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 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 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