RISK FACTORS:
β’ Multiple sexual partners
β’ History of sexually transmitted disease
β’ Postpartum period
MEDICAL TREATMENT :
Human papilloma virus
HPV can infect the ectocervix and can cause warty lesions similar to those seen in the vagina or on the vulva; however, the virus on the cervix typically causes flat warts. These are macular or papular lesions that become more visible to the naked eye when swabbed with 3-5% acetic acid. The acetic acid causes cellular dehydration. The resulting increase in nuclear density appears clinically as a white lesion. This phenomenon is transient. The term aceto-white describes this finding. In addition to HPV, squamous metaplasia and cervical intraepithelial neoplasia can appear aceto-white.
HPV lesions tend to have indistinct and feathered borders, and the lesions may appear broken or flocculated. Unlike cervical intraepithelial neoplasia (CIN), satellite lesions may be present, and HPV lesions may be within or outside the transformation zone on the portio of the cervix. Another appearance of HPV may be snow-white, shiny, and raised lesions. Frequently, fine-caliber blood vessels are present.
Lesions suggestive of HPV should be confirmed by performing a biopsy. The hallmark histologic feature is the koilocyte. On both cytologic preparations of cervical biopsy specimens, koilocytes are cells with wrinkled nuclear membranes (like raisins) that frequently are binucleate and occasionally are multinucleate. The nuclei are surrounded by a clear halo, which gives the cells their name. Cytologic and nuclear atypia typically is present. In cervical biopsy specimens, a few normal mitotic figures may be seen in the basal layer of the squamous epithelium, while koilocytes occupy the intermediate and superficial layers.
Currently, more than 60 types of HPV are described, but only a few types cause genital tract lesions. The typical exophytic warts that present on the vulva, vagina, and cervix are type 6 or type 11. Types 16, 18, 31, 33, and 35 are more commonly associated with flat warts and have an epidemiologic link to CIN. Kits are available that classify HPV lesions as either benign (ie, 6 or 11) or at risk (ie, 16, 18, 31, 33, and 35). Currently, for reflex HPV testing of thin layer cervical cytology, 14 different oncogenic HPV types are tested: HPV types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 and 68.
A vaccine for HPV (Gardasil) has been recently approved by the FDA. It is a quadrivalent HPV recombinant vaccine containing activity against HPV types 6, 11, 16, and 18. The vaccine is indicated for prevention of HPV-associated dysplasias and neoplasias, including cervical cancer, genital warts (condyloma acuminata), and precancerous genital lesions (eg, cervical adenocarcinoma in situ; cervical intraepithelial neoplasia grades 1, 2, and 3; vulvar intraepithelial neoplasia grades 2 and 3; vaginal intraepithelial neoplasia grades 2 and 3). The immunization series should be completed in girls and young women aged 9-26 years.
Herpes simplex virus
Of women with their first episode of HSV-2 infection, 70-90% have herpetic cervicitis as part of the manifestation. In recurrent infections, cervicitis is present in 15-20% of women.
Primary herpetic cervicitis frequently is asymptomatic; however, it may present as a purulent or bloody vaginal discharge. Grossly, the cervix may appear diffusely red and friable. At times, ulcerations, which may be extensive, are present on the ectocervix.
Making a clinical diagnosis may be difficult. Colposcopic findings of acute cervicitis are identifiable in two thirds of women with primary herpes cervicitis. Multinucleate cells with typical ground-glass inclusions may be identified on cervical cytology results in 60% of these women.
The differential diagnosis includes the chancre of syphilis. Gonorrhea and chlamydia infection can cause a similar type of discharge, although ulceration in these conditions is uncommon. Syphilis, gonorrhea, and chlamydia infection may coexist with HSV-2 infection. Women with primary genital herpes involving the cervix should be started on antiviral therapy.
The other presentation of herpes involving the cervix is asymptomatic shedding. In these instances, the classic multinucleate cells with ground-glass inclusions may be identified on cervical cytology results as an incidental finding. In a sexually transmitted disease clinic, HSV was isolated from 4% of randomly selected women. Treatment for asymptomatic shedding is not recommended.
T pallidum
The primary lesion of syphilis develops at the site of inoculation 2-6 weeks after infection. The primary lesion begins as a papule and then ulcerates. Typically, the diameter is 0.5-1.5 cm.
In women, besides the labia and posterior fourchette, the cervix is a common site for the primary chancre. Because the primary lesion is asymptomatic and the cervix is not visualized readily, primary lesions in this location frequently remain undiagnosed. If untreated, they heal in 3-6 weeks. The disease then enters the latent period.
