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==Classification==
==Classification==


Cervicitis may be classified according to the etiology, anatomical location and disease duration as infectious, non-infectious, acute, subacute and chronic cervicitis. The infectious causes are [[Gonococcal]], [[C. trachomatis]] and [[Herpes]]. Examples of the non-infectious causes are traumatic injury to the cervix, chemical exposure; douching, latex, contraceptive creams, systemic inflammation example Behcet syndrome as well as radiation exposure.
Cervicitis may be classified according to the [[etiology]], anatomical location and disease duration, such as [[infectious]], non-infectious, [[Acute (medicine)|acute]], [[subacute]] and [[Chronic (medical)|chronic]] cervicitis. The [[infectious]] causes are [[gonococcal]], ''[[C. trachomatis]]'' and [[herpes]]. Examples of the non-infectious causes are [[traumatic injury]] to the [[cervix]], chemical exposure, douching, [[latex]], [[contraceptive]] creams, [[systemic]] [[inflammation]] (e.g. [[Behcet syndrome]]), as well as [[radiation exposure]].


==Pathophysiology==
==Pathophysiology==
The pathophysiology of Cervicitis depends on the etiological agent and the [[physiological]] state of the patient. Under the influence of [[estrogen]], the normal vaginal [[epithelium]] cornifies making it somewhat resistant to infectious agents. The [[endocervix]] is lined by [[columnar epithelium]] which is susceptible to infectious agents leading to cervicitis.
The pathophysiology of cervicitis depends on the etiological agent and the [[physiological]] state of the patient. Under the influence of [[estrogen]], the normal vaginal [[epithelium]] cornifies, making it somewhat resistant to [[infectious]] agents. The [[endocervix]] is lined by [[columnar epithelium]] which is susceptible to [[infectious]] agents leading to cervicitis.


[[Gonococcal]] cervicitis results after the exposure of the cervix to [[N. gonorrhea]] in seminal fluid during sexual intercourse. [[N. gonorrhea]] infectivity is facilitated by type IV pilus-mediated motility of the [[bacterium]]. In the presence of [[seminal fluid]], the bacterial motility is characterized by high velocity, low directional persistence and enhanced microcolony formation.<ref name="pmid24595372">{{cite journal| author=Anderson MT, Dewenter L, Maier B, Seifert HS| title=Seminal plasma initiates a Neisseria gonorrhoeae transmission state. | journal=MBio | year= 2014 | volume= 5 | issue= 2 | pages= e01004-13 | pmid=24595372 | doi=10.1128/mBio.01004-13 | pmc=3958800 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24595372  }} </ref> Once [[pilus]] is attached, local [[inflammation]] results from release of neutrophilic [[cytokines]] leading to [[purulent]] or [[mucopurulent]] discharge.  
[[Gonococcal]] cervicitis results after the exposure of the [[cervix]] to [[N. gonorrhea|''N. gonorrhea'']] in [[seminal fluid]] during sexual intercourse. [[N. gonorrhea|''N. gonorrhea'']] infectivity is facilitated by type IV [[pilus]]-mediated motility of the [[bacterium]]. In the presence of [[seminal fluid]], the bacterial motility is characterized by high velocity, low directional persistence and enhanced microcolony formation.<ref name="pmid24595372">{{cite journal| author=Anderson MT, Dewenter L, Maier B, Seifert HS| title=Seminal plasma initiates a Neisseria gonorrhoeae transmission state. | journal=MBio | year= 2014 | volume= 5 | issue= 2 | pages= e01004-13 | pmid=24595372 | doi=10.1128/mBio.01004-13 | pmc=3958800 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24595372  }} </ref> Once the [[pilus|pili]] are attached, local [[inflammation]] results from the release of neutrophilic [[cytokines]], leading to [[purulent]] or [[mucopurulent]] discharge.
[[C. trachomatis]] infection is often associated with intense lymphocytic and neutrophilic inflammtory reaction in the affected areas and occasionally with follicular aggregation of [[lymphocyte]].<ref name="pmid7078909">{{cite journal| author=Paavonen J, Vesterinen E, Meyer B, Saksela E| title=Colposcopic and histologic findings in cervical chlamydial infection. | journal=Obstet Gynecol | year= 1982 | volume= 59 | issue= 6 | pages= 712-5 | pmid=7078909 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7078909  }} </ref><ref name="pmid2921049">{{cite journal| author=Dunlop EM, Garner A, Darougar S, Treharne JD, Woodland RM| title=Colposcopy, biopsy, and cytology results in women with chlamydial cervicitis. | journal=Genitourin Med | year= 1989 | volume= 65 | issue= 1 | pages= 22-31 | pmid=2921049 | doi= | pmc=1196182 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2921049  }} </ref> The chronic course of [[chlamydial]] cervicitis is associated with low content of [[cytokines]] mainly [[IL-1]] alpha, IL-1 beta, [[TNF-alpha]] and an elevated concentration of [[IL-8]] in the pathogenesis.<ref name="pmid15346950">{{cite journal| author=Dolgushin II, Kurnosenko IV, Dolgushina VF, Ugaĭ IIu, Abramovskikh OS, Gol'tsfarb VM| title=[Clinical and immunological aspects of cervicitis of chlamydial etiology]. | journal=Zh Mikrobiol Epidemiol Immunobiol | year= 2004 | volume=  | issue= 3 | pages= 48-52 | pmid=15346950 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15346950  }} </ref>
 
