Cervicitis

INTRODUCTION

Background: Cervicitis is an inflammation of the uterine cervix. Infectious cervicitis might be caused by Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, herpes simplex virus, or human papilloma virus. Noninfectious cervicitis might be caused by local trauma, radiation, or malignancy. The infectious etiologies are significantly more common than the noninfectious causes, and all possible infectious causes of cervicitis are sexually transmitted diseases (STDs). This chapter focuses on the infectious etiologies of cervicitis.

Pathophysiology: Because the female genital tract is contiguous from the vulva to the fallopian tubes, there is some overlap between vulvo-vaginitis and cervicitis. Vulvo-vaginitis and cervicitis commonly are grouped together as lower genital tract infections. Infections involving the endometrium and fallopian tubes commonly are grouped together as upper genital tract infections and are not discussed in this chapter.

Frequency:
　

• In the US: In the US, approximately 12 million cases of sexually transmitted diseases were reported in 1990. Annually, 4-6 million people acquire Trichomonas vaginalis infections. Annually, 3-5 million people acquire chlamydial genital infections. Annually, 500,000 to 1 million people acquire gonorrhea infections. The annual rate of infection by herpes simplex virus and human papilloma virus is difficult to estimate because a vast majority of initial infections are asymptomatic or unrecognized. In the US, seroprevalence studies show that 22% of adults have herpes simplex virus type 2 antibodies. In the US, 1% of sexually active adults are estimated to have genital warts secondary to human papilloma virus infection.

• Internationally: Worldwide, the World Health Organization estimates that at least 250 million new cases of sexually transmitted diseases occur each year. Trichomoniasis is the most common STD with approximately 120 million cases a year. Chlamydia is the next most common STD with approximately 50 million cases a year. Human papilloma virus, gonorrhea, and herpes simplex virus each account for roughly 20-30 million cases a year.

Mortality/Morbidity: Complications from untreated infectious cervicitis depend on the pathogen. Morbidity includes pelvic inflammatory disease, infertility, ectopic pregnancy, spontaneous abortion, cervical cancer, premature rupture of membranes, and preterm delivery. Perinatal and neonatal infections can cause mental retardation, blindness, low birth weight, stillbirth, meningitis, and death. The social stigma also is strong and might expose women to verbal, emotional, or physical abuse from others, particularly male partners.

Race: No racial predilection exists. Known risk factors include urban residence and low socioeconomic status.

Sex: Male urethritis is more often symptomatic; therefore, diagnosis usually is made earlier in males than in females. Females with cervicitis most often are completely asymptomatic so they do not seek evaluation or treatment as readily.

CLINICAL

History:

• Gonorrhea, chlamydia, and Trichomonas vaginalis infections are often asymptomatic. When symptoms are present, they are often nonspecific. Symptoms include increased vaginal discharge, dysuria, urinary frequency, and intermenstrual or postcoital bleeding. If the infection has been long standing, symptoms also can include low abdominal or low back pain.

• Infection with human papilloma virus often is asymptomatic because the genital warts often are flat and internal. When the warts are raised and on the labia, perineum, or perianal area, they are called condylomata acuminata and are easily visible.

• In contrast, infection with herpes simplex virus frequently is highly symptomatic. Primary infection is marked by painful ulcerations associated with fever, myalgia, headache, and general malaise. Dysuria, vaginal discharge, and urethral discharge also are common symptoms. Recurrent outbreaks of herpes simplex virus tend to be milder, but a majority of patients have prodromal symptoms of itching or tingling followed by the appearance of vesicles.

• Because many causes of cervicitis initially are asymptomatic, ask all sexually active women for their complete gynecologic and sexual history at the initial evaluation and yearly thereafter. In addition to the basic gynecologic history (eg, age of menarche, date of last menstrual period, gravida, para, pregnancy or delivery complications, date of last Papanicolaou [Pap] smear), a complete sexual history is needed. This information includes number of recent and current partners (in the last 3 months), condom use, nonbarrier contraception use, exchanging of sex for money or drugs, and previous diagnoses of sexually transmitted diseases. A focused review of symptoms asking about dyspareunia, vaginal discharge, genital skin lesions, abnormal vaginal bleeding, dysuria, genital burning, genital itching, genital malodor, and lower abdominal or pelvic pain is recommended.

