Cervicitis
Cervicitis: Excerpt from The 5-Minute Pediatric Consult
Sarah E. Winters, MDJane Lavelle, MD
Cervicitis - BASICS
Cervicitis - description
Infection of the endocervix resulting in inflammation, leading to mucopurulent cervical discharge, edema, erythema, bleeding, and friability of the cervix and endocervical canal
Cervicitis - epidemiology
The true incidence of mucopurulent cervicitis is unknown, but the primary causes (gonorrhea/chlamydia) are more common in adolescents and young adults than any other age group. Because many patients are asymptomatic and the interpretation and presence of the clinical signs is quite variable, many cases go undiagnosed.
Cervicitis - risk factors
- Early age of coitarche
- Multiple sexual partners
- Absent/Inconsistent condom use
Cervicitis - etiology
In most young women, no pathogen is isolated. Common causes include:
- Chlamydia trachomatis
- Neisseria gonorrhoeae
- Herpesvirus hominis
- Trichomonas vaginalis
- Mycoplasma genitalium
Cervicitis - associated conditions
The presence of other sexually transmitted diseases must be considered, including:
- Syphilis
- Hepatitis B
- HIV
- Bacterial vaginosis
Cervicitis - DIAGNOSIS
Cervicitis - signs & symptoms
Cervicitis - history
- Often asymptomatic, if symptomatic: Symptoms consistent with but not diagnostic of cervicitis:
- Abnormal vaginal bleeding and/or discharge? Inflamed cervix may bleed spontaneously or following sexual intercourse.
- Dysuria? May indicate urethritis or bladder infection
- Vulvar itching? May be associated discharge from cervical inflammation or a coexisting vaginal infection
- Dyspareunia? Common complaint owing to the sensitive cervix
- Past medical history—important to evaluate risk factors related to sexual health, but not diagnostic of cervicitis:
- Previous STD? Identifies patients at increased risk for reinfection
- Last menstrual period? Symptomatic infection often occurs within 7 days of the last menstrual period because of loss of the protective endocervical mucous plug.
- Birth control method? Condoms are protective.
- Exposure to infected partner? Identifies patient at increased risk
- Gravity?
- Parity?
Cervicitis - physical exam
- Abdominal: No tenderness on palpation of the abdomen–-infection is limited to the cervix.
- Vaginal: Signs of vaginal/external lesions consistent with HSV
- Pelvic:
- Mucopurulent discharge from the cervical os or yellow exudative discharge present on a cotton-tipped swab from the endocervical canal: Clinical evidence of cervical infection
- No cervical motion or adnexal tenderness or masses: Pathology has not extended beyond the cervix to the upper genital tract.
- Friability of the exocervix: Easily induced bleeding from the cervical canal, not to be confused with normal cervical ectopy (area of columnar epithelium around the cervical os presenting as a discrete, nonfriable, reddish circle)
Pitfalls:
- Failure to recognize the importance of evaluating the internal pelvic organs by physical examination with the presenting symptoms of dysuria, vaginal discharge, or abnormal menstrual bleeding in the postpubertal female
- Imperative not to confuse normal cervical ectropion in an adolescent with cervicitis.
Cervicitis - tests
Cervicitis - lab
- Nucleic acid amplification tests done on the patient’s urine offers the least invasive method to detect chlamydia and/or gonococcal infection. Cervical or vaginal swabs may also be used for nucleic acid amplification tests provided that there is no bleeding:
- Cervical swabs, vaginal swabs obtained by the health care provider, and urine have similar sensitivity and specificity.
- Cervical cultures for chlamydia and gonorrhea will also identify the pathogen, but require a speculum examination.
- Identifies the pathogen, which is important for patient and partner treatment and disease surveillance
- Herpes simplex virus culture if vesicular rash or ulcers are present: Important to identify the cause of the ulcers for treatment and patient counseling
- Wet preparation, culture or antigen testing for T. vaginalis: Often coexisting infection when other sexually transmitted infections are identified.
Cervicitis - differencial diagnosis
- It is helpful to consider cervicitis/vaginitis as a single disease in the evaluation process because the symptoms of these 2 entities are the same.
- Inflammation of the vulva, urethra, and/or bladder, and vagina
- In patients presenting with abnormal menstrual bleeding, these infectious causes are common.
- Pregnancy is a frequent cause of abnormal vaginal bleeding.
- Foreign body can beassociated with both discharge and bleeding.
- PCOS, thyroid dysfunction and hyperprolactinemia can all present with abnormal vaginal bleeding.
