Cervicitis overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Prince Tano Djan, BSc, MBChB [2]
Overview
Cervicitis means nflammation of the tissues of the cervix. Cervicitis has many features in common with urethritis in men. These are commonly due to sexually transmitted infections.
Historical Perspective
Cervicitis was first described formally by Dr. Voilet I. Russell and Dr. D. Cochrane Logan in 1926 during their addresses made before the Medical Society for the Study of Veneral Diseases on January 29, 1926. Before this time, no accurate record was made about the disease in literature.[1]
Classification
Cervicitis may be classified according to the etiology, anatomical location and disease duration as infectious, non-infectious, acute, subacute and chronic cervicitis. The infectious causes are Gonococcal, C. trachomatis and Herpes. Examples of the non-infectious causes are traumatic injury to the cervix, chemical exposure; douching, latex, contraceptive creams, systemic inflammation example Behcet syndrome as well as radiation exposure.
Pathophysiology
The pathophysiology of Cervicitis depends on the etiological agent and the physiological state of the patient. Under the influence of estrogen, the normal vaginal epithelium cornifies making it somewhat resistant to infectious agents. The endocervix is lined by columnar epithelium which is susceptible to infectious agents leading to cervicitis.
Gonococcal cervicitis results after the exposure of the cervix to N. gonorrhea in seminal fluid during sexual intercourse. N. gonorrhea infectivity is facilitated by type IV pilus-mediated motility of the bacterium. In the presence of seminal fluid, the bacterial motility is characterized by high velocity, low directional persistence and enhanced microcolony formation.[2] Once pilus is attached, local inflammation results from release of neutrophilic cytokines leading to purulent or mucopurulent discharge. C. trachomatis infection is often associated with intense lymphocytic and neutrophilic inflammtory reaction in the affected areas and occasionally with follicular aggregation of lymphocyte.[3][4] The chronic course of chlamydial cervicitis is associated with low content of cytokines mainly IL-1 alpha, IL-1 beta, TNF-alpha and an elevated concentration of IL-8 in the pathogenesis.[5]
Causes
Cervicitis is caused by infectious [6][7][8][9][10][11][12][13][14][15] and non infectious causes. The infectious causes are most commonly caused by chlamydia and gonorrhea, with chlamydia accounting for the majority of cases. Trichomonas vaginalis and herpes simplex are less common causes of cervicitis. Non-infectious causes of cervicitis include: intrauterine devices, contraceptive diaphragms, and allergic reactions to spermicides or latex condoms
Differentiating Cervicitis overview from Other Diseases
Cervicitis must be differentiated from other diseases that cause vaginal discharge and/or pelvic pain, such as endometritis, salpingitis, vaginitis and vulvovaginatis.
Epidemiology and Demographics
The incidence and prevalence of cervicitis depends on the study population. The prevalence of cervicitis is estimated to be 18000 per 100000 women diagnosed of gonococcal infection.[16] The prevalence of cervicitis ranges from 7600 to 24900 per 100000 female sex workers. The broad range is due to variation in demographic location.[17][18] Cervicitis is relatively more prevalent in HIV-positive women than non-HIV positive women.[19]. Among this population, prevalence of cervicitis is estimated to be 7400 per 100000 women diagnosed of HIV infection.[20] Screening and treatment of M. genitalium among HIV-infected individuals may be needed to improve cervical health, and reduce mobidity.[20] The overall prevalence of nongonococcal cervicitis is higher than gonococcal cervicitis.[7]. Chlamydia cervicitis is four to five times more prevalent than gonococcal cervicitis.[21][7] However, coinfection of gonococcal and chlamydia cervicitis is higher in PID than in cervicitis.[21] Cervicitis commonly follows the pattern of age prevalence of sexually transmitted infections with highest incidence among women aged 15-24.[22][23][24] There is no racial predilection to developing cervcitis. The prevalence of cervicitis is higher in underserved communities and developing countries.[25][26]
Risk Factors
Common risk factors in the development of cervicitis include high-risk sexual behavior, history of sexually transmitted diseases, sexual intercourse at an early age, sexual partners who have engaged in high-risk sexual behavior or have previous history of STD, single marital status, urban residence, low socioeconomic status, smoking, alcohol or drug use , multiple sex partners, and bacterial vaginosis.[27][27][19][28][29]
Screening
Screening for the infectious causes of cervicitis is recommended according to the 2015 Sexually Transmitted Diseases Treatment Guidelines by the CDC.[30][31][23][32] Gonococcal and Chlamydial screening is recommended in sexually active women under 25 years of age, sexually active women aged 25 years and older if at increased risk, all pregnant women under 25 years of age and pregnant women aged 25 and older if at increased risk.
