Cervicitis

Background

• Inflammation of the cervix most commonly caused by Chlamydia (about 40%) and Gonorrhea
  • Less commonly caused by Trichomonas and HSV-2

Clinical Features

Edematous and reddened cervix.

• Mucopurulent endocervical discharge
• May see endocervical bleeding easily induced by cotton swab
• Frequently asymptomatic
  • Women may complain of abnormal vaginal discharge or post-coital vaginal bleeding
• Pelvic/Abdominal pain or tenderness to palpation should prompt a diagnosis of pelvic inflammatory disease rather than cervicitis

Differential Diagnosis

Acute Pelvic Pain

Differential diagnosis of acute pelvic pain

Gynecologic/Obstetric

• Normal variants may be noted on exam but generally do not cause pain or other symptoms
  • Nabothian cysts: Epithelial cells within mucous glans that appear as yellow inclusions on the cervix
  • Cervial Ectropion: Edothelial cells on the exterior of the cervix
  • Parous cervix: The is no longer round but may have multiple shapes after birth
• Pregnancy-related
  • Ectopic pregnancy
  • Spontaneous abortion, threatened or incomplete
  • Septic abortion
• Pelvic organ prolapse
• Acute Infections
  • Herpes
  • Cervicitis
  • Endometritis
  • Bartholin gland abscess
  • Pelvic inflammatory disease (PID)
  • Tubo-ovarian abscess
• Vulvovaginitis
  • Bacterial Vaginosis
  • Candida Vaginitis
  • Trichomonas
  • Contact Vulvovaginitis
  • Atrophic vaginitis
• Adnexal Disorders
  • Hemorrhage/rupture of ovarian cyst
  • Ovarian torsion
  • Twisted paraovarian cyst
• Other
  • Myoma (degenerating)
  • Genitourinary trauma
  • Ovarian hyperstimulation syndrome
  • Sexual assault
• Recurrent
  • Mittelschmerz
  • Primary/Secondary Dysmenorrhea
  • Pelvic Congestion Syndrome
  • Endometriosis

Genitourinary

• Cystitis
• Pyelonephritis
• Urethritis (e.g. N. gonorrhoeae/Chlamydia)
• Urolithiasis

Gastrointestinal

• Gastroenteritis
• Appendicitis
• Bowel obstruction
• Perirectal abscess
• Diverticulitis
• Inflammatory bowel disease
• Irritable bowel syndrome
• Mesenteric adenitis

Musculoskeletal

• Abdominal wall hematoma
• Psoas hematoma, psoas abscess
• Hernia

Vascular

• Pelvic thrombophlebitis
• Abdominal aortic aneurysm
• Ischemic bowel (Mesenteric Ischemia)

Evaluation

• Swab (for GC, Chlamydia)
  • Patient-obtained vaginal swabs are MORE sensitive than clinician-collected endocervical swabs for GC/Chlamydia
• Wet mount
• Urine pregnancy test

Management

Presumed GC/chlamydia of cervix, urethra, or rectum (uncomplicated)

Typically, treatment for both gonorrhea and chlamydia is indicated, if one entity is suspected.

Standard

• Gonorrhea
  • Ceftriaxone IM x 1
    • 500 mg, if weight <150 kg
    • 1 g, if weight ≥150 kg
• Chlamydia
  • Nonpregnant: doxycycline 100 mg PO BID x 7 days
  • Pregnant: azithromycin 1 g PO x 1

Ceftriaxone contraindicated

• Gonorrhea
  • Gentamicin 240 mg IM x 1 PLUS azithromycin 2 g PO x 1, OR
  • Cefixime 800 mg PO x 1
• Chlamydia^
  • Nonpregnant: doxycycline 100 mg PO BID x 7 days
  • Pregnant: azithromycin 1 g PO x 1

^Additional chlamydia coverage only needed if treated with cefixime only

Partner Treatment

• Gonorrhea
  • Cefixime 800mg PO x 1
• Chlamydia
  • Nonpregnant: doxycycline 100mg PO BID x 7 days, OR
  • Pregnant: azithromycin 1g PO x 1

Associated Bacterial Vaginosis or Trichomonas vaginalis

Non-Pregnant

• Metronidazole 500mg PO BID for 7 days
• Tinidazole 2g PO once

Pregnant

Only treat if the patient is symptomatic

• Metronidazole 500mg PO BID for 7 days

Sexual Partner Treatment

• Female: Same as above
• Male: Metronidazole 2 gm PO x1

Disposition

• Discharge

See Also

• Sexually transmitted diseases

External Links

• http://www.cdc.gov/std/treatment/2010/urethritis-and-cervicitis.htm