• In high-risk populations, (eg, women with multiple partners, adolescents, women with a history of previous sexually transmitted diseases, and pregnant women), screen for gonorrhea, chlamydia, and Trichomonas vaginalis infections. Screening in this population has been proven to be cost effective. Screening can be performed annually in conjunction with the Pap smear. Pap smears are not an effective screening test for sexually transmitted diseases, vaginitis, or cervicitis; however, a significant proportion of abnormal Pap smears are representative of subclinical human papilloma virus. Screening directly for human papilloma virus (HPV) is not standard and has not been proven cost effective, but further study is ongoing. Screening for herpes simplex virus is not standard because there is no curative therapy available yet.

Physical: The physical exam should include general survey, pelvic exam, external inspection, speculum exam, bimanual exam, and in certain patients, a rectal exam.

• The physical examination is crucial to the evaluation and diagnosis of cervicitis, but do not limit the examination to the pelvic region. A survey for lymphadenopathy, skin lesions, oral lesions, joint redness or swelling, abdominal pain, and costovertebral angle tenderness can point to disseminated infection.

• The pelvic examination needs to be performed in a competent and sensitive manner. The presence of a nursing assistant is advised to help the examiner and to act as chaperone. Always explain to the patient what is going to be done before proceeding. Begin with a neutral touch on the patient's thigh.

• The pelvic examination begins by visually investigating the external genitalia in good lighting. Note any skin lesions (eg, warts, ulcers, vesicles, excoriations, erythema), inflammation of the Bartholin or Skene glands, or inguinal lymphadenopathy.

• Perform the speculum exam with water lubrication only, and include direct visualization of the vaginal walls and cervix. Remember normal vaginal secretions are nonadherent to the vaginal walls, clear to white in color, and nonodorous. Normal vaginal secretions have an acidic pH less than 4.5. Vaginitis is present if the vaginal discharge is copious, colored, and malodorous, or if the pH is greater than 4.5. Cervicitis is suspected if the cervix is erythematous, edematous, or easily friable. Classic mucopurulent cervicitis is present if thick yellow-green pus is visible in the endocervical canal (the cervical os) or on an endocervical swab specimen. It is at this point that laboratory specimens are collected for study. Note cervical warts or ulcerations.

• After the speculum is removed, the bimanual examination is performed to assess tenderness or enlargement of the cervix, uterus, and adnexa. Cervicitis is suspected if the patient has cervical motion tenderness, ie, she experiences pain or tenderness while the examiner gently moves the cervix from side to side.

Causes: All of the infectious etiologies of cervicitis are sexually transmitted diseases.

WORKUP

Lab Studies:
　

• Because there is overlap between the causes of vulvo-vaginitis and cervicitis, the initial diagnostic approaches to vulvo-vaginitis and cervicitis are the same. Appearance of vaginal secretions is assessed, pH of the secretions is measured, microscopy with normal saline and 10% potassium hydroxide (KOH) is performed, and "whiff" test is performed.

• Infection with Trichomonas vaginalis usually produces a purulent, frothy, malodorous, thin discharge and can cause vulvar erythema and edema. The cervix can be erythematous and may have punctate hemorrhages (ie, "strawberry" cervix). The diagnosis is confirmed by seeing the motile flagellated protozoan on the normal saline wet mount under the microscope.

• If cervicitis is suspected or mucopurulent cervicitis is seen, then cervical discharge is collected for Gram staining and culture.

• The microscopic finding of gram-negative intracellular diplococci has sensitivity of 60% and specificity above 90% for gonorrhea.

• The observation of 10-30 leukocytes per oil-immersion field is highly suggestive of chlamydia.

• Although culture is still regarded as the criterion standard, there are many alternative techniques for the diagnosis of gonorrhea and chlamydia. They include enzyme immunoassay, direct fluorescent antibody staining, deoxyribonucleic acid (DNA) probe techniques, polymerase chain reaction (PCR), and ligase chain reaction (LCR).

• The advantages over conventional cultures include reduced turnaround time and lack of dependence on the complex and expensive systems needed to culture chlamydia. The main disadvantage of all the nonculture diagnostic techniques is the inability to assess microbial resistance. Nonetheless, many clinic-based and hospital-based practices already have stopped using cultures and have switched to these alternative techniques.

• If genital ulcer disease is seen, exclude the diagnosis of syphilis by serologic testing.

