Interview Questions
It is important to ask the patient the following questions:
- Is your pain worse at the start or the end of urination?;
- How severe is your pain with urination?;
- When did your pain with urination start?;
- Do you have any blood in your urine?;
- What are the events surrounding the start of your pain with urination?;
- Do you have any genital sores or discharge?;
- When did your last period begin?
Clinical Findings
Clinical findings are an increase in the urinary frequency, vaginal discharge, cervical friability, heavier periods, spotting, pain during sexual intercourse, fever, and pain in the lower abdomen (Hethcote & Yorke, 2014). Additional findings might also include a sore throat and dysuria.
Diagnostic Studies
The three approaches to laboratory testing for diagnosing gonorrhea include microscopy, bacterial culture, and NAAT (Public Health Ontario, 2013). Microscopy provides high sensitivity and specificity, but only for men, and is not recommended for women. Bacterial culture should be viewed as a more suitable diagnostic study since it has a test specificity of more than 99 percent; it is the most accurate testing method among the suggested ones. Nucleic Acid Amplification Testing or NAAT is also a highly specific method of testing, although it is slightly less accurate than bacterial culture, and can sometimes lead to false positive results.
Genitourinary exam (external exam, vaginal exam, speculum exam (including vaginal pH), and bimanual exam), evaluation of vaginal mucosa for inflammation, examination of the cervix, and evaluation of pH of the vaginal discharge are also necessary to provide the right diagnosis.
Primary and Differential Diagnoses
The differential diagnoses include bacterial vaginosis, candida vaginitis, and herpes genital. The primary diagnosis is cervicitis.
Bacterial vaginosis has the symptoms similar to the ones described by the patient and observed by the clinician: vaginal discharge that might have a bad odor or be grayish or yellow (Srinivasan et al., 2012). However, bacterial vaginosis does not usually lead to painful urination and increased urinary frequency.
Candida vaginitis can have the following symptoms: burning, irritation, dyspareunia, as well as erythema or edema (De Bernardis, Arancia, Sandini, Graziani, & Norelli, 2015). However, thick and white vaginal discharge on the vaginal walls is also common for this condition, which was not observed in the patient.
Herpes genital is a sexually transmitted infection that has the following symptoms: blisters and ulcers in the genital area, itching, and burning. Body aches and fever can also be observed in some cases (Awasthi & Friedman, 2014). Despite some similarity in symptoms, no ulcers in the genital area were noticed.
Cervicitis is the infection of the lower end of the uterus that can be caused by different factors, including sexually transmitted diseases, allergies, or bacterial imbalance. However, due to patient’s recent unprotected sex, specific symptoms such as vaginal discharge, dysuria and increased urinary frequency, gonococcal cervicitis is assumed to be the primary diagnosis.
Management Plan
Pharmacotherapy for this patient includes ceftriaxone 250 mg IM x 1 dose and azithromycin 1000 mg orally x 1 dose. Gonorrheal infection shows resistance to previous generations of antibiotics, whereas ceftriaxone is recommended as an effective treatment for it (Bolan & Wasserheit, 2012). Additionally, the clinician can prescribe azithromycin 1000 mg orally x 1 dose, which is used for the treatment of both ceftriaxone-resistant gonorrhea and presumed concurrent chlamydia infection. If ceftriaxone is proven to be ineffective for this patient, azithromycin is a suitable choice.
The patient will need to be educated about the treatment of recent sexual partners, receive additional information about the influence of barrier protection on the risk of having STDs, as well as a referral to HIV, HepB, syphilis screening, and HPV vaccination (Moore, 2013). HPV vaccination is specifically recommended because the patient is 25 years old, and the vaccination’s effectiveness still can be high, thus preventing the patient from the risk of developing HPV-associated cervical cancer (Fu, Bonhomme, Cooper, Joseph, & Zimet, 2014). Additional counseling about the abstinence from sexual intercourse until the end of the treatment is needed too.
References
Awasthi, S., & Friedman, H. M. (2014). Status of prophylactic and therapeutic genital herpes vaccines. Current Opinion in Virology, 6(1), 6-12.
Bolan, G. A., & Wasserheit, J. N. (2012). The emerging threat of untreatable gonococcal infection. The New England Journal of Medicine, 366(6), 485-487.
De Bernardis, F., Arancia, S., Sandini, S., Graziani, S., & Norelli, S. (2015). Studies of immune responses in Candida vaginitis. Pathogens, 4(4), 697-707.
Fu, L. Y., Bonhomme, L. A., Cooper, S. C., Joseph, J. G., & Zimet, G. D. (2014). Educational interventions to increase HPV vaccination acceptance: A systematic review. Vaccine, 32(17), 1901-1920.
Hethcote, H. W., & Yorke, J. (2014). Gonorrhea transmission dynamics and control. New York, NY: Springer.
Moore, E. W. (2013). Human immunodeficiency virus and chlamydia/gonorrhea testing among heterosexual college students: Who is getting tested and why do some not? Journal of American College Health, 61(4), 196-202.
Public Health Ontario. (2013). Guidelines for testing and treatment of gonorrhea in Ontario. Web.
Srinivasan, S., Hoffman, N. G., Morgan, M. T., Matsen, F. A., Fiedler, T. L., Hall, R. W., & Fredricks, D. N. (2012). Bacterial communities in women with bacterial vaginosis: High resolution phylogenetic analyses reveal relationships of microbiota to clinical criteria. PloS One, 7(6), 202-230.