Natural History, Complications, and Prognosis
If left untreated, cervicitis may progress to PID with associated infectility especially in chronic cervicitis.[33][34] Untreated active HSV infections in the perinatal and neonatal period may lead to neonatal morbidity. Complications that can develop as a result of infectious cervicitis include:[35][33][36][14][25][37] pelvic inflammatory disease, infertility, chronic pelvic pain, ectopic pregnancy, spontaneous abortion, premature rupture of membranes and preterm delivery
Diagnosis
History and Symptoms
Mucopurulent cervicitis is often asymptomatic,[33][16] however, some patients may present with abnormal vaginal discharge, painful sexual intercourse and intermenstrual vaginal bleeding.[27][4]
Physical Examination
Two major diagnostic signs characterize cervicitis:[24][38]
1) a purulent or mucopurulent endocervical exudate visible in the endocervical canal or on an endocervical swab specimen (commonly referred to as mucopurulent cervicitis or cervicitis)
2) sustained endocervical bleeding easily induced by gentle passage of a cotton swab through the cervical os. Either or both signs might be present.
Laboratory Findings
Diagnosis of cervicitis is mostly clinical however, a finding of >10 WBC in vaginal fluid, in the absence of trichomoniasis, may indicate endocervical inflammation caused specifically by C. trachomatis or N. gonorrhea although culture is more accurate for gonococcal cervicitis.[39] The use of nucleic acid amplification tests is very helpful for the diagnosis of trichomoniasis.[40] Wet mount microscopy and direct visualisation have low sensitivity in detecting N. gonorrhea and T. vaginalis, because of this symptomatic women with cervicitis and negative microscopy should receive further testing (i.e., culture or other FDA-cleared method). Although HSV-2 infection has been associated with cervicitis, the utility of specific testing (i.e., culture or serologic testing) for HSV-2 is unknown. DNA amplification techniques has good sensitivity, but are not yet approved for diagnostic purposes of Trichomoniasis.[41] Microscopy (wet prep) and vaginal pH are useful for identifying bacterial vaginosis which may show clue cells.[42]
Ultrasound
Ultrasound is not needed in diagnosing cervicitis, however, when complicated by PID, it may be helpful.[21]
Other Diagnostic Studies
There are no other diagnostic studies for cervicitis.
Treatment
Medical Therapy
Antimicrobial therapy with adequate coverage against C. trachomatis should be provided for women at increased risk for C. trachomatis or if follow-up cannot be ensured and if a relatively insensitive diagnostic test is used in place of NAAT. Patients may also require concomitant therapy against N. gonorrhea. Medical therapies include either azithromycin, doxycycline, or a fluoroquinolone. Treatment of sexual partners is also indicated. Follow-up after completion of antimicrobial therapy regimen is required to evaluate for microbial resistance.[43]
Surgery
Surgical intervention is unnecessary in the management of cervicitis.
Prevention
Effective measures for the primary prevention of cervicitis include avoidance of the risk factors of cervicitis click here. Secondary prevention strategies of cervicitis include early diagnosis and treatment of patients with sexually treatment infections especially gonorrhea and chlamydia.
References
- ↑ Russell VI (1926). "DIAGNOSIS AND TREATMENT OF URETHRITIS AND CERVICITIS". Br J Vener Dis. 2 (6): 182–93. PMC 1046487. PMID 21772527.
- ↑ Anderson MT, Dewenter L, Maier B, Seifert HS (2014). "Seminal plasma initiates a Neisseria gonorrhoeae transmission state". MBio. 5 (2): e01004–13. doi:10.1128/mBio.01004-13. PMC 3958800. PMID 24595372.