• If typical grouped vesicles mixed with small ulcers are seen, in addition to a typical history, the diagnosis of herpes simplex viral infection can be made on clinical grounds alone. For atypical ulcers or first infection, attempt definitive diagnosis by culture. Although culture is considered the criterion standard, alternative techniques, eg, cytology, antigen detection, and DNA probes, are used. There is currently no role for serology because there is cross-reactivity between types 1 and 2 in the assays.

• If genital warts are seen, subclinical lesions can be identified after applying a 3- 5% solution of acetic acid and performing magnification with colposcopy.

• While there have been more than 80 types of human papilloma virus identified, types 16, 18, 31, 33, 35, 45, 51, and 56 are associated with higher oncogenic risks, particularly cervical cancer. There is currently no definitive role for routine typing of all infections.

TREATMENT

Medical Care: Treatment of all causes of cervicitis is medical. Treatment needs to include the patient's sexual partners to prevent reinfection. In cases of unclear diagnosis, pregnancy, or refractory infections or symptoms, consultation with an infectious disease specialist may be appropriate.

Activity:

• No sexual activity for 7 days after initiating treatment

• No sexual activity until partner has been treated

MEDICATION

Oral antibiotics effectively cure gonorrhea, chlamydia, and Trichomonas vaginalis infections. Oral antivirals reduce duration of symptoms, lesions, and viral shedding in the first and recurrent episodes of genital herpes infections. Topical therapy initially is used for symptomatic genital wart removal. Other options include intralesional injection and surgery.
　

Drug Category: Antibiotic -- Therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting.

Drug Category: Antiviral

Drug Category: Topical skin product -- Topical products for genital/perianal warts

FOLLOW-UP

Further Inpatient Care:
　

• Admit to hospital if disseminated infection is suspected, the diagnosis is uncertain, or if patient is unable to take oral medications.

• If disseminated infection is suspected, then patients can quickly destabilize and require intensive monitoring and parenteral medication.

• If the diagnosis is uncertain, and competing diagnoses cannot be reliably excluded (eg, appendicitis, ectopic pregnancy) then further testing and monitoring is indicated.

• If the patient is unable to take PO medication due to intractable nausea, vomiting or abdominal pain, then hospitalization for IV medication is warranted.

Further Outpatient Care:
　

• In high-risk patients, consider screening for human immunodeficiency virus (HIV), syphilis, and tuberculosis (TB).

• In most cases, a test of cure is not necessary, but in the case of persistent symptoms or pregnancy, follow-up testing is recommended.

Deterrence/Prevention:
　

• The most effective way to prevent the transmission of the infective agents that cause cervicitis is to avoid sexual intercourse with infected partners. Ideally, both partners should be tested for common sexually transmitted diseases, including HIV, before initiating a sexual relationship. If the risk of infection is unknown by testing, then use a condom for all sexual acts. Condoms are available for men and women and have been proven to decrease the transmission of many sexually transmitted diseases, including HIV, when used appropriately and consistently.

Complications:
　

• Untreated gonorrheal and chlamydial infections can lead to pelvic inflammatory disease (PID), which can then lead to infertility and ectopic pregnancy. Untreated Trichomonas vaginalis infections have been linked to spontaneous abortions, premature rupture of membranes, and preterm delivery. Certain subtypes of human papilloma virus are linked with the development of cervical cancer. Severe cases of condyloma may obstruct the birth canal during pregnancy resulting in the need for cesarean section. Untreated active herpes simplex viral infections can cause significant perinatal and neonatal complications such as mental retardation, blindness, meningitis, and death.

Prognosis:
　

• Gonorrhea, chlamydia, and Trichomonas vaginalis infections can be cured with antibiotic therapy.

• The number of herpes simplex virus outbreaks, the duration of symptoms, and the severity of symptoms can be reduced with antiviral therapy.

• External genital warts caused by infection with human papilloma virus can be controlled but not always eradicated by topical therapy and surgical therapy.

Patient Education:
　

• Patients must understand that their infection is a preventable sexually transmitted disease. They must ensure that all their sexual partners are also treated, or they will become reinfected. Using condoms reduces the risk of infection in most cases.

MISCELLANEOUS

Medical/Legal Pitfalls:

• In women of childbearing age, always check a urine pregnancy test before prescribing any medication.

Special Concerns:
　

• In a pregnant patient, referral to an infectious disease specialist may be indicated.

• In a young adolescent or child, suspect abuse and notify the proper authorities.