Cervicitis

INTRODUCTION @

Background: Cervicitis is an inflammation of the uterine cervix. Infectious cervicitis might be caused by Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, herpes simplex virus, or human papilloma virus. Noninfectious cervicitis might be caused by local trauma, radiation, or malignancy. The infectious etiologies are significantly more common than the noninfectious causes, and all possible infectious causes of cervicitis are sexually transmitted diseases (STDs). This chapter focuses on the infectious etiologies of cervicitis.

Pathophysiology: Because the female genital tract is contiguous from the vulva to the fallopian tubes, there is some overlap between vulvo-vaginitis and cervicitis. Vulvo-vaginitis and cervicitis commonly are grouped together as lower genital tract infections. Infections involving the endometrium and fallopian tubes commonly are grouped together as upper genital tract infections and are not discussed in this chapter.

Frequency:
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Mortality/Morbidity: Complications from untreated infectious cervicitis depend on the pathogen. Morbidity includes pelvic inflammatory disease, infertility, ectopic pregnancy, spontaneous abortion, cervical cancer, premature rupture of membranes, and preterm delivery. Perinatal and neonatal infections can cause mental retardation, blindness, low birth weight, stillbirth, meningitis, and death. The social stigma also is strong and might expose women to verbal, emotional, or physical abuse from others, particularly male partners.

Race: No racial predilection exists. Known risk factors include urban residence and low socioeconomic status.

Sex: Male urethritis is more often symptomatic; therefore, diagnosis usually is made earlier in males than in females. Females with cervicitis most often are completely asymptomatic so they do not seek evaluation or treatment as readily.

Age: Youth (eg, <25 y) and single marital status are both risk factors for cervicitis. Therefore, routine screening of sexually active adolescents and young adults is recommended.

CLINICAL @

History:

Physical: The physical exam should include general survey, pelvic exam, external inspection, speculum exam, bimanual exam, and in certain patients, a rectal exam.

Causes: All of the infectious etiologies of cervicitis are sexually transmitted diseases.

Risk factors include multiple sex partners, young age, single marital status, urban residence, low socioeconomic status, and alcohol or drug use.

WORKUP @

Lab Studies:
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TREATMENT @

Medical Care: Treatment of all causes of cervicitis is medical. Treatment needs to include the patient's sexual partners to prevent reinfection. In cases of unclear diagnosis, pregnancy, or refractory infections or symptoms, consultation with an infectious disease specialist may be appropriate.

Activity:

MEDICATION @

Oral antibiotics effectively cure gonorrhea, chlamydia, and Trichomonas vaginalis infections. Oral antivirals reduce duration of symptoms, lesions, and viral shedding in the first and recurrent episodes of genital herpes infections. Topical therapy initially is used for symptomatic genital wart removal. Other options include intralesional injection and surgery.
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Drug Category: Antibiotic -- Therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting.

Drug Name
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Ceftriaxone (Rocephin) -- Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin binding proteins.
Adult Dose 125 mg IM once
Pediatric Dose Administer as in adults
Contraindications Documented hypersensitivity
Interactions Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Partner must be treated; adjust dose in renal impairment; caution in breast-feeding women and allergy to penicillin; treat also for chlamydia since 20-40% of patients with gonorrhea are coinfected; partner(s) must also be treated
Drug Name
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Cefixime (Suprax) -- Third-generation cephalosporin effective in treating gonorrhea. By binding to one or more of the penicillin binding proteins it arrests bacterial cell wall synthesis and inhibits bacterial growth.
Adult Dose 400 mg PO once
Pediatric Dose <45 kg: Not established

>45 kg: Administer as in adults
Contraindications Documented hypersensitivity
Interactions Coadministration of aminoglycosides increase nephrotoxicity; probenecid may increase effects of cefixime; false-positive Clinitest results
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Partner must be treated; adjust dose in renal impairment; colitis may occur
Drug Name
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Ofloxacin (Floxin) -- Fluoroquinolone effective in treating gonorrhea. A pyridine carboxylic acid derivative with broad spectrum bactericidal effect.
Adult Dose 400 mg PO once
Pediatric Dose <18 years: Not recommended

>18 years: Administer as in adults
Contraindications Documented hypersensitivity
Interactions Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations
May increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Partner must be treated; in prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Drug Name
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Ciprofloxacin (Cipro) -- Inhibits bacterial DNA synthesis, and consequently growth.
Adult Dose 500 mg PO once
Pediatric Dose <18 years: Not recommended

