Cervicitis The 5 Minute Pediatric Consult


	Cervicitis

Jane Lavelle

Database
Differential Diagnosis
Data Gathering
Physical Examination
Laboratory Aids
Therapy
Follow-Up
Common Questions and Answers
Bibliography

DATABASE

DEFINITION

Cervicitis is infection of the endocervix resulting in inflammation leading to mucopurulent cervical discharge, edema, erythema, and friability of the cervix and endocervical canal.

CAUSES

In the majority of young women, no pathogen is isolated. Common identifiable causes include:

Chlamydia trachomatis
Neisseria gonorrhoeae
Herpesvirus hominis
Trichomonas vaginalis
Candida albicans

ASSOCIATED DISEASES

The presence of other sexually transmitted diseases must be considered including T. vaginalis, syphilis, hepatitis B, HIV, and bacterial vaginosis.

EPIDEMIOLOGY

The true incidence of mucopurulent cervicitis is unknown; however, it is quite common. As many patients are asymptomatic and the interpretation and presence of the clinical signs is quite variable, many cases go undiagnosed.

COMPLICATIONS

The patient with endocervical infection is at risk for reinfection and symptomatic or asymptomatic upper genital tract disease with all its sequelae, including infertility, ectopic pregnancy, and chronic pelvic pain. In addition, these patients are at risk for reinfection, other sexually transmitted diseases, and pregnancy.

PROGNOSIS

If treated appropriately, these patients are cured and have no sequelae from the infection.

Etiology of Infection of Tumors

DIFFERENTIAL DIAGNOSIS

The differential diagnosis includes potential causes of inflammation of the vulva, the urethra and/or bladder, the vagina, and the endocervical canal. In patients presenting with abnormal menstrual bleeding, these infectious causes are common.
However, there are numerous other causes including pregnancy. (See Dysfunctional Uterine Bleeding.)

DATA GATHERING

HISTORY

Symptoms

Question: Abnormal vaginal bleeding and/or discharge
Significance: Result of infection

Question: Dysuria
Significance: Urethritis

Question: Vulvar itching
Significance: Irritation from infection

Question: Dyspareunia
Significance: Pain from mobility of tender cervix

Medical History

Question: Previous sexually transmitted disease (STD)
Significance: Common association

Question: Gravity
Significance: May lead to infertility

Question: Parity
Significance: May lead to infertility

Question: Last menstrual period
Significance: May lead to ectopic pregnancy

Question: Birth control method
Significance: Condoms are protective

Question: Exposure to infected partner
Significance: Important to treat both partners

PHYSICAL EXAMINATION

Abdomen

Finding: No tenderness
Significance: Infection is limited to cervix

Pelvic

Finding: Mucopurulent discharge from the cervical os or yellow exudative discharge present on a cotton-tipped swab from the endocervical canal
Significance: Classic finding for cervicitis

Finding: No cervical motion or adenexal tenderness or masses
Significance: Infection has not spread beyond cervix

Friability of the exocervix

LABORATORY AIDS

Test: Cervical Gram stain from cervical discharge (uncontaminated by vaginal secretions) with >.10 polymorphonuclear leukocytes per high-power field and/or gram-negative intracellular diplococci
Significance: Typical findings

Test: Cervical gonococcal culture or LCR
Significance: Gonococcus is a common infection cause

Test: Cervical chlamydia culture or fluorescence antibody test or LCR
Significance: Chlamydia is a common infection cause

Test: HSV culture
Significance: Herpes is a common infection cause

Test: Wet preparation or culture for T. vaginalis
Significance: Test for trichomonas

Test: Potassium hydroxide preparation for budding hyphae
Significance: Test for candida

THERAPY

Patients should receive therapy for N. gonorrhoeae and C. trachomatis. Treat other pathogens if clinically indicated or if documented by laboratory studies.
Gonorrhea
- Cefixime, 400 mg PO
- Ceftriaxone, 125 mg IM
- Ciprofloxacin, 500 mg PO
- Doxycycline, 100 mg PO b.i.d. for 7 days
C. trachomatis
- Azithromycin, 1 g PO
- 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
- Metronidazole, 500 mg PO b.i.d. for 7 days
H. hominis
- Acyclovir, 200 mg PO five times daily for 7 to 10 days, or until resolution
C. albicans
- Clotrimazole 1% cream, 5 g intravaginally for 3 days
- Clotrimazole 100 mg vaginal tablet, for 7 days

FOLLOW-UP

The recommended treatment regimens have an excellent cure rate. The patient should have resolution of symptoms 3 to 5 days after starting therapy. Routine follow-up cultures are not necessary unless the patient remains symptomatic. Reculturing may be considered 2 to 3 months following therapy to identify reinfection.

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.

COMMON QUESTIONS AND ANSWERS

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 set forth by the CDC for pelvic inflammatory disease. This does not include the use of a single dose of azithromycin.

BIBLIOGRAPHY

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.

Neinstein LS. Adolescent health care: a practical guide, 2nd ed. Baltimore: Urban and Schwarzenberg, 1991.

US Department of Health and Human Services. 1998 Guidelines for treatment of sexually transmitted diseases. MMWR 1998 Jan 23:47(RR-1).

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