CERVICITIS

Background 1. Definition: inflammation of cervix 2. General information: may be acute, recurrent or persistent

Pathophysiology1,2 1. Typical organisms for acute cervicitis: o C. trachomatis o N. gonorrhoeae o Trichomonas vaginalis o Herpes simplex virus o Mycoplasma genitalium o Bacterial vaginosis (BV) 2. Incidence, Prevalence o Common problem in clinical setting o True incidence/prevalence difficult to measure due to variety of definitions o Women over age 30 at low risk to acquire sexually transmitted diseases (STDs) 3. Risk factors for STD o Age <=25 years o New sex partner or multiple sex partners o Engage in unprotected sex 4. Morbidity / Mortality o Risk of poor pregnancy outcome o Increased viral shedding in HIV patients o May be sign of upper genital tract infection (pelvic inflammatory disease) . endometritis . salpingitis . tubo-ovarian abscess . pelvic peritonitis

Diagnostics1,2 1. History o Vaginal discharge o Intermenstrual bleeding (after intercourse) o Asymptomatic 2. Physical examination: both or either o Purulent or mucopurulent endocervical exudate visible in endocervical canal . PPV 74% (92% nonpregnant, 60% in pregnant women) . NPV 92-99% overall o Endocervical bleeding easily induced by gentle passage of cotton swab through cervical os (friability) . PPV of 40% in women < 19 yo

Cervicitis Page 1 of 4 4.18.12 3. Diagnostic testing by laboratory evaluation4 o Chlamydial and gonococcal infection: . leukorrhea > 10 WBC per high power field on microscopic examination of vaginal fluid . nucleic acid amplification test (urine, vaginal or endocervical samples) o Trichomonias vaginalis on microscopic examination . sensitivity of microscopy to detect trichomonas - 50% . if microscopy negative - symptomatic women should get further testing (culture or other FDA approved test) 4. Other studies o Polymorphonuclear leukocytes on gram stain . not standard criterion . low positive predictive value o Gram-negative intracellular diplococci on gram stain of fluid . specific for gonococcal infection . not sensitive, PPV 21% . only observed in 50% of women with infection o HSV-2 by culture or serology

Differential Diagnosis1,2 1. Key differential diagnoses o C. trachomatis o N. gonorrhoeae o Trichomonas vaginalis o Herpes simplex virus o Mycoplasma genitalium o Bacterial vaginosis 2. Extensive differential diagnoses o Irritant substance use . chemical douches . spermicides (nonoxynol-9) . chemical deodorants . betadine . cornstarch . topical anesthetics . vaginal lubricants . latex o Other infections . vulvuvaginal candidiasis . cytomegalovirus . Streptococcus species o Pelvic inflammatory disease o Cervical intraepithelial neoplasia o Abnormal host immune response attacking genital mucosa, eg. Psoriasis and Behcet syndrome

Cervicitis Page 2 of 4 4.18.12 Therapeutics1 1. Acute presumptive treatment o For C. trachomatis, if risk factors are present (especially if follow up not ensured) . Recommended regimen: Azithromycin 1 g orally in single dose OR doxycycline 100 mg orally BID for 7 days o Concurrent therapy for N. gonorrhea if the prevalence of this infection is >5% (younger age groups, incarceration) . Recommended regimen: Ceftriaxone 250 mg IM in single dose OR cefixime 400 mg orally in single dose 2. Treatment for trichomoniasis if detected o Recommended regimen: Metronidazole 2 gm orally single dose OR tinadazold 2 gm orally single dose 3. Treatment for bacterial vaginosis if detected o Recommended regimen: Metronidazole 500 mg BID for 7 days OR metronidazole gel 0.75% 5 gm intravaginally daily for 5 days OR clindamycin cream 2% 5 gm intravaginally at bedtime for 7 days 4. Chronic cervicitis o Recurrent cervicitis . evaluate for possible reexposure to STD . if STD excluded, BV not present and sex partners evaluated and treated - options limited o Persistent cervicitis . symptoms despite repeated antibiotic courses . likely not relapse or reinfection . due to:  abnormal vaginal flora  douching  exposure to chemical irritants  idiopathic inflammation 5. Management of sex partners o Empirical treatment for same STD as index patient is as or more effective than referral for exam and testing with chlamydia and gonorrhea (SOR:A)3 o Expedited treatment equivalent to test-first approach in trichomoniasis (SOR:B)3 o To avoid reinfection - patients and sex partners should abstain from intercourse for 7 days (completed treatment) 6. Special consideration: HIV o Same treatment regimens o Cervicitis increases cervical HIV shedding o Treatment of STD might reduce HIV transmission to susceptible partners

Follow-Up1 1. Return to office o If symptoms persist, women should be re-evaluated for STD o High rate of reinfection within 6 months in women with chlamydial or gonococcal infection

Cervicitis Page 3 of 4 4.18.12 2. Repeat testing o Women with chlamydia or gonorrhea o Recommended 3-6 months after treatment o Regardless of sex partner treatment 3. Additional reasons to return for care o Pelvic or lower abdominal pain o Fever > 101° F o Intrauterine device in place

Prognosis 1. Good with proper treatment

Prevention1 1. Abstinence 2. Condom use – male or female 3. Limited number of partners 4. Modifying sexual practice

Patient Education 1. Cervicitis. Pri-Med Education Center, Harvard Medical School. Available at: http://www.patientedu.org/aspx/HealthELibrary/HealthETopic.aspx?cid=210480 2. How to prevent sexually transmitted diseases. ACOG. Available at: http://www.acog.org/~/media/For%20Patients/faq009.pdf?dmc=1&ts=20120306T162756 3207 3. Gonorrhea, Chlamydia, and Syphilis. ACOG. Available at: http://www.acog.org/~/media/For%20Patients/faq071.pdf?dmc=1&ts=20120306T162836 0941

References 1. Workowsi KA, Berman S. Sexually Transmitted Diseases Treatment Guideline. MMWR Recomm Rep. 2010. 59(RR-12): 1-110. Available at: http://www.cdc.gov/mmwr/pdf/rr/rr5912.pdf. 2. Marrazzo JM, Martin DH. Management of women with cervicitis. Clin Infect Dis. 2007. 44(Suppl 3): S102-110. 3. Saperstein AK, Firnhaber GC. Should you test or treat partners of patients with gonorrhea, chlamydia, or trichomoniasis? J Fam Prac. 2010. 59(1): 46-48. 4. New York State Department of Health. Gonococcal and chlamydial infections. New York (NY): New York State Department of Health; 2007 Oct.

Author: Julia Fashner, MD, Saint Joseph Regional Medical Center FMRP, IN

Editor: Robert Marshall, MD, MPH, MISM, CMIO, Madigan Army Medical Center, Tacoma, WA

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