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Background Cervicitis is an inflammation of the uterine cervix, characteristically diagnosed by: (1) avisible, purulent or mucopurulent endocervical exudate

in the endocervical canal or onan endocervical swab specimen and/or (2) sustained, easily induced endocervical bleeding when a cotton swab is gently passed through the cervical os. A normal cervixis pictured below. Normal cervix Noninfectious cervicitis Noninfectious cervicitis can be caused by the following: Local trauma - Eg, cervical irritation caused by tampons, a cervical cap, the string froman intrauterine contraceptive device, a pessary, or a diaphragm Radiation Chemical irritation - Eg, vaginal douches, latex exposure, or contraceptive creams Systemic inflammation - Eg, Behet syndrome Malignancy Infectious cervicitis The infectious etiologies of cervicitis, all of which are sexually transmitted infections (STIs), are significantly more common than the noninfectious causes. This article focuses on the infectious etiologies of cervicitis. Infectious cervicitis may be caused by Chlamydia trachomatis, Neisseria gonorrhoeae , herpes simplex virus (HSV) or human papillomavirus (HPV). In most cases of cervicitis, however, lab tests fail to isolate an organism; this is particularly true in women with low risk factors. Signs of chlamydial cervicitis on speculum examination may include mucopurulentendocervical discharge and spontaneous or easily induced endocervical bleeding or any zonesof ectopy

Herpes simplex virus (HSV) cervicitis may involve the exocervix or endocervix, and it may be symptomatic or asymptomatic. Usually, the cervix appears abnormal to inspection, with diffuse vesicular lesions, ulcerative lesions, erythema, or friability. Trichomonas vaginalis, which, technically, causes vaginal infections, is commonlyincluded in the discussion of cervicitis. Because the female genital tract is contiguous from the vulva to the fallopian tubes,there is some overlap between vulvovaginitis and cervicitis; both conditions are commonly categorized as lower genital tract infections. Infections involving the endometrium and fallopian tubes are commonly categorized as upper genital tract infections and are not discussed in this article. Etiology The most common etiologies of cervicitis are infectious, with sexual transmission of organisms such as with C trachomatis and N gonorrhoeae being the primary means bywhich it is spread. Other etiologic organisms include Trichomonas vaginalis and herpes simplex virus (HSV), especially primary type 2 HSV.

Noninfectious causes of cervicitis include local trauma, radiation, chemical irritation,systemic inflammation, and malignancy. Limited data exist to suggest frequent douching, as well as Mycoplasma genitalium infection and bacterial vaginosis, as potential causes.

Risk factors Risk factors for cervicitis include the following:

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Genetic predisposition, largely due to a variable host immune response, also plays an important role in the variability in infectious complications.[2] Variants in the genes that regulate toll-like receptors (TLRs), an important component in the innate immune system, have been associated with an increased progression of C trachomatis infection to pelvic inflammatory disease (PID).[3] M genitalium Although the role of M genitalium in PID is unclear, a study of 2378 British female students reported that this organism does not appear to be a significant etiologic agent for PID in this population (the incidence of PID was 3.9% over 12 mo in women with M genitalium infection vs 1.7% in noninfected women).[4] In a later study, howevera Swedish report on 5519 women at an outpatient gynecologic serviceit was noted that M genitalium was a strong independent risk factor for PID and cervicitis, although there was a lower frequency of both conditions relative to women with C trachomatis infection.[5] Further investigation is needed to determine the role of M genitalium in PID, infertility, and cervicitis.[6] Epidemiology Occurrence in the United States The Centers for Disease Control and Prevention (CDC) estimates that over 19 million new sexually transmitted infections (STIs) occur annually, almost half of them among persons aged 15-24 years.[7] In addition to potentially severe health consequences, STIs pose a tremendous economic burden, with direct medical costs as high as $17 billion in a single year.[7] Trichomonas is the most common curable STI. Although an estimated 3.7 million people are infected (2.3 million in women ages 14-49 y), about 70% of these individuals are asymptomatic.[8] About 7.4 million new cases occur each year in women and men.[9] Chlamydia, however, is the most frequently reported infectious disease in the US, with the majority of cases occurring in individuals aged 25 years or younger.[10] The reported incidence of chlamydial infections has steadily increased over the past 2 decades, with