- ↑ Paavonen J, Vesterinen E, Meyer B, Saksela E (1982). "Colposcopic and histologic findings in cervical chlamydial infection". Obstet Gynecol. 59 (6): 712–5. PMID 7078909.
- ↑ 4.0 4.1 Dunlop EM, Garner A, Darougar S, Treharne JD, Woodland RM (1989). "Colposcopy, biopsy, and cytology results in women with chlamydial cervicitis". Genitourin Med. 65 (1): 22–31. PMC 1196182. PMID 2921049.
- ↑ Dolgushin II, Kurnosenko IV, Dolgushina VF, Ugaĭ IIu, Abramovskikh OS, Gol'tsfarb VM (2004). "[Clinical and immunological aspects of cervicitis of chlamydial etiology]". Zh Mikrobiol Epidemiol Immunobiol (3): 48–52. PMID 15346950.
- ↑ Lusk MJ, Garden FL, Rawlinson WD, Naing ZW, Cumming RG, Konecny P (2016). "Cervicitis aetiology and case definition: a study in Australian women attending sexually transmitted infection clinics". Sex Transm Infect. 92 (3): 175–81. doi:10.1136/sextrans-2015-052332. PMID 26586777.
- ↑ 7.0 7.1 7.2 Gaydos C, Maldeis NE, Hardick A, Hardick J, Quinn TC (2009). "Mycoplasma genitalium as a contributor to the multiple etiologies of cervicitis in women attending sexually transmitted disease clinics". Sex Transm Dis. 36 (10): 598–606. doi:10.1097/OLQ.0b013e3181b01948. PMC 2924808. PMID 19704398.
- ↑ Mobley VL, Hobbs MM, Lau K, Weinbaum BS, Getman DK, Seña AC (2012). "Mycoplasma genitalium infection in women attending a sexually transmitted infection clinic: diagnostic specimen type, coinfections, and predictors". Sex Transm Dis. 39 (9): 706–9. doi:10.1097/OLQ.0b013e318255de03. PMC 3428747. PMID 22902666.
- ↑ Ona S, Molina RL, Diouf K (2016). "Mycoplasma genitalium: An Overlooked Sexually Transmitted Pathogen in Women?". Infect Dis Obstet Gynecol. 2016: 4513089. doi:10.1155/2016/4513089. PMC 4860244. PMID 27212873.
- ↑ Lusk MJ, Konecny P (2008). "Cervicitis: a review". Curr Opin Infect Dis. 21 (1): 49–55. doi:10.1097/QCO.0b013e3282f3d988. PMID 18192786.
- ↑ Marrazzo JM, Martin DH (2007). "Management of women with cervicitis". Clin Infect Dis. 44 Suppl 3: S102–10. doi:10.1086/511423. PMID 17342663.
- ↑ Korte JE, Baseman JB, Cagle MP, Herrera C, Piper JM, Holden AE; et al. (2006). "Cervicitis and genitourinary symptoms in women culture positive for Mycoplasma genitalium". Am J Reprod Immunol. 55 (4): 265–75. doi:10.1111/j.1600-0897.2005.00359.x. PMID 16533338.
- ↑ Hezarjaribi HZ, Fakhar M, Shokri A, Teshnizi SH, Sadough A, Taghavi M (2015). "Trichomonas vaginalis infection among Iranian general population of women: a systematic review and meta-analysis". Parasitol Res. 114 (4): 1291–300. doi:10.1007/s00436-015-4393-3. PMID 25732256.
- ↑ 14.0 14.1 Nugent RP, Hillier SL (1992). "Mucopurulent cervicitis as a predictor of chlamydial infection and adverse pregnancy outcome. The Investigators of the Johns Hopkins Study of Cervicitis and Adverse Pregnancy Outcome". Sex Transm Dis. 19 (4): 198–202. PMID 1411834.
- ↑ Eschenbach DA, Buchanan TM, Pollock HM, Forsyth PS, Alexander ER, Lin JS; et al. (1975). "Polymicrobial etiology of acute pelvic inflammatory disease". N Engl J Med. 293 (4): 166–71. doi:10.1056/NEJM197507242930403. PMID 806017.
