What is the most likely diagnosis and appropriate treatment for a 22-year-old woman presenting with thin purulent mildly odorous vaginal discharge, dysuria, intermenstrual bleeding, deep dyspareunia, and a friable cervix?

Mucopurulent Cervicitis

Most Likely Diagnosis

This 22-year-old woman has mucopurulent cervicitis, most likely caused by Chlamydia trachomatis or Neisseria gonorrhoeae, and requires immediate empiric antibiotic therapy with azithromycin 1 g orally as a single dose (or doxycycline 100 mg orally twice daily for 7 days) plus treatment for gonorrhea given her high-risk profile. 1

Clinical Reasoning

The constellation of findings strongly indicates cervicitis rather than vaginitis or other conditions:

• Cervical friability (sustained endocervical bleeding with gentle swabbing) is one of the two cardinal signs of mucopurulent cervicitis 1
• Thin purulent discharge represents the second cardinal sign—purulent or mucopurulent endocervical exudate visible in the cervical canal 1
• Intermenstrual bleeding and deep dyspareunia are characteristic manifestations of chlamydial and gonococcal cervicitis 1, 2
• Dysuria commonly accompanies cervical infection, particularly with chlamydia 1

The mild odor is nonspecific but does not suggest bacterial vaginosis (which typically produces a fishy odor), making cervicitis the primary diagnosis. 3

Immediate Management Algorithm

Step 1: Initiate Empiric Therapy Without Delay

Start treatment immediately before test results return because this patient meets multiple criteria for empiric therapy: 1

• Age < 25 years
• Sexually active with clinical cervicitis
• High community STD prevalence likely given age and presentation

Step 2: Recommended Empiric Regimen

For chlamydia coverage (required): 1

• Azithromycin 1 g orally single dose OR
• Doxycycline 100 mg orally twice daily for 7 days

For gonorrhea coverage (add when local prevalence >5% or high-risk setting): 1

• Given her age and presentation, add gonococcal treatment per current CDC guidelines for dual therapy

Step 3: Essential Diagnostic Testing

Obtain these tests while initiating treatment: 1

• NAATs for C. trachomatis and N. gonorrhoeae from cervical or urine specimens—these have markedly higher sensitivity (≈50%) than microscopy 1
• Wet-mount microscopy of vaginal secretions to assess for ≥10 WBC per high-power field and detect Trichomonas vaginalis 1
• Test for bacterial vaginosis and treat if present 1
• Syphilis and HIV testing for every patient with new STI diagnosis 1

Step 4: Partner Management (Critical)

All sexual partners within the preceding 60 days must be: 1

• Notified and examined
• Treated with the same regimen regardless of symptoms
• Instructed to abstain from intercourse for 7 days after single-dose therapy or until completing 7-day course

Why Immediate Treatment Matters

Prevention of long-term sequelae—including pelvic inflammatory disease, infertility, ectopic pregnancy, and chronic pelvic pain—is directly linked to immediate administration of appropriate antibiotics. 4, 1 Delaying treatment while awaiting test results risks progression to upper genital tract infection. 3

Common Pitfalls to Avoid

• Do not wait for test results in this high-risk patient before starting antibiotics—she meets clear criteria for empiric therapy 1
• Do not treat for vaginitis alone—the friable cervix and purulent cervical discharge indicate cervicitis, not simple vaginitis 1
• Do not omit gonococcal coverage in a 22-year-old with mucopurulent cervicitis in most U.S. settings where prevalence exceeds 5% 1
• Do not forget partner treatment—failure to treat partners leads to reinfection and continued transmission 1

Follow-Up Protocol

• Return for reassessment if symptoms persist after completing therapy or if new symptoms develop 1
• For persistent cervicitis after initial treatment: 1
  • Re-evaluate for possible re-exposure to an STD
  • Reassess vaginal flora
  • Exclude relapse or reinfection with specific pathogens
  • Verify that all sex partners have been evaluated and treated

Additional Considerations

• Most cases are caused by C. trachomatis or N. gonorrhoeae when a pathogen is identified 1, 5
• Concurrent trichomoniasis should be treated with metronidazole 2 g orally single dose if identified on wet mount 1
• Patients should demonstrate substantial improvement within 3 days after starting therapy; those who do not improve require reevaluation and possible hospitalization 4