Pathophysiology: Cervicitis is caused by sexually transmitted bacterial infection. Infection of the cervix results in inflammation and may be accompanied by vulvovaginitis. An ascending infection can cause endometritis, salpingitis, tuboovarian abscess, or perihepatitis.

Frequency:

• In the US: In the United States, prevalence of chlamydial infection is 5-15% in sexually active teenagers and young adults who are asymptomatic. Prevalence increases to almost 50% in symptomatic patients; however, the incidence of gonorrhea has declined steadily over the past 20 years. Adolescents and young adults continue to have the highest rates of infection, with a transmission risk of 20-50% per sexual contact. The incidence of co-infection with both gonorrheal and chlamydial organisms may be 15-20%.

• Internationally: Chlamydia trachomatis is the most prevalent bacterial pathogen causing sexually transmitted infections worldwide. According to the World Health Organization (WHO), 50-70 million cases occur annually in the world.

Mortality/Morbidity: Primary morbidity results from ascending infection to the uterus and fallopian tubes (pelvic inflammatory disease) leading to chronic abdominal pain and infertility.

Age: Compared to older populations, sexually active adolescents and young adults have a higher incidence of both chlamydial and gonococcal cervicitis.

History: Elicit the patient’s history of sexual activity, number of sexual partners, and type of contraception used (if any). Increased incidence of chlamydial cervicitis in women has been associated with use of oral contraception.

• Most patients with cervicitis present with complaints of vaginal discharge or vaginal bleeding.

• Other associated symptoms include dyspareunia and dysuria.

• Abdominal pain and fever are associated with involvement of the upper genital tract.

• Patients with mild cervicitis may be asymptomatic, and many patients with chlamydial cervicitis are asymptomatic.

Physical: On physical examination, findings in the cervix include the following:

• Erythematous and inflamed cervix on speculum examination

• Possible purulent discharge from the cervical os

• Cervix tender to palpation

Causes:

• Gonorrheal and chlamydial infections

• The most common causative organisms are Neisseria gonorrhea and C trachomatis.

• Gonococcal and chlamydial cervicitis may be associated with upper genital tract infection.

• Associated urethritis may be present in patients with gonorrhea.

• Patients with chlamydial infections are often asymptomatic.

• Other bacterial pathogens implicated in cervicitis and upper genital infections include Mycoplasma hominis, Ureaplasma urealyticum, and anaerobes such as Streptococcus, Peptostreptococcus, and Bacteroides species. Other sexually transmitted infections, such as those caused by Trichomonas species and herpes simplex virus, also may be associated with cervicitis.

• Trichomonas infection may result in a friable cervix with prominent papillae and punctate hemorrhages (strawberry cervix).

• Herpetic cervicitis may be associated with multiple ulcerations.

Lab Studies:

• Traditional tests

• Wet mount of the discharge usually demonstrates more than 5 WBCs per high-power field.

• Gram stain of the cervical mucopus may reveal gram-negative intracellular diplococci in cases of gonorrhea. Culturing in modified Thayer-Martin medium is the criterion standard for confirming gonorrhea.

• Enzyme-linked immunoassay or direct fluorescent antibody testing often is used to detect chlamydial infection. DNA probes with 90-97% sensitivity are also available for the simultaneous detection of gonococcal and chlamydial organisms.

• When indicated, chlamydial cultures are performed on McCoy cells (evaluations in prepubertal children in whom sexual abuse is suspected, testing response to therapy in a previously treated infection).

• Newer tests

• Several highly specific and sensitive tests have been developed, including include polymerase chain reaction (PCR), ligase chain reaction (LCR), and transcription-mediated amplification (TMA).

• PCR and LCR testing consists of amplification of specific DNA sequences, while TMA testing is an RNA amplification assay.

• Although endocervical specimens are preferred, these tests may be easily performed on first-void morning urine samples.

Medical Care:

The Centers for Disease Control and Prevention (CDC) released treatment guidelines for sexually transmitted diseases in 1998. Therapy for cervicitis depends on the etiologic agent. Ceftriaxone is the recommended drug for gonorrhea; doxycycline is recommended for chlamydial cervicitis. Other effective antibiotics for treatment of gonorrheal disease include cefixime 400 mg, ciprofloxacin 500 mg, or ofloxacin 400 mg. All are administered as single oral doses.

Alternatives for patients presenting with ceftriaxone allergy include spectinomycin, ciprofloxacin, or norfloxacin. Fluoroquinolones are not approved by the US Food and Drug Administration (FDA) for use in children younger than 18 years. Erythromycin is recommended for patients with chlamydial infections who are unable to take doxycycline. A single oral 1-g dose of azithromycin also is highly effective for treatment of chlamydial disease. If a patient has clinical cervicitis, both ceftriaxone and azithromycin are recommended as empirical treatment. Acyclovir may be used for primary herpes infection, but it is not curative, and recurrences are common. Metronidazole is the drug of choice for infection by Trichomonas organisms.
 

Drug Category: Antibiotics -- Testing to determine the specific microorganism causing the infection is recommended because both chlamydial and gonococcal infections are reportable to state health departments. If diagnostic tools (eg, Gram stain, microscope) are unavailable, treat patients for both infections.

Further Outpatient Care:

• Gonococcal cultures are recommended 4-8 weeks after standard treatment or 1 week after alternative regimens are used.

• Routine testing for chlamydial eradication is not indicated after treatment; however, repeat testing may be worthwhile 1-2 months later in patients with a high risk of reinfection to identify inadequate partner treatment or new infections.

• Routine annual screening for chlamydial infection is recommended in all sexually active adolescents because of the high prevalence of asymptomatic females.

• Treat sexual partners.

Complications:

• Ascending infection

• Arthritis, rash, or both (from disseminated gonorrhea)

Prognosis:

• Prognosis is excellent when the patient is compliant.

Patient Education:

• Instruct patients to avoid sexual intercourse until treatment efficacy is confirmed.

• Instruct patients how to prevent reinfection by using condoms.

• Recommend prevention counseling to patients with sexually transmitted infections.

• Recommend that patients receive screening for other diseases, including HIV infection and syphilis.