1.3 million cases reported in 2010.[7] Although this increased incidence may reflect changes in screening efforts, many cases are not reported or are undiagnosed. More than 50% of sexually active young women are not screened annually, despite CDC recommendations.[7] Gonorrhea is the second most commonly reported infectious disease in the United States, with more than 300,000 cases reported in 2010.[7] Annually, approximately 700,000 new gonococcal infections occur.[11] Much like chlamydia, gonorrhea is believed to be underreported. In a study of 1469 emergency department patients diagnosed with cervicitis, Burnett et al found that 1.8% and 9.3% of patients with cervicitis were also positive for gonorrhea or chlamydia, respectively.[12] Of a separate group of 343 patients with pelvic inflammatory disease (PID), 4.4% and 10% were positive for gonorrhea or chlamydia, respectively.[12] The annual rates of infection by herpes simplex virus (HSV) and human papillomavirus (HPV) are difficult to estimate, because the vast majority of initial infections are asymptomatic or unrecognized. In addition, both infections are not required to be reported in the US.[7] The prevalence of HSV type 2 is about 16% (primarily among black women: 48%).[13] However, HPV infection affects about 20 million people, with an addition 6 million new cases annually, making this the most common STI in the US.[9] International occurrence Worldwide, 448 million adults (ages 15-49 y) become infected with a curable STI (trichomoniasis, chlamydia, syphilis, or gonorrhea) every year.[14] Other STIs are caused by various bacterial (chancroid, donovanosis) and viral (eg, human immunodeficiency virus [HIV], hepatitis B virus [HBV], cytomegalovirus [CMV]) pathogens, as well as by parasites (vaginal trichomoniasis, vulvovaginitis, balanoposthitis [men]).[14] Human papillomavirus The prevalence of HPV, a cause of cervical cancer, varies roughly 20-fold internationally. In various studies, the seroprevalence of HSV-2 is higher in the United States (13-40%) than in Europe (7-16%) and is highest in Africa (30-40%). Among the countries evaluated in a worldwide analysis, Spain had the lowest prevalence of HPV; only 1.4% of women in Spain tested positive for HPV.[15] The highest prevalence of HPV was seen in sub-Saharan Africa; 26% of women in Nigeria tested positive for the virus. South America tended to have rates that were between those of Europe and sub-Saharan Africa, whereas rates in Asia varied widely (with the lowest rates in Hanoi, Vietnam, and the highest in India and Korea).[15] M genitalium M genitalium infections have been implicated in cervicitis, PID, and female infertility.[5, 6] A review of more than 27,000 women from 48 published reports found an overall global prevalence of 7.3% M genitalium urogenital infection in high-risk populations

and 2.0% in low-risk populations.[6] The investigators reported the prevalence of this agent in the general population as between that of C trachomatis and N gonorrhoeae. Furthermore, in 7 of 14 studies of lower tract inflammation, there was a positive association between M genitalium with urethritis, vaginal discharge, and microscopic evidence of cervicitis and/or mucopurulent discharge.[6] Race-, sex-, and age-related differences No race predilection exists for cervicitis. Known risk factors include urban residence and low socioeconomic status . Male urethritis is more often symptomatic; therefore, diagnosis is usually made earlier in males than in females. Females with cervicitis are most often asymptomatic, so they do not seek evaluation or treatment as readily. Risk factors for cervicitis include age younger than 25 years, single marital status, and a new sexual partner within the past 6 weeks. Biologic (eg, postulated immaturity of the female reproductive tract) and behavioral factors (eg, greater number of partners, low awareness of acquired immunodeficiency syndrome [AIDS] and other STIs, and limited use of protection against STIs) are thought to contribute to this risk. Routine screening of sexually active adolescents and young adults is therefore recommended. Routine chlamydia screening of sexually active young women is recommended by the US Preventive Services Task Force (USPSTF), American Cancer Society (ACS), American College of Obstetricians and Gynecologists (ACOG), American Society for Colposcopy and Cervical Pathology (ASCCP), and American Society for Clinical Pathology (ASCP) to prevent the consequences of untreated chlamydial infection (eg, PID, infertility, ectopic pregnancy, chronic pelvic pain).[16] Fewer than half of young, sexually active females in the United States are screened for chlamydia.[7] Prognosis Gonorrhea, chlamydia, and trichomoniasis infections can be cured with antibiotic therapy, whereas antiviral therapy can reduce the number of herpes simplex virus (HSV) outbreaks, the duration of symptoms, and the severity of symptoms. External genital warts caused by infection with human papillomavirus (HPV) can be controlled but are not always eradicated by topical or surgical therapy. Complications from untreated infectious cervicitis depend on the pathogen. Untreated gonorrhea and chlamydia infections can lead pelvic inflammatory disease (PID), which can then result in infertility, chronic pelvic pain, and ectopic pregnancy. Other morbidity may include spontaneous abortion, premature rupture of membranes, and preterm delivery. Certain subtypes of HPV are linked with the development of cervical cancer, and severe cases of condyloma may obstruct the birth canal during pregnancy, resulting in the need for cesarean section. Untreated active HSV infections in the perinatal and neonatal period can cause mental retardation, blindness, low birth weight, stillbirth, meningitis, and death. Moreover, the social stigma of having HPV is strong and may expose women to verbal, emotional, or physical abuse from others, particularly male partners.