The differential diagnosis of these ulcers includes HSV-2 and H ducreyi. Diagnosis is best made using a dark-field microscopic examination of exudate taken from the surface of the lesion. The rapid plasma reagin (RPR) test results may be positive at a relatively low titer (1:16 or less) at this time. If syphilis is strongly considered and both the dark-field examination and the RPR test findings are negative, a repeat RPR test in 2 weeks will have positive results.
Treatment for primary syphilis is benzathine penicillin G at 2.4 million units. If the patient is allergic to penicillin, doxycycline at 100 mg twice daily for 2 weeks by mouth or tetracycline at 500 mg 4 times/d by mouth for 2 weeks is acceptable. If the patient is pregnant, desensitization followed by treatment with penicillin is recommended.
All patients with a diagnosis should be tested for HIV.
H ducreyi (ie, chancroid)
The primary ulcer is typically on the fourchette, labia, or vestibule.
Vaginal wall ulcers can occur and, at times, involve the cervix. Involvement of the cervix alone is very rare.
Donovanosis (ie, granuloma inguinale)
The typical site of infection in women is the labia minora and the fourchette. Lesions of the cervix are uncommon but are easily confused with cervical carcinoma.
Four distinct types of lesions are described; the most common lesion on the cervix is the necrotic, deep, foul-smelling ulcer associated with tissue destruction.
A tissue smear is the mainstay of diagnosis. A Giemsa stain typically is used. The Donovan bodies are identified in monocytes. The characteristic histologic picture is that of chronic inflammation, with plasma cells and polymorphonuclear leukocytes. Rarely, Donovan bodies are identified on cervical cytology.
Treatment is with trimethoprim-sulfamethoxazole double-strength tablets twice daily or doxycycline at 100 mg orally twice daily. Alternative regimens include ciprofloxacin at 750 mg twice daily or erythromycin base at 500 mg 4 times daily. Treatment is for a minimum of 3 weeks.
Actinomyces organisms
Actinomyces organisms are isolated most commonly in women with intrauterine devices (IUDs), but infection can be a result of surgical instrumentation and abortion.
Demonstrating the organism in the center of large abscesses confirms the diagnosis.
Lesions appear yellow and granular to the naked eye, hence the term sulfur granule.
Tuberculosis
When the cervix is involved, the lesion almost always is secondary to tuberculous salpingitis, which is secondary to pulmonary tuberculosis.
The gross appearance can be confused with invasive carcinoma.
Histologically, multiple granulomas or tubercles with central caseation necrosis, epithelioid histiocytes, and multinucleated Langhans giant cells characterize the lesions.
The differential diagnosis includes lymphogranuloma venereum and sarcoidosis. An unequivocal diagnosis requires the identification of acid-fast Mycobacterium tuberculosis.
Protozoal and parasitic cervicitis: These are usually part of a more generalized process.
Schistosomiasis and amebiasis: These are common in certain geographic areas.
ALTERNATIVE DRUGS:
. Any of the following can be substituted for ceftriaxone(quinolones should not be used for gonorrhea in
patients who have traveled to Hawaii, California, or Southeast Asia because of high levels of resistance):
. Ofloxacin (Floxin) 400 mg po single dose
. Ciprofloxacin (Cipro) 500 mg po single dose
. Levofloxacin (Levaquin) 250 mg single dose
. Erythromycin base or stearate 500 mg po qid, or
erythromycin ethylsuccinate 800 mg po qid can be substituted for doxycycline
PATIENT MONITORING:
β’ Repeat cultures after treatment for chlamydia or gonorrhea are indicated in pregnant or high risk patients
β’ Annual Pap smears in sexually active patients screen for chronic cervicitis
PREVENTION/AVOIDANCE : Patients with more than one sexual partner should be advised to use condoms at every encounter
POSSIBLE COMPLICATIONS:
β’ Cervicitis with C. trachomatis or N. gonorrhoeae is associated with an 8-10% risk of subsequent pelvic
inflammatory disease
β’ Moderate to severe inflammation is associated with condyloma acuminatum and cervical carcinoma
EXPECTED COURSE/PROGNOSIS:
β’ Infectious cervicitis usually responds to systemic antibiotics
β’ Chronic cervicitis may be resistant to treatment, and should be monitored closely for cervical dysplasia
AGE-RELATED FACTORS:
Pediatric: Infectious cervicitis in children should lead to investigation for possible sexual abuse
Geriatric:
β’ Chronic cervicitis in postmenopausal women may be related to lack of estrogen
β’ The possibility of infectious cervicitis should not be overlooked, as many geriatric patients remain sexually
active