>18 years: Administer as in adults
Contraindications Documented hypersensitivity
Interactions Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations
May increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Partner must be treated; in prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Drug Name
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Spectinomycin (Trobicin) -- Inhibits protein synthesis in bacterial cells. Site of action is 30S ribosomal subunit and is structurally different from related aminoglycosides.
Use if allergic to penicillin and quinolones.
Adult Dose 2 g IM once
Pediatric Dose <45 kg: 40 mg/kg IM once

>45 kg: Administer as in adults
Contraindications Documented hypersensitivity
Interactions None reported
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Partner must be treated; benzyl alcohol used as a diluent associated with fatal gasping syndrome in infants
Drug Name
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Azithromycin (Zithromax) -- Semisynthetic macrolide antibiotic effective in treating chlamydia. Treats mild-to-moderate microbial infections.
Adult Dose 1 g PO once
Pediatric Dose <6 months: Not established

>6 months: Administer as in adults
Contraindications Documented hypersensitivity; hepatic impairment; use of pimozide
Interactions May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Partner must be treated; if pregnant, use erythromycin; site reactions can occur with IV route; bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients
Drug Name
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Doxycycline (Vibramycin) -- Long-acting tetracycline derived from oxytetracycline effective in treating chlamydia. Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Adult Dose 100 mg PO bid for 7 d
Pediatric Dose <8 years: Not recommended

>8 years: Administer as in adults
Contraindications Documented hypersensitivity; children <8 years; severe hepatic impairment
Interactions Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Pregnancy D - Unsafe in pregnancy
Precautions Partner must be treated; if pregnant, use erythromycin; photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one-half of pregnancy through age 8 years) can cause permanent discoloration of teeth; Fanconi-like syndrome may occur with outdated tetracyclines
Drug Name
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Ofloxacin (Floxin) -- A pyridine carboxylic acid derivative with broad spectrum bactericidal effect.
Adult Dose 300 mg PO bid for 7 d
Pediatric Dose <18 years: Not recommended

>18 years: Administer as in adults
Contraindications Documented hypersensitivity
Interactions Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations
May increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Partner must be treated; in prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Drug Name
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Erythromycin base (E-Mycin) -- Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest.
Adult Dose 500 mg PO bid for 7 d
Pediatric Dose <12 years: Not established

>12 years: Administer as in adults
Contraindications Documented hypersensitivity; hepatic dysfunction; current use of pimozide
Interactions Decrease clearance of alfentanil, bromocriptine, carbamazepine, cyclosporine, digoxin, disopyramide, ergot alkaloids, methylprednisolone, protease inhibitor, theophylline, and triazolam; increases anticoagulant effect of warfarin; decreases metabolism of vinblastine; serum levels increased by protease inhibitors, increased levels and rhabdomyolysis with use of lovastatin and simvastatin
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Partner must be treated; estolate formulation may cause cholestatic jaundice; GI side effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur
Drug Name
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Erythromycin ethylsuccinate (EES) -- Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest.
Adult Dose 800 mg PO qid for 7 d
Pediatric Dose <12 years: Not established

>12 years: Administer as in adults
Contraindications Documented hypersensitivity; hepatic dysfunction; current use of pimozide
Interactions Decrease clearance of alfentanil, bromocriptine, carbamazepine, cyclosporine, digoxin, disopyramide, ergot alkaloids, methylprednisolone, protease inhibitor, theophylline, and triazolam; increases anticoagulant effect of warfarin; decreases metabolism of vinblastine; serum levels increased by protease inhibitors, increased levels and rhabdomyolysis with use of lovastatin and simvastatin
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Partner must be treated; caution in liver disease; discontinue if GI distress, malaise, or fever occurs
Drug Name
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Metronidazole (Flagyl) -- Synthetic antibacterial and antiprotozoal agent. Only drug proven effective in treating Trichomonas vaginalis infections.
Adult Dose 2 g PO once; alternatively, 500 mg PO bid for 7 d
Pediatric Dose <1 year: 10-30 mg/kg/d PO for 5-8 d

<12 years: 15 mg/kg/d PO in 3 divided doses for 7-10 d

>12 years: Administer as in adults
Contraindications Documented hypersensitivity; controversy exists about treatment during first trimester (category D) despite no proof of harm, some suggest waiting until second trimester to treat using 500 mg PO bid for 7 d
Interactions Avoid alcohol for 7 d (disulfiramlike reaction); effect decreased by phenobarbital and phenytoin; increases PT with warfarin; increases toxicity/serum level of lithium; serum level increased by cimetidine
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Partner must be treated; adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy

