Pediatric Cervicitis

Cervicitis is inflammation of the cervix, caused by a sexually transmitted bacterial infection.[1]  Patients usually present with cervical erythema and discharge. Primary morbidity results from ascending infection to the uterus and fallopian tubes (pelvic inflammatory disease [PID]) that leads to chronic abdominal pain and infertility. The prognosis is excellent when the patient is compliant.

Infection of the cervix results in inflammation and may be accompanied by vulvovaginitis. Mucopurulent cervicitis is a clinical diagnosis, one typically characterized by friability of the cervix, mucopurulent discharge from the os, and increased numbers of polymorphs in endocervical secretions.[2, 3] An ascending infection can cause endometritis, salpingitis, tubo-ovarian abscess, or perihepatitis.

Gonorrheal and chlamydial infections

The most common causative organisms are Neisseria gonorrhoeae and Chlamydia trachomatis.[4] Gonococcal and chlamydial cervicitis may be associated with upper genital tract infection. Patients with gonorrhea may have associated urethritis.[5]  Patients with chlamydial infections are often asymptomatic. More recent studies have focused on diagnosis and treatment of cervicitis of unknown etiology.[6, 7]

Other bacterial pathogens

Other bacterial pathogens implicated in cervicitis and upper genital infections include Mycoplasma genitalium,[8] Ureaplasma urealyticum and parvum, and anaerobes such as Streptococcus,[9] Peptostreptococcus, and Bacteroides species. Other sexually transmitted infections, such as those caused by Trichomonas species, herpes simplex virus, and human papilloma virus, may also be associated with cervicitis.

Although an uncommon finding, Trichomonas vaginalis is known to cause multiple punctate hemorrhages and swollen papillae in the cervix, giving it a strawberry appearance. This causes the cervix to become friable and bleed easily on touch.

Herpetic cervicitis may be associated with multiple ulcerations.

In the United States, the prevalence of chlamydial infection is 5-15% in sexually active teenagers and young adults who are asymptomatic.[10] The prevalence increases to almost 50% in symptomatic patients; however, the incidence of gonorrhea has declined steadily over the past 20 years.[11] Adolescents and young adults continue to have the highest rates of infection, with a transmission risk of 20-50% per sexual contact. The incidence of coinfection with both gonorrheal and chlamydial organisms may be 15-20%.

C trachomatis is the most prevalent bacterial pathogen that causes sexually transmitted infections worldwide. According to the World Health Organization (WHO), 50-70 million cases occur each year.

Compared with older populations, sexually active adolescents and young adults have a higher incidence of both chlamydial and gonococcal cervicitis.

Patients should be instructed to avoid sexual intercourse until treatment efficacy is confirmed. They should also be instructed in how to prevent reinfection by using condoms.[12]

Prevention counseling should be recommended to patients with sexually transmitted infections. Screening for other diseases, including HIV infection and syphilis, should be recommended as well.

For patient education resources, see the Women's Health Center, as well as Cervicitis.

Elicit the patient's history of sexual activity, number of sexual partners, and type of contraception used (if any). An increased incidence of chlamydial cervicitis in women has been associated with use of oral (PO) contraceptives.

Most patients with cervicitis present with vaginal discharge or intermenstrual vaginal bleeding. Other associated symptoms include dyspareunia and dysuria. Abdominal pain and fever are associated with involvement of the upper genital tract. Patients with mild cervicitis may be asymptomatic, and many patients with chlamydial cervicitis are asymptomatic.

Upon physical examination, findings in the cervix include the following:

• Erythematous and inflamed cervix on speculum examination; possible edema of the cervical ectropion may be noted
• Possible purulent discharge from the cervical os
• Cervix tender to palpation

Potential complications include the following:

• Ascending infection
• Arthritis, rash, or both (from disseminated gonorrhea)

Traditional tests

Wet mount of the discharge usually demonstrates more than five white blood cells (WBCs) per high-power field (HPF). Most practice guidelines recommend a polymorphonuclear leukocyte (PMN) count of 10-30/HPF as the threshold value to support the diagnosis of mucopurulent cervicitis. However, the leukocyte criterion is not standardized, and inflammation alone is not considered presumptive evidence of chlamydial infection.

Gram stains of the cervical mucus may reveal gram-negative intracellular diplococci in cases of gonorrhea. Culturing in modified Thayer-Martin medium is the criterion standard for confirming gonorrhea.

Enzyme-linked immunosorbent assay (ELISA) or direct fluorescent antibody testing is often used to detect chlamydial infection. DNA probes with 90-97% sensitivity are also available for the simultaneous detection of gonococcal and chlamydial organisms.

When indicated, chlamydial cultures are performed on McCoy cells (evaluations in prepubertal children in whom sexual abuse is suspected, testing response to therapy in a previously treated infection).