- ↑ 16.0 16.1 Barlow D, Phillips I (1978). "Gonorrhoea in women. Diagnostic, clinical, and laboratory aspects". Lancet. 1 (8067): 761–4. PMID 76760.
- ↑ Efosa OB, Uwadiegwu AP (2015). "Cytopathological Examination and Epidemiological Study of Cervicitis in Commercial Sex Workers (CSWs) in Coal City (Enugu), Nigeria". Ethiop J Health Sci. 25 (3): 225–30. PMC 4650877. PMID 26633925.
- ↑ Pollett S, Calderon M, Heitzinger K, Solari V, Montano SM, Zunt J (2013). "Prevalence and predictors of cervicitis in female sex workers in Peru: an observational study". BMC Infect Dis. 13: 195. doi:10.1186/1471-2334-13-195. PMC 3664214. PMID 23631602.
- ↑ 19.0 19.1 Lewis DA, Chirwa TF, Msimang VM, Radebe FM, Kamb ML, Firnhaber CS (2012). "Urethritis/cervicitis pathogen prevalence and associated risk factors among asymptomatic HIV-infected patients in South Africa". Sex Transm Dis. 39 (7): 531–6. doi:10.1097/OLQ.0b013e31824cbecc. PMID 22706215.
- ↑ 20.0 20.1 Dehon PM, Hagensee ME, Sutton KJ, Oddo HE, Nelson N, McGowin CL (2016). "Histological Evidence of Chronic Mycoplasma genitalium-Induced Cervicitis in HIV-Infected Women: A Retrospective Cohort Study". J Infect Dis. 213 (11): 1828–35. doi:10.1093/infdis/jiw025. PMC 4857473. PMID 26783349.
- ↑ 21.0 21.1 21.2 Burnett AM, Anderson CP, Zwank MD (2012). "Laboratory-confirmed gonorrhea and/or chlamydia rates in clinically diagnosed pelvic inflammatory disease and cervicitis". Am J Emerg Med. 30 (7): 1114–7. doi:10.1016/j.ajem.2011.07.014. PMID 22030186.
- ↑ Satterwhite CL, Torrone E, Meites E, Dunne EF, Mahajan R, Ocfemia MC; et al. (2013). "Sexually transmitted infections among US women and men: prevalence and incidence estimates, 2008". Sex Transm Dis. 40 (3): 187–93. doi:10.1097/OLQ.0b013e318286bb53. PMID 23403598.
- ↑ 23.0 23.1 Chlamydia CDC Fact Sheet. CDC.http://www.cdc.gov/std/chlamydia/stdfact-chlamydia-detailed.htm#_ENREF_3. Accessed on December 29, 2015
- ↑ 24.0 24.1 Marrazzo JM, Handsfield HH, Whittington WL (2002). "Predicting chlamydial and gonococcal cervical infection: implications for management of cervicitis". Obstet Gynecol. 100 (3): 579–84. PMID 12220782.
- ↑ 25.0 25.1 Chico RM, Mayaud P, Ariti C, Mabey D, Ronsmans C, Chandramohan D (2012). "Prevalence of malaria and sexually transmitted and reproductive tract infections in pregnancy in sub-Saharan Africa: a systematic review". JAMA. 307 (19): 2079–86. doi:10.1001/jama.2012.3428. PMID 22665107.
- ↑ Toomey KE, Moran JS, Rafferty MP, Beckett GA (1993). "Epidemiological considerations of sexually transmitted diseases in underserved populations". Infect Dis Clin North Am. 7 (4): 739–52. PMID 8106727.
- ↑ 27.0 27.1 27.2 Marrazzo JM, Wiesenfeld HC, Murray PJ, Busse B, Meyn L, Krohn M; et al. (2006). "Risk factors for cervicitis among women with bacterial vaginosis". J Infect Dis. 193 (5): 617–24. doi:10.1086/500149. PMID 16453256.
