Guidelines 2016 – Cervicitis

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Guidelines for Nurse Practitioners in Gynecologic Settings 2016
Care Plan – Cervicitis
ICD 10 – O86.11

I.  DEFINITION

  1. Chronic or acute inflammation of the cervix that is visible to the clinician; causes symptoms observed by the woman and/or by cytology examination
  2. Mucopurulent cervicitis is characterized by mucopurulent  exudate and easily induced cervical bleeding. For the Centers for Disease Control and Prevention (CDC) sexually transmitted Diseases treatment Guidelines (stDtG), see cdc.gov/std/treatment/2015.

II.  ETIOLOGY

  1. bacterial
    1. Neisseria gonorrhoeae
    2. Mycoplasmas such as Mycoplasma genitalium
    3. Ureaplasmas
    4. Chlamydia trachomatis
    5. bacterial vaginosis
  2. viral
    1. Herpes simplex
    2. Human papillomavirus (HPv)
  3. Parasitic
    1. Trichomonas vaginalis
  4. nonmicrobiologic
    1. inflammation in zone of ectopy
    2. Diethylstilbestrol (Des) exposure
    3. Chemical irritants
    4. Frequent douching

III.  HISTORY

  1. What the patient may present with
    1. no symptoms
    2. Friable cervix
    3. Postcoital bleeding
    4. erythema of cervix (if friable with first pass of swab)
    5. edematous cervix
    6. Ulcerated or eroded cervix
    7. Hypertrophied cervix
    8. ectropion
    9. Cervical discharge; may be purulent or mucopurulent endocervi- cal exudate on exam
    10. vaginal discharge
    11. leukoplakia on cervix
    12. endocervical bleeding
  2. additional information to be considered
    1. onset of symptoms
    2. Partner with symptoms
    3. History of sexually transmitted infections (stis)
    4. sexual lifestyle; use of sex toys
    5. last Pap smear and results; any history of abnormal Pap smear result
    6. Contraception past and present
    7. Colposcopy, cone biopsy, cauterization of cervix, cryo, loop elec- trosurgical excision procedure (leeP)
    8. laceration of cervix: childbirth, abortion, dilation and curettage (D&C), biopsy, partner with genital jewelry
    9. Pregnancy history, infertility
    10. Dyspareunia, pelvic pain
    11. Urinary symptoms: frequency, urgency, dysuria
    12. Menstrual history: last menstrual period
    13. Des exposure

IV. PHYSICAL EXAMINATION

  1. Cervix
    1. Color
    2. Character of any discharge: green, yellow, opaque, white, clear, cloudy, purulent, mucopurulent, serous, pH
    3. size
    4. lesions
    5. Friability
    6. Hood
    7. any polyps noted
  2. vagina
    1. Color
    2. erythema
    3. lesions
    4. Discharge
  3. bimanual exam
    1. Masses
    2. tenderness
    3. Cervical motion tenderness
    4. Uterine enlargement
    5. Position of organs
  4. adenopathy

V. LABORATORY EXAMINATION

  1. Gonorrhea culture
  2. Chlamydia smear
  3. nucleic acid amplification tests (naats), which are the most sensitive tests available for Chlamydia and gonorrhea
  4. bacterial vaginosis
  5. trichomoniasis
  6. Wet prep; saline, KoH; more than 10 white blood cells/high-power field associated with gonorrhea, Chlamydia
  7. Pap smear
  8. Culture for bacteria
  9. Gram stain more than 30 polymorphonuclear (PMn) leukocytes
  10. serology test for syphilis
  11. Herpes culture, antibodies
  12. viratyping
  13. Hiv testing (this criterion may be helpful but not standardized)

VI.  DIFFERENTIAL DIAGNOSIS

  1. bacterial vaginosis
  2. trichomoniasis
  3. Condyloma acuminata
  4. Chlamydia
  5. Gonorrhea
  6. Cervical cancer
  7. Cervical infection; bacterial, including mycoplasma, ureaplasma
  8. ectropion
    1. leukoplakia
  9. Herpetic exocervicitis
  10. trichomonas
  11. l. Cervical ulceration  (erosion)  because  of  trauma;  fingernail,  cervical biopsy, postpartum, sex toys
  12. Pelvic inflammatory disease (PiD)
  13. infection secondary to trauma with sex toy
  14. Cervical polyp

VII.  TREATMENT

  1. Medication
    1. as indicated by organism; see sections for gonorrhea, Chlamydia, her- pes, condyloma, and trichomoniasis in Chapter 21 and PID in Chapter 17
    2. bacterial (mycoplasma, urea plasma); see PID section in Chapter 17
    3. Mucopurulent cervicitis (women meeting CDC criteria) without confirmed organism can be treated empirically for gonorrhea and Chlamydia, bacterial vaginosis, and trichomoniasis
      1. Prevalence of these is high in patient population, such as women 25 years of age or younger
      2. new or multiple sex partners
      3. Unprotected sexual encounters
      4. Patient who might be difficult to locate for treatment
    4. Presumptive treatment—azithromycin 1 g orally in single dose or doxycycline 100 mg orally twice a day for 7 days and consider treatment for gonorrhea, bacterial vaginosis, and trichomoniasis per CDC stDtG (see Chapter 21)
  2. other measures
    1. ectropion—evaluate Pap smear results and follow up as indicated; document with diagram and description for later follow-up; with persistent friability, refer or evaluate with colposcopy and biopsy
    2. leukoplakia—refer or evaluate with colposcopy and biopsy
    3. Cervical cancer—refer for medical evaluation and intervention; in suspected cases despite negative Pap smear, refer or evaluate with colposcopy and biopsy
    4. Cervical ulceration, erosion—follow up as indicated by extent and nature of trauma; consider referral for medical evaluation and intervention
    5. Consider colposcopy for all women who do not meet CDC guide- lines for mucopurulent cervicitis, have a negative sti screen, and negative Pap smear
    6. Manage sex partners appropriate for  identified  or  suspected  sti
    7. Patients and sex partners should abstain from sexual intercourse for course of treatment 7 days after single-dose regimen or comple- tion of 7-day regimen

VIII.  COMPLICATIONS

Progression of condition to secondary or systemic infection (depending on organism) or PiD; to metastatic disease; infertility; cervical stenosis

IX.  CONSULTATION/REFERRAL

  1. Unable to evaluate and diagnose
  2. no response to treatment; persistent symptoms with poor response to treatment

X.  FOLLOW-UP

  1. Unless therapeutic compliance is in question, symptoms persist or reinfection is suspected, except in pregnant women, test of cure is not advised for persons treated with the recommended or alternative regimes.
  2. as indicated by condition and treatment
  3. return for reevaluation if symptoms persist

See Bibliographies.

Website: www.mayoclinic.com/health/cervicitis/DS00518

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