Nucleic acid amplification tests

Several highly specific and sensitive tests have been developed. These nucleic acid amplification tests (NAATs) include the polymerase chain reaction (PCR), the ligase chain reaction (LCR),[14] and transcription-mediated amplification (TMA).[15] Probes used in these tests are at least 20% more sensitive than the earlier DNA probes and are the tests of choice. PCR and LCR testing consists of amplification of specific DNA sequences, whereas TMA testing is an RNA amplification assay.

Although endocervical specimens are preferred, these tests may be easily performed on first-void morning urine samples as well as on vaginal and cervical samples. Urine NAATs are highly sensitive for the diagnosis of endocervical chlamydial infection.

Because of the possible association between bacterial vaginosis and mucopurulent cervicitis, the NAATs described above should be performed. In addition, Amsel criteria for the diagnosis of bacterial vaginosis should be sought. The presence of three of the following four criteria suffices for the diagnosis of bacterial vaginosis:

• Homogenous vaginal discharge
• Vaginal fluid pH greater than 4.5
• Clue cells greater than 20% of total vaginal epithelial cells on ×100 magnification
• Amine odor on addition of potassium hydroxide to vaginal fluid

Therapy for cervicitis depends on the etiologic agent. The Centers for Disease Control and Prevention (CDC) revised their treatment guidelines for sexually transmitted diseases in 2010[16] ; in 2015, a further update was published. The 2015 CDC guidelines recommended the following for presumptive treatment of cervicitis[17] :

• Azithromycin, 1 g PO in a single dose, or
• Doxycycline, 100 mg PO q12hr for 7 days

Recommendations for treatment of chlamydial infection in adolescents and young adults were as follows[17] :

• Azithromycin, 1 g PO in a single dose, or
• Doxycycline, 100 mg PO q12hr for 7 days
• Alternative regimens - Erythromycin base, 500 mg PO q6hr for 7 days; erythromycin ethylsuccinate, 800 mg PO q6hr for 7 days; levofloxacin, 500 mg PO q24hr for 7 days; ofloxacin, 300 mg PO q12hr for 7 days

Recommendations for treatment of uncomplicated gonococcal infection of the cervix in adolescents and young adults were as follows[17] :

• Ceftriaxone, 250 mg intramuscularly (IM) in a single dose, plus
• Azithromycin, 1 g PO in a single dose

If ceftriaxone is unavailable, the following regimen may be employed instead[17] :

• Cefixime, 400 mg PO in a single dose, plus
• Azithromycin, 1 g PO in a single dose

Cefixime, however, has limited efficacy in the treatment of gonococcal pharyngitis and does not provide a high and sustained bactericidal level as compared with ceftriaxone, the preferred treatment choice.

Acyclovir may be used for primary herpes infection, but it is not curative, and recurrences are common. Valacyclovir and famciclovir are alternatives.[17]

Recommendations for infection by Trichomonas organisms were as follows[17] :

• Metronidazole, 2 g PO in a single dose, or
• Tinidazole, 2 g orally in a single dose

Ensuring that the patient's sexual contacts receive the appropriate examination and treatment is also essential. Most treatment failures are actually reinfections from an untreated sexual partner.

Advise patients to abstain from sexual activity until test results after therapy are negative and partners are treated. Advise them to use condoms when they resume sexual activity. Dual-method contraceptive use may be considered.[18]

Gonococcal cultures are recommended 4-8 weeks after standard treatment or 1 week after alternative regimens are used.

Routine "test of cure" for chlamydial eradication is not indicated after treatment except in pregnant women; however, because of the risk of reinfection, repeat testing is advised fro all women 3-6 months after treatment of cervicitis.

Routine annual screening for chlamydial infection is recommended in all sexually active adolescents because of the high prevalence among asymptomatic females.

Treat sexual partners.

Therapy for cervicitis depends on the etiologic agent. The Centers for Disease Control and Prevention (CDC) revised their treatment guidelines for sexually transmitted diseases in 2010[16] ; in 2015, a further update was published.[17]  Agents used to treat cervicitis include azithromycin, doxycycline, ceftriaxone, cefixime, and metronidazole.

Class Summary

Testing to determine the specific microorganism causing the infection is recommended because both chlamydial and gonococcal infections are reportable to state health departments. If diagnostic tools (eg, Gram stain, microscope) are unavailable, treat patients for both infections.

Ceftriaxone (Rocephin)

First choice for treatment for gonococcal cervicitis.

Doxycycline (Bio-Tab, Vibramycin, Doryx)

Treatment of choice for chlamydial cervicitis.

Metronidazole (Flagyl)

Synthetic antimicrobial agent active against most obligate anaerobes. Used in Trichomonas infection.

Azithromycin (Zithromax)

Macrolide antibiotic for treatment of C trachomatis infection.

Cefixime (Suprax)

Effective PO for treating gonococcal cervicitis. Arrests bacterial cell-wall synthesis and inhibits bacterial growth by binding to one or more penicillin-binding protein.