Cervicitis - TREATMENT
Cervicitis - initial stabilization
Patients meeting the criteria for the clinical diagnosis of cervicitis or those who have a high likelihood of infection should receive presumptive therapy for N. gonorrhoeae and C. trachomatis. Treat other pathogens if clinically indicated or if documented by laboratory studies.
Cervicitis - medication
- Gonorrhea:
- Ciprofloxacin 500 mg PO, single dose
- Cefixime 400 mg PO in a single dose
- Recently noticed patterns of resistance to fluoroquinolones have caused the CDC to no longer recommend this class as 1st line of treatment of gonococcal cervicitis in the US
- C. trachomatis:
- Azithromycin 1 g PO, single dose
- Doxycycline 100 mg PO b.i.d. for 7 days
- Erythromycin base 500 mg PO q.i.d. for 7 days
- T. vaginalis:
- Metronidazole 2 g PO, single dose
- Metronidazole 500 mg PO b.i.d. for 7 days
- Tinidazole 2 g PO in a single dose
- H. hominis:
- Acyclovir 400 mg PO t.i.d. for 7–10 days or until resolution
- Acyclovir 200 mg PO 5 times daily for 7–10 days or until resolution
- Famciclovir 250 mg PO t.i.d. for 7–10 days or until resolution
- Valacyclovir 1 g PO b.i.d. for 7–10 days or until resolution
Cervicitis - FOLLOW UP
- The recommended treatment regimens have an excellent cure rate.
- The patient should have resolution of symptoms 3–5 days after starting therapy.
- Routine follow-up cultures are not necessary unless the patient remains symptomatic.
- Nucleic acid amplification tests done <6 weeks following treatment may yield false-positive results because of persistence of dead organisms.
- Detection of a sexually transmitted infection at follow-up is most likely the result of re-exposure and reinfection.
Cervicitis - prognosis
If treated appropriately, patients are cured and have no sequelae from the infection.
Cervicitis - complications
The patient with endocervical infection is at risk for:
- Reinfection
- Other STDs
- Pregnancy
- Symptomatic or asymptomatic upper genital tract disease, (pelvic inflammatory disease),with all its sequelae:
- Tubo-ovarian abscess
- Infertility
- Ectopic pregnancy
- Chronic pelvic pain
Cervicitis - patient monitoring
- Partners should be referred for evaluation and treatment if laboratory diagnosis of GC/Chlamydia or Trichomonas is made
- GC/chlamydia are reportable STDs
Cervicitis - bibliography
American Academy of Pediatrics. Sexually transmitted diseases. In: Pickering LK, eds. 2006 Red Book: Report of the Committee on Infectious Diseases. 27th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2006.Emans JS, Laufer MR, Goldstein DP. Pediatric and Adolescent Gynecology. 5th Ed. Philadelphia: Lippincott Williams & Wilkins; 2005.Holmes KK. Lower genital tract infections in women: Cystitis, urethritis, vulvovaginitis, and cervicitis. In: Holmes KK, Mardh P, Sparling PF, et al., eds. Sexually Transmitted Diseases. 2nd ed. New York: McGraw-Hill; 1990:527–545.Long SS, Pickering LK, Prober CG. Principles and Practice of Pediatric Infectious Disease. 2nd ed. New York: Churchill Livingstone; 2003.MMWR, April 13, 2007, Update to CDC’s Sexually Transmitted Diseases Treatment Guidelines, 2006: Fluoroquinolones no longer recommended for treatment of gonoccal infections.Neinstein LS. Adolescent Health Care: A Practical Guide. 4th ed. Baltimore: Urban & Schwarzenberg; 2002.- U.S. Department of Health and Human Services. 2006 Guidelines for treatment of sexually transmitted diseases. MMWR Recomm Rep. 2006;55(RR-11):1–91.
Cervicitis - CODES
Cervicitis - icd9
616.0 Cervicitis and endocervicitis
Cervicitis - FAQ
- Q: How much cervical motion tenderness is present in patients with cervicitis?
- A: None. Patients with cervicitis have inflammation and infection of the cervix only. They do not have any evidence of peritoneal inflammation on physical examination; therefore, patients with tenderness should be treated with the protocols recommended by the Centers for Disease Control and Prevention for pelvic inflammatory disease. This does not include the use of a single dose of azithromycin.
- Q: Which partners should be referred for treatment?
- A: Sex partners from the preceding 60 days should be referred for evaluation and treatment. Treatment is based on documented or presumptive etiologies.
- Q: What is the appropriate treatment for M. genitalium?
- A: M. genitalium has clearly been implicated in the development of urethritis in males and is thought to play some role in the development of cervicitis in females (although that role is not entirely clear). Data suggests that Azithromycin may be the best treatment for this infection.
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Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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» Next page: Cervical Adenitis (Pediatric Infectious Disease)
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