Drug Category: Antiviral

Drug Name
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Acyclovir (Zovirax) -- Synthetic purine nucleoside analog indicated for genital herpes simplex virus infections. First episode, begin treating within 6 d after appearance of first symptoms. If recurrent attack, begin treating during prodrome or within 1 d after onset of lesions. Suppression requires daily treatment for 1 y.
Adult Dose First episode: 400 mg PO tid for 7-10 d; alternatively 200 mg PO 5 times qd for 7-10 d
Recurrent attack: 200 mg PO 5 times qd for 5 d; alternatively 400 mg PO tid for 5 d or 800 mg PO bid for 5 d

For suppression: 400 mg PO bid for 1 y
Pediatric Dose First episode: 400 mg PO tid for 7-10 d; not to exceed 80 mg/kg/d

Recurrent attack: 400 mg PO tid for 5 d; alternatively 800 mg PO bid for 5 d; not to exceed 80 mg/kg/d

>12 years: Administer as in adults
Contraindications Documented hypersensitivity
Interactions Probenecid and zidovudine increase CNS side effects
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Register pregnant patients on acyclovir at
1-800-722-9292; caution in renal failure or coadministration of nephrotoxic drugs
Drug Name
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Famciclovir (Famvir) -- Prodrug for penciclovir (active moiety) indicated for genital herpes simplex virus infections. First episode, begin treating within 6 days after appearance of first symptoms. Recurrent attack, begin treating during prodrome or within 1 day after onset of lesions. Suppression requires daily treatment for 1 y.
Adult Dose First episode: 250 mg PO tid for 7-10 d
Recurrent attack: 125 mg PO bid for 5 d

For suppression: 250 mg PO bid for 1 y
Pediatric Dose Not established
Contraindications Documented hypersensitivity
Interactions Cimetidine and probenecid increase toxicity/serum level of penciclovir; increases digoxin level
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Register pregnant patients at 1-800-722-9292; caution in renal failure or coadministration of nephrotoxic drugs
Drug Name
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Valacyclovir (Valtrex) -- Indicated for genital herpes simplex virus infections. First episode, begin treating within 6 days after appearance of first symptoms. Recurrent attack, begin treating during prodrome or within 1 day after onset of lesions. Suppression requires daily treatment for 1 year.
Adult Dose First episode: 1 g PO bid for 7-10 d
Recurrent attack: 500 mg PO bid for 5 d

For suppression: 1 g PO qd for 1 y; alternatively 500 mg PO qd for 1 y or 250 mg PO bid for 1 y
Pediatric Dose <12 years: Not established

>12 years: Administer as in adults
Contraindications Documented hypersensitivity
Interactions Cimetidine/probenecid decrease conversion rate to acyclovir
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Register pregnant patients at 1-800-722-9292; monitor patient who are immunocompromised for thrombotic thrombocytopenic purpura/hemolytic uremic syndrome; adjust dose in renal impairment

Drug Category: Topical skin product -- Topical products for genital/perianal warts

Drug Name
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Imiquimod (Aldara), Podofilox (Condylox), Trichloroacetic acid, 5-fluorouracil -- Topical products for genital/perianal warts. Available as 5% topical cream.
Podofilox is available as a 0.5% solution. Trichloroacetic acid in available in an 80-90% solution. 5-fluorouracil is available in a 5% cream.
Adult Dose Imiquimod: Apply to warts qhs 3 times/wk for up to 16 wk, rinse treatment area with soap and water 6-10 h after application

Podofilox: Apply to warts bid for 3 d, no therapy for 4 d, then repeat up to 4 cycles. Trichloroacetic acid: Apply to warts and powder with talc or sodium bicarbonate (baking soda) to remove unreacted acid, may repeat weekly. 5-flurorouracil cream: Apply daily, may use an applicator for urethral warts
Pediatric Dose Not established
Contraindications Documented hypersensitivity
Interactions None reported
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions In pregnancy, most lesions may be treated postpartally, however, consideration may be given to using topical liquid nitrogen qwk or surgical treatments (eg, excision, electrocauterization, laser vaporization); avoid contact with genital mucous membranes; burning, pain, inflammation, erosion, and pruritus have occurred
FOLLOW-UP @

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Patient Education:
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MISCELLANEOUS @

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Special Concerns:
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BIBLIOGRAPHY @