Mycoplasma genitalium, along with imaging of the kidneys to evaluate the reported perinephric swelling, followed by empiric antibiotic treatment if PID is suspected clinically.

Initial Diagnostic Work-Up

Sexual Health Testing (Priority)

• Obtain NAATs for Neisseria gonorrhoeae and Chlamydia trachomatis from endocervical swab or first-void urine, as these are the most sensitive and specific tests available 1
• Test specifically for Mycoplasma genitalium using NAAT, as this pathogen is strongly associated with cervicitis, endometritis, and pelvic inflammatory disease independent of gonorrhea and chlamydia 2, 3
• Perform HIV testing and syphilis serology as part of comprehensive sexual health screening 1
• Cervical examination to assess for mucopurulent cervicitis (yellow endocervical discharge), cervical motion tenderness, and friability 1

Gynecological Assessment

• Pelvic examination looking specifically for:
  • Cervical motion tenderness (suggests PID) 1
  • Uterine tenderness 1
  • Adnexal tenderness, particularly on the left side given her symptoms 1
  • Presence of mucopurulent cervical discharge 1
• Vaginal wet mount and pH testing to evaluate for bacterial vaginosis, trichomoniasis, or candidiasis, though blood-colored discharge is more concerning for infection or inflammation 1

Abdominal and Renal Evaluation

• Renal ultrasound or CT scan to evaluate the reported perinephric swelling and assess kidney, liver, and spleen 1
• Urinalysis and urine culture to rule out concurrent urinary tract infection, given her urinary symptoms 1
• Complete blood count to assess for leukocytosis suggesting infection 1
• Liver and kidney function tests given her concerns about these organs 1

Clinical Decision-Making for Treatment

If PID is Suspected Clinically

The presence of lower abdominal pain, cervical motion tenderness, blood-colored discharge, and recent antibiotic failure strongly suggests pelvic inflammatory disease. Given her recent 5-week antibiotic course without resolution, empiric treatment must cover atypical organisms, particularly Mycoplasma genitalium 3.

Outpatient Treatment Regimen (if mild-moderate symptoms)

• Ceftriaxone 250 mg IM single dose PLUS Doxycycline 100 mg orally twice daily for 14 days PLUS Metronidazole 500 mg orally twice daily for 14 days 1
• However, given her recent antibiotic failure and request for M. genitalium testing, consider adding or substituting Azithromycin 500 mg on day 1, then 250 mg daily for 4 days OR Moxifloxacin 400 mg daily for 14 days if M. genitalium is suspected or confirmed 2, 4

Hospitalization Criteria

Consider hospitalization if 1:

• Severe pain suggesting abscess or other surgical emergency
• Fever present
• Unable to tolerate oral medications
• Pregnancy (though patient is requesting sexual health screening, pregnancy status should be confirmed)
• Failed outpatient therapy

Critical Consideration for Mycoplasma genitalium

M. genitalium is strongly associated with treatment failure following standard PID regimens (cefoxitin and doxycycline) and is often resistant to doxycycline 3. Given this patient's recent 5-week antibiotic course without improvement:

• If M. genitalium testing is positive: Treat with Moxifloxacin 400 mg orally daily for 7-14 days as this is currently the most effective treatment for azithromycin-resistant strains 2, 4
• If M. genitalium testing is unavailable or results pending: Consider empiric moxifloxacin given treatment failure and high suspicion 2

Follow-Up Protocol

• Re-evaluate within 72 hours if outpatient treatment is initiated to assess for clinical improvement (reduction in pain, tenderness, fever) 1
• If no improvement within 3-5 days, hospitalization and IV antibiotics are indicated, or further diagnostic work-up for abscess, tumor, or other pathology 1
• Repeat testing for C. trachomatis and N. gonorrhoeae 7-10 days after completing therapy, and again at 4-6 weeks to assess for reinfection 1
• Test-of-cure for M. genitalium if initially positive, as treatment failure rates are significant 2

Partner Management

All sexual partners within the past 60 days must be evaluated and treated empirically regardless of symptoms, as asymptomatic carriage is common 1. Partners should receive treatment effective against gonorrhea, chlamydia, and M. genitalium 1.

Common Pitfalls to Avoid

• Do not delay treatment waiting for test results if PID is clinically suspected, as delays increase risk of infertility and chronic pain 1
• Do not use doxycycline alone for suspected M. genitalium infection, as resistance is common 4, 3
• Do not ignore persistent symptoms after standard PID treatment—this strongly suggests M. genitalium or other resistant organisms 3
• Do not forget to abstain from sexual intercourse until patient and all partners complete treatment and symptoms resolve 1