Resident Editor, 2018 Update: Kelly A. Johnson, MD, MPH
Faculty Editor, 2018 Update: Iris Huang, MD, MPH
BOTTOM LINE ✔ Diagnosing and treating cervicitis and PID can help prevent long-term complications such as infertility, ectopic pregnancy, and HIV transmission ✔ Consider treating cervicitis empirically for chlamydia +/- gonorrhea infection. ✔ Remember to empirically treat sexual partners |
Background/Epidemiology
- Cervicitis: inflammation of the cervix (often infectious)
- Complications: pelvic inflammatory disease, increases HIV viral shedding and risk of HIV transmission
- Pelvic inflammatory disease (PID): infection-induced inflammation of the upper female reproductive tract, caused by ascension of microorganisms from the lower genital tract
- Spectrum of disease: endometritis, salpingitis, and tubo-ovarian abscess
- Complications: ectopic pregnancy, infertility, and chronic abdominal pain
- Cervicitis and PID are most common among young (< age 25) sexually active women and adolescents
Microbiology
Cervicitis |
PID |
|
|
Signs and Symptoms
- Cervicitis: often asymptomatic. Can cause vaginal discharge, inter-menstrual or post-coital bleeding, dyspareunia, dysuria. Unlike vaginitis, does not typically cause vaginal itching and irritation
- PID: pelvic/lower abdominal pain, vaginal discharge, dyspareunia, dysuria, inter-menstrual or post-coital bleeding
- Constitutional symptoms: Not often a prominent feature, but may include fever, nausea, and/or vomiting
- Right upper quadrant pain may be seen if the infection ascends to the liver capsule resulting in inflammation and formation of adhesions (Fitz-Hugh-Curtis Syndrome)
Evaluation
- Pelvic Exam: mucopurulent discharge, cervix may appear edematous and erythematous, and demonstrate easy bleeding when probed (friability)
- Hallmarks of PID: reproductive organ tenderness on bimanual exam (e.g., cervical motion or adnexal tenderness)
- Wet mount/KOH: increased numbers of WBCs, especially PMNs (e.g., >1 neutrophil per epithelial cell). Evaluate for evidence of candida, trichomonas, and/or BV
- Pregnancy test to r/o ectopic pregnancy
- 4th generation HIV test given risk of co-infection
- Nucleic Acid Amplification Testing (cervical swab, vaginal swab or urine): preferred for the diagnosis of chlamydia and gonorrhea
Treatment
Diagnosis |
Empiric Treatment |
Cervicitis |
- Chlamydia: Doxycycline 100 mg BID x 7 days - Gonorrhea (penicillin allergic): Azithromycin 2 gm PO x 1 + Gentamicin 240 mg IM x 1
|
Pelvic Inflammatory Disease Outpatient (mild-moderate symptoms, able to tolerate PO) |
or
or
|
Pelvic Inflammatory Disease Inpatient (pregnant patients, severe systemic illness, inability to tolerate PO intake, poor response to oral therapy, and/or tubal abscess) |
or
or
|
Prevention and Screening
- CDC and USPSTF recommendations: annual screening for chlamydia (and gonorrhea) among all sexually active women < 25 years old, and in older women with high risk sexual behavior
- Routine screening should be performed along with safe sex counseling including regular condom use
- Sexual partners should be treated empirically in all confirmed or suspected cases of cervicitis or PID due to STIs
- Consider ordering additional prescriptions for the patient to give to their partner(s)
- Recommend abstinence for at least 7 days after treatment or until both partners are symptom free
- Gonorrhea and chlamydia cases are reported to the public health department
References
Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. Available at https://www.cdc.gov/std/tg2015/tg-2015-print.pdf. Accessed 29 July 2018.
Brunham RC, Gottlieb SL, and Paavonen J. Pelvic inflammatory disease. N Engl J Med 2015; 372(21): 2039-48.
Marrazzo JM and Martin DH. Management of women with cervicitis. CID 2007; 44 (Suppl 3): S102-110.
Risser WL, Risser JM, Risser AL. Current perspectives in the USA on the diagnosis and treatment of pelvic inflammatory disease in adolescents. Aolesc Health Med Ther 2017; 8: 87-94.
Wiesenfeld HC and Manhart LE. Mycoplasma genitalium in women: current knowledge and research priorities for this recently emerged pathogen. JID 2017: 216 (Suppl 2): S389-95.
Workowski KA. Centers for disease control and prevention sexually transmitted diseases treatment guidelines. CID 2015; 61 (Suppl 8): S759-62.