Patient Education Patients must understand that cervicitis is a preventable, sexually transmitted infection (STI) and that the most effective way to prevent the transmission of the infective agents that cause the disease is to avoid sexual intercourse with infected partners. Ideally, both partners should be tested for common STIs, including human immunodeficiency virus, before initiating a sexual relationship. If the risk of infection is unknown by testing, then a condom should be used for all sexual acts. Condoms are available for men and women and have been proven to decrease the transmission of many STIs, including HIV, when used appropriately and consistently. To avoid reinfection following cure, infected women must ensure that all of their sexual partners are treated for STIs. For patient education resources, see the Women's Health Center and the Pregnancy Center, as well as Cervicitis, Pelvic Inflammatory Disease, Ectopic Pregnancy, Female Sexual Problems, and Pap Smear. History Cervicitis is often asymptomatic in gonorrhea, chlamydia, and T vaginalis infections. When present, symptoms are often nonspecific and may include increased vaginal discharge, dysuria, urinary frequency, and intermenstrual or postcoital bleeding.[1] If the infection has been long-standing, symptoms can include low abdominal or low back pain. Infection with human papillomavirus (HPV) is frequently asymptomatic, because the genital warts are often flat and internal. When the warts are raised and on the labia, perineum, or perianal area, they are called condylomata acuminata and are easily visible. Similarly, most patients with herpes simplex virus (HSV) infection are asymptomatic. However, the first episode of genital herpes is frequently highly symptomatic and is marked by painful ulcerations associated with fever, myalgia, headache, and general malaise. Dysuria, vaginal discharge, and urethral discharge are also common symptoms. Recurrent outbreaks of HSV tend to be milder, but most patients have prodromal symptoms of itching or tingling, followed by the appearance of vesicles. Because many causes of cervicitis are initially asymptomatic, ask all sexually active women for their complete gynecologic and sexual history at the initial evaluation and yearly thereafter. In addition to the basic gynecologic history (eg, age of menarche, date of last menstrual period, gravida, para, pregnancy or delivery complications, date of last Papanicolaou test [Pap smear]), a complete sexual history is needed. This information includes the following: (in the last 3 mo) -barrier contraception use

A focused review of symptoms is recommended that asks about the following:

Physical Examination The physical examination should include a general survey, an external inspection, and pelvic speculum and bimanual examinations. In certain patients, a rectal examination should be performed. The physical examination is crucial to the evaluation and diagnosis of cervicitis, but it should not be limited to the pelvic region. An assessment for lymphadenopathy, skin lesions, oral lesions, joint redness or swelling, abdominal pain, and costovertebral angle tenderness can point to disseminated infection. The pelvic examination must be performed in a competent and sensitive manner. The presence of a nursing assistant is advised to help with the examination and to act as a chaperone. Always explain to the patient what is going to be done before proceeding. Begin with a neutral touch on the patient's thigh and visually investigate the external genitalia in good lighting. Note any skin lesions (eg, warts, ulcers, vesicles, excoriations, erythema), inflammation of the Bartholin or Skene glands, or inguinal lymphadenopathy. Speculum examination Perform the speculum examination with water or gel lubrication (eg, Surgilube or K-Y jelly), and include direct visualization of the vaginal walls and cervix. Remember that normal vaginal secretions are nonadherent to the vaginal walls, clear to white in color, and nonodorous. Normal vaginal secretions have an acidic pH of less than 4.5. Vaginitis is present if the vaginal discharge is copious, colored, and malodorous, or if the pH is greater than 4.5. Cervicitis is suspected if the cervix is erythematous, edematous, or easily friable. Classic mucopurulent cervicitis is present if thick, yellow-green pus is visible in the endocervical canal (the cervical os) or on an endocervical swab specimen. Laboratory specimens are collected for study at this point. Note cervical warts or ulcerations. Bimanual examination After the speculum is removed, a bimanual examination is performed to assess

tenderness or enlargement of the cervix, uterus, and adnexa. Cervicitis or pelvic inflammatory disease (PID) is suspected if the patient has cervical motion tenderness (ie, if she experiences pain or tenderness while the examiner gently moves the cervix from side to side). The following images depict a normal cervix, followed by images of cervicitis caused by various organisms.

Diagnostic Considerations Screen for sexually transmitted infections (STIs), particularly C trachomatis and N gonorrhoeae, in patients who present with symptoms of an STI. In high-risk patients, consider screening for HIV, syphilis, and hepatitis B. Consider also the possibility of a retained foreign body (eg, tampon, condom), or, in a young adolescent or child, sexual abuse, and notify the proper authorities if abuse is suspected. Other conditions to consider in the differential diagnosis of cervicitis include the following:

n women of childbearing age, always perform a urine pregnancy test before prescribing any medication.

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