Pediatric emergency medicine trisk 2133 2133
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swab used during the examination due to cervical friability. Testing for etiology is
essential as it is difficult to determine based on examination findings alone. There
are, however, several characteristic findings that may aid the diagnosis. Edema in
the zone of ectopy may suggest gonorrhea or chlamydia; ulcerations or vesicles
are characteristic of HSV; and punctate hemorrhages are seen in T. vaginalis. As
many adolescent patients, particularly those in the ED setting, can be assessed
without a speculum examination, the diagnosis can be made based on the clinical
picture. After determining the patient has cervicitis based on physical
examination findings of cervical discharge or endocervical friability, or based on
vaginal discharge in a patient at risk for a sexually transmitted disease, testing
should be performed for gonorrhea, chlamydia, bacterial vaginosis,
trichomoniasis, and Mycoplasma genitalium . Testing for gonorrhea and
chlamydia can be performed with a nucleic acid amplification test (NAAT) using
urine, a vaginal sample, or an endocervical sample (least preferred, and not
necessary if the speculum examination is not indicated). Trichomonas can also be
detected using NAAT. Testing for bacterial vaginosis generally requires wet prep
and vaginal pH testing (see bacterial vaginitis discussion). M. genitalium testing
is available through a recently approved NAAT; testing and treatment is
controversial. It is important to remember that the diagnosis of one sexually
transmitted infection does not exclude other infections. In addition to laboratory
tests, the clinician should perform a bimanual examination to assess for
concurrent PID.
Management
Patients with acute cervicitis should receive empiric therapy for gonorrhea and
chlamydia while awaiting test results. This can be treated with ceftriaxone (250
mg intramuscularly or intravenously; lidocaine hydrochloride can be used as
diluent to decrease discomfort) and azithromycin (1 g orally), or doxycycline
(100 mg orally twice a day for 7 days). Treatment of trichomonas, bacterial
vaginosis, and herpes simplex virus (HSV) are discussed in the corresponding
sections. Patients should be counseled to abstain from sexual activities for 7 days
following treatment.
PELVIC INFLAMMATORY DISEASE
Goals of Treatment
The goals of treatment of PID are early recognition, initiation of appropriate
antimicrobial treatment, and detection of complications.
