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CERVICITIS
Resident Author: Orli Shachar, MD
Faculty Advisor: Anu Joneja, MD, CCFP
Created: December 2012
Overview3,7
Cervicitis is inflammation of the cervix, most commonly affecting the columnar epithelial cells of the endocervical glands. It is characterized most commonly
by the presence of mucopurulent endocervical discharge and/or easily induced endocervical friability. Clinical symptoms also may include dysuria, urinary
frequency, dyspareunia, and vulvovaginal irritation. It can be due to infectious or non-infectious etiology. Acute cervicitis is usually due to infection with
Chlamydia trachomatis (CT) and Nesseria gonorrhoeae (GC) being the most common causes, whereas chronic cervicitis usually has a non-infectious cause.
Complications of infectious cervicitis include: endometritis, PID, transmission to sexual partners, and pregnancy/neonatal complications.
Etiology2,3,6,7
Infectious:
CT, GC, Herpes simplex virus (HSV), Trichomonas vaginalis, Bacterial vaginosis, Mycoplasma genitalis
Non-infectious:
Trauma from surgery or foreign objects (tampons, diaphragm, IUD string, pessary),chemical irritant (douching, spermicides, latex exposure), systemic
inflammatory disease (Behcet's syndrome), radiation therapy, malignancy
Diagnostic Considerations3,6,7
Diagnosis
History & Physical
Investigations
CT and GC
-Mucopurulent discharge
-Intermenstrual bleeding
-Postcoital bleeding
-Friable cervix
-Often asymptomatic
-Nucleic acid amplification test (NAAT) from
vaginal swab, cervical swab or first-catch urine
sample
HSV
90% HSV-2
-Diffuse vesicular lesions/ ulceration
-Erosive inflammation and hemorrhagic lesions
-Viral culture if ulcer present (decreased
sensitivity as lesions heal)
-Cytologic smear
-HSV DNA PCR
Bacterial Vaginosis
-Homogeneous grey, thin vaginal discharge
-Post-coital fishy odour
-Vaginal fluid pH > 4.5
-Clue cells on saline microscopy
-Positive Whiff test
Trichomonas Vaginalis
-Vaginal discharge, pruritus or dysuria
-Erosive inflammation and hemorrhagic
lesions(“strawberry cervix”)
Saline wet mount
-Rapid antigen–based diagnostic tests
-NAAT
**Vaginal swabs identify more CT and GC infections than cervical swabs or first-catch urine specimens. Patient-collected vaginal swabs are as sensitive as clinician-collected specimens5
Management1,2,3,4,7
The main goal of treatment is to prevent upper genital tract disease (endometritis, PID) and its sequelae. During pregnancy, the goal also includes prevention
of peripartum complications and neonatal infections.
Women should receive empiric antibiotic therapy at time of initial evaluation that covers CT. Should also cover GC if patient at high risk (<26 years old,
multiple sexual partners, inconsistent condom use).
Confirmed cases of GC should also receive concomitant treatment for CT, a common co-pathogen.
Partners of women with CT, GC or Trichomonas, with sexual contact during the 60 days preceding the onset of symptoms should be evaluated and treated.
Intercourse should be avoided for 7 days post-treatment. Women should be offered counselling for HIV and syphillis testing.
Test of cure (performed at 1 mo post treatment) for CT and GC is required if symptoms persist after use of an alternate treatment regimen or in pregnancy.
Diagnosis
Recommended Treatment
CT
Azithromycin 1 g po single dose
Or
Doxycycline 100 mg po BID x 7 days
Alternative Treatment
Pregnancy
Azithromycin 1 g po single dose
Or
Amoxicillin 500 mg po TID x 7 days
GC
Ceftriaxone 250 mg IM single dose
Or
Cefixime 800 mg PO single dose
*must always treat for concomitant CT as well
Spectinomycin 2g IM (not available in
Canada)
AVOID quinolones
Ceftriaxone 250 mg IM single dose
Or
Cefixime 400 mg PO single dose
*must always treat for concomitant CT
as well
HSV
First symptomatic episode:
Acyclovir 400 mg TID for 5-7 days
First symptomatic episode:
Famciclovir 250 mg TID for 5 -7 days
OR
Valacyclovir 500-1000 mg BID for 5-7 days
First symptomatic episode:
Acyclovir 200 mg five times daily for 5
-10 days
Trichomonas
Metronidazole 2g PO single dose
Or
Tinidazole 2g PO (not available in Canda)
Metronidazole, 500 mg PO twice daily for
7d
Metronidazole 2g PO single dose
Intravaginal metronidazole is not
effective
vaginalis
No treatment if asymptomatic
Clindamycin 2% 5g intravaginally QHS x 5
SOGC guidelines – if asymptomatic do
*theoretical risk of increased acquisition of
days
not need to treat, limited evidence for
other STIs8
Metronidazole gel 0.75% daily x 5 days
risk of preterm labour
Metronidazole 500 mg po BID x 7 days
References can be found online at http://www.dfcm.utoronto.ca/programs/postgraduateprograme/One_Pager_Project_References.htm
Dr. Michael Evans developed the One-Pager concept to provide clinicians with useful clinical information on primary care topics.
Bacterial
Vaginosis