- ↑ Ramos BR, Polettini J, Marcolino LD, Vieira EP, Marques MA, Tristão AR; et al. (2011). "Prevalence and risk factors of Chlamydia trachomatis cervicitis in pregnant women at the genital tract infection in obstetrics unit care at Botucatu Medical School, São Paulo State University-UNESP, Brazil". J Low Genit Tract Dis. 15 (1): 20–4. doi:10.1097/LGT.0b013e3181ed3d58. PMID 21192172.
- ↑ Nguyen TV, Van Khuu N, Thi Le TT, Nguyen AP, Cao V, Tham DC; et al. (2008). "Sexually transmitted infections and risk factors for gonorrhea and chlamydia in female sex workers in Soc Trang, Vietnam". Sex Transm Dis. 35 (11): 935–40. doi:10.1097/OLQ.0b013e3181812d03. PMC 2903543. PMID 18685547.
- ↑ "2015 Sexually Transmitted Diseases Treatment Guidelines (CDC)".
- ↑ Workowski KA, Bolan GA. Sexually transmitted diseases treat- ment guidelines, 2015. MMWR Recomm Rep 2015;64:60–68.
- ↑ Screening recommendation for chlamydia. UPSTF. http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/chlamydia-and-gonorrhea-screening?ds=1&s=chlamydia(2014). Acessed on September 8, 2016
- ↑ 33.0 33.1 33.2 Holló P, Jókai H, Herszényi K, Kárpáti S (2015). "[Genitourethral infections caused by D-K serotypes of Chlamydia trachomatis]". Orv Hetil. 156 (1): 19–23. doi:10.1556/OH.2015.30078. PMID 25544050.
- ↑ Soper DE (2010). "Pelvic inflammatory disease". Obstet Gynecol. 116 (2 Pt 1): 419–28. doi:10.1097/AOG.0b013e3181e92c54. PMID 20664404.
- ↑ Majeroni BA (1994). "Chlamydial cervicitis: complications and new treatment options". Am Fam Physician. 49 (8): 1825–9, 1832. PMID 8203320.
- ↑ Hill MG, Menon S, Smith S, Zhang H, Tong X, Browne PC (2015). "Screening for Chlamydia and Gonorrhea Cervicitis and Implications for Pregnancy Outcome. Are We Testing and Treating at the Right Time?". J Reprod Med. 60 (7–8): 301–8. PMID 26380488.
- ↑ Manhart LE, Jensen JS, Bradshaw CS, Golden MR, Martin DH (2015). "Efficacy of Antimicrobial Therapy for Mycoplasma genitalium Infections". Clin Infect Dis. 61 Suppl 8: S802–17. doi:10.1093/cid/civ785. PMID 26602619.
- ↑ Berntsson M, Tunbäck P (2013). "Clinical and microscopic signs of cervicitis and urethritis: correlation with Chlamydia trachomatis infection in female STI patients". Acta Derm Venereol. 93 (2): 230–3. doi:10.2340/00015555-1536. PMID 23460336.
- ↑ McLellan R, Spence MR, Brockman M, Raffel L, Smith JL (1982). "The clinical diagnosis of trichomoniasis". Obstet Gynecol. 60 (1): 30–4. PMID 6896368.
- ↑ Workowski KA, Bolan GA, Centers for Disease Control and Prevention (2015). "Sexually transmitted diseases treatment guidelines, 2015". MMWR Recomm Rep. 64 (RR-03): 1–137. PMID 26042815.
- ↑ Swygard H, Seña AC, Hobbs MM, Cohen MS (2004). "Trichomoniasis: clinical manifestations, diagnosis and management". Sex Transm Infect. 80 (2): 91–5. PMC 1744792. PMID 15054166.
- ↑ Storti-Filho A, Souza PC, Souza RJ, Pereira MW, Mello IC, Svidizinski TI; et al. (2011). "Prevalence of clue cells suggestive for Gardnerella vaginalis in population-based cervical screening in the public versus private health care in Maringá, Paraná, Brazil". Arch Gynecol Obstet. 283 (4): 781–5. doi:10.1007/s00404-010-1400-x. PMID 20221621.
- ↑ Diseases Characterized by Urethritis and Cervicitis. Centers for Disease Control and Prevention (2015). http://www.cdc.gov/std/tg2015/urethritis-and-cervicitis.htm Accessed on July 28, 2016