Week 4: Genitourinary Clinical Case For A 28-Year-Old

Week 4: Genitourinary Clinical Case Patient Setting: 28-year-old female presents to the clinic with a 2 day history of frequency, burning and pain upon urination; increased lower abdominal pain and vaginal discharge over the past week

This clinical case centers around a 28-year-old woman presenting with symptoms indicative of a urinary tract infection (UTI) and possible sexually transmitted infection (STI). Her history, clinical findings, and diagnostic results provide essential data for understanding the patient's condition and guiding appropriate management strategies.

Introduction

Genitourinary infections remain a significant concern in primary care and reproductive health, especially among women of reproductive age. They encompass a broad spectrum of conditions ranging from uncomplicated urinary tract infections to sexually transmitted diseases (STDs), which can have lasting health implications if not properly diagnosed and treated. The present case emphasizes a comprehensive assessment of a young woman with recurrent UTIs, coexisting STDs, and associated symptoms, illustrating key concepts in clinical diagnosis and management within advanced nursing practice.

Patient Presentation and History

The patient is a 28-year-old female with a two-day history of urinary frequency, dysuria, and lower abdominal pain. She reports experiencing foul-smelling vaginal discharge following unprotected intercourse with her ex-boyfriend. Her medical history is notable for recurrent UTIs, with three episodes occurring within the current year, and prior diagnoses of gonorrhea twice and chlamydia once, highlighting her susceptibility to urogenital infections.

Her surgical history includes bilateral tubal ligation, completed two years prior, which is relevant to her reproductive health status. Family and social histories reveal a single status, multiple sexual partners, current cohabitation with a new boyfriend, and three children. This information underscores her potential exposure risks and supports a sex-positive, patient-centered approach to care.

Clinical Findings and Examination

On physical examination, the patient appears moderately distressed, with vital signs within normal limits except for a slight fever (T 99.7°F). Abdominal examination reveals tenderness and increased suprapubic tenderness consistent with urinary bladder irritation or inflammation. Pelvic examination demonstrates cervical motion tenderness, adnexal tenderness, and foul-smelling vaginal discharge, suggestive of possible pelvic inflammatory disease (PID) or concurrent infection.

The genital exam findings, combined with her history, warrant further investigation into both urinary and genital tract infections. The presence of vaginal discharge with an odor raises suspicion of bacterial vaginosis or STDs, specifically gonorrhea and chlamydia, consistent with her history.

Laboratory and Diagnostic Tests

Diagnostic testing provides critical insights into the etiology of the patient's symptoms:

• Urinalysis (UA): Dark urine, specific gravity 1.015, pH 8.0, presence of bacteria, and 0-1 RBCs suggest an infection.
• Urine Gram stain: Gram-negative rods point towards common uropathogens such as Escherichia coli.
• Vaginal discharge culture: Cultured gram-negative diplococci confirm Neisseria gonorrhoeae infection.
• Chlamydia testing: Positive monoclonal antibody test indicates concurrent chlamydial infection.
• KOH prep, wet mount, and VDRL: Negative results for yeast, Trichomonas, and syphilis, helping narrow differential diagnoses.

Discussion of Diagnoses

The patient's presentation suggests a complex urogenital infection involving both bacterial and sexually transmitted pathogens. The identification of gram-negative diplococci from vaginal cultures with gram-negative rods in urine points toward gonorrhea and urinary pathogens such as E. coli respectively. Her history of recurrent UTIs and prior STDs indicates vulnerability to such infections, often exacerbated by unprotected sex, multiple partners, and inadequate treatment.

Her symptoms are consistent with urethritis, cystitis, and possibly vaginitis or cervicitis. The presence of cervical motion and adnexal tenderness raises concerns about PID, which requires prompt diagnosis and treatment due to the risk of fertility complications.

Management and Treatment Strategies

Effective management involves targeted antibiotic therapy, patient education, and partner notification. Considering her positive gonorrhea and chlamydia results, empiric treatment aligned with CDC guidelines should include dual therapy:

• Intramuscular ceftriaxone 500 mg for gonorrhea
• Oral azithromycin 1 g for chlamydia

Given her recurrent UTIs, a review of her hygiene practices and potential prophylactic measures may be warranted.

Additionally, counseling on safe sex practices, use of protection, and routine screening is essential for prevention. Follow-up testing post-treatment ensures eradication of pathogens and minimizes resistance development.

Conclusion

This case exemplifies the complexities involved in diagnosing and managing genitourinary infections in women. The integration of history, physical exam, and diagnostic testing is vital for effective intervention. An advanced practice nurse plays a crucial role in comprehensive patient education, partner management, and ensuring adherence to therapy, thus improving health outcomes and reducing the burden of STDs and UTIs.

References

• CDC. (2021). Sexually transmitted infections treatment guidelines. Centers for Disease Control and Prevention. https://www.cdc.gov/std/tg2019/default.htm
• Hooton, T. M. (2012). Uncomplicated urinary tract infection. New England Journal of Medicine, 366(11), 1028-1037.
• Workowski, K., & Bolan, G. (2015). Sexually transmitted diseases treatment guidelines, 2015. MMWR. Recommendations and Reports, 64(RR-03), 1-137.
• ZoBell, J. A., et al. (2019). Management of urinary tract infections in women. American Family Physician, 99(3), 170-177.
• Shaw, J. L., et al. (2018). Pelvic inflammatory disease: update on management. Journal of the National Medical Association, 110(3), 209-217.
• National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). (2017). Urinary tract infection (UTI). https://www.niddk.nih.gov/health-information/urologic-diseases/urinary-tract-infections
• Holtz, S. D., et al. (2018). The diagnosis and management of gonorrhea and chlamydia infections. Medical Clinics of North America, 102(4), 713-731.
• Schaeffer, A. J. (2016). Urinary tract infections. In: Carlson, K. E., et al. (Eds.), Principles and Practice of Infectious Diseases. Elsevier, 3427-3434.
• Morris, M., et al. (2016). Advances in the management of genitourinary infections. Infectious Disease Clinics, 30(4), 765-778.
• Royal College of Obstetricians and Gynaecologists. (2016). Management of pelvic inflammatory disease. Green-top Guideline No. 34. https://www.rcog.org.uk