Ep 182 STIs: Cervicitis, Vulvovaginitis and Urethritis Emergency Recognition and Management

In this Part 1 or our two-part podcast series on STIs we discuss a general approach to cervicitis, vulvovaginitis and urethritis, elucidate some key historical features, debate who needs a pelvic exam in the ED, understand who needs what testing, debate self swabs vs physician taken swabs, dig into some specific under-recognized organisms like Mycoplasma Genitalium, figure out who needs what kind of empiric treatment, sexual partner treatment and which discharge instructions are key...

Podcast production, sound design & editing by Anton Helman

Written Summary and blog post by Hanna Jalali, edited by Anton Helman May, 2023

Cite this podcast as: Helman, A. Shafer, R. Varner, C. STIs: Vulvovaginitis, Cervicitis and Urethritis Emergency Recognition and Management. Emergency Medicine Cases. May, 2023. https://emergencymedicinecases.com/stis-cervicitis-vulvovaginitis-urethritis. Accessed May 30, 2024

Résumés EM CasesWhy should Emergency Medicine care about STIs?

STIs are on the rise with 20 million identified each year in the United States, and are under-recognized in the ED at least partly because only 30% of patients are symptomatic. While many STIs are relatively asymptomatic and/or relatively benign, certain STIs such as syphilis can have a mortality rate as high as 58%. Additionally, when recognized and treated early, ED physicians can prevent many of the long term sequelae of STIs such as Pelvic Inflammatory Disease and infertility. Many patients do not have access to primary care and the ED may be the only opportunity for screening, counseling and treatment of STIs.

General approach to cervicitis and vulvovaginitis

Common causes of vulvovaginitis include bacterial vaginosis, trichomoniasis, while cervicitis is commonly caused by chlamydia and gonorrhea. In the ED on first point of contact the organism is difficult to determine with certainty as no clinical feature or combination of features rules in any of these etiologies. Even with lab testing , the etiology will remain unknown in 83% of patients presenting with STI symptoms. Our approach needs to take this into consideration, especially when counseling patients.

History taking for suspected STI

* Make the patient comfortable: Consider a private setting/exuse visitors from the room, use understandable, non-judgemental language that normalizes questions, ask the patient if they would like a chaperone present

* Elicit symptoms of STIs: STI complaints may include abnormal vaginal or urethral discharge, lower pelvic pain, genital rash, painful/painless ulcer, dysuria, dyspareunia, throat pain, rectal pain or rectal discharge

* Assess risk: There is the 5Ps approach to eliciting risk of STIs (see below) however, simply being sexually active in combination with any new symptoms of STI confers a high pretest probability

Are pelvic exams necessary for patients who present with symptoms suggestive of an STI?

Proponents of not performing a pelvic exam for females with symptoms suggestive of an STI site studies that suggest no change in management when pelvic exams are performed for assessment of adnexal mass or during first trimester bleeding to assess for ectopic pregnancy in the outpatient setting. No studies to date prove that pelvic exams have no impact on management in patients suspected of an STI in the ED setting.  Our experts recommend pelvic exams for all females suspected of an STI as they can both identify concerning lesions such as ulcers that patient's may not visualize/identify themselves and to help facilitate swabs to identify the specific etiology.