[[C. trachomatis|''C. trachomatis'']] infection is often associated with intense [[lymphocytic]] and neutrophilic inflammtory reactions in the affected areas, and is occasionally associated with follicular aggregation of [[lymphocyte|lymphocytes]].<ref name="pmid7078909">{{cite journal| author=Paavonen J, Vesterinen E, Meyer B, Saksela E| title=Colposcopic and histologic findings in cervical chlamydial infection. | journal=Obstet Gynecol | year= 1982 | volume= 59 | issue= 6 | pages= 712-5 | pmid=7078909 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7078909  }} </ref><ref name="pmid2921049">{{cite journal| author=Dunlop EM, Garner A, Darougar S, Treharne JD, Woodland RM| title=Colposcopy, biopsy, and cytology results in women with chlamydial cervicitis. | journal=Genitourin Med | year= 1989 | volume= 65 | issue= 1 | pages= 22-31 | pmid=2921049 | doi= | pmc=1196182 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2921049  }} </ref> The [[Chronic (medical)|chronic]] course of [[chlamydial]] cervicitis is associated with low content of [[cytokines]], mainly [[Interleukin 1|IL-]], [[Interleukin 1|IL-1β]], and [[TNF-alpha|TNFα]], and an elevated concentration of [[IL-8]] in the pathogenesis.<ref name="pmid15346950">{{cite journal| author=Dolgushin II, Kurnosenko IV, Dolgushina VF, Ugaĭ IIu, Abramovskikh OS, Gol'tsfarb VM| title=[Clinical and immunological aspects of cervicitis of chlamydial etiology]. | journal=Zh Mikrobiol Epidemiol Immunobiol | year= 2004 | volume=  | issue= 3 | pages= 48-52 | pmid=15346950 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15346950  }} </ref>


==Causes==
==Causes==

Revision as of 20:57, 24 February 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Prince Tano Djan, BSc, MBChB [2]

Overview

Cervicitis means nflammation of the tissues of the cervix. Cervicitis has many features in common with urethritis in men. These are commonly due to sexually transmitted infections.

Historical Perspective

Cervicitis was first described formally by Dr. Voilet I. Russell and Dr. D. Cochrane Logan in 1926 during their addresses made before the Medical Society for the Study of Veneral Diseases on January 29, 1926. Before this time, no accurate record was made about the disease in literature.[1]

Classification

Cervicitis may be classified according to the etiology, anatomical location and disease duration, such as infectious, non-infectious, acute, subacute and chronic cervicitis. The infectious causes are gonococcal, C. trachomatis and herpes. Examples of the non-infectious causes are traumatic injury to the cervix, chemical exposure, douching, latex, contraceptive creams, systemic inflammation (e.g. Behcet syndrome), as well as radiation exposure.

Pathophysiology

The pathophysiology of cervicitis depends on the etiological agent and the physiological state of the patient. Under the influence of estrogen, the normal vaginal epithelium cornifies, making it somewhat resistant to infectious agents. The endocervix is lined by columnar epithelium which is susceptible to infectious agents leading to cervicitis.

Gonococcal cervicitis results after the exposure of the cervix to N. gonorrhea in seminal fluid during sexual intercourse. N. gonorrhea infectivity is facilitated by type IV pilus-mediated motility of the bacterium. In the presence of seminal fluid, the bacterial motility is characterized by high velocity, low directional persistence and enhanced microcolony formation.[2] Once the pili are attached, local inflammation results from the release of neutrophilic cytokines, leading to purulent or mucopurulent discharge.

C. trachomatis infection is often associated with intense lymphocytic and neutrophilic inflammtory reactions in the affected areas, and is occasionally associated with follicular aggregation of lymphocytes.[3][4] The chronic course of chlamydial cervicitis is associated with low content of cytokines, mainly IL-1α, IL-1β, and TNFα, and an elevated concentration of IL-8 in the pathogenesis.[5]

Causes

Cervicitis is caused by infectious [6][7][8][9][10][11][12][13][14][15] and non infectious causes. The infectious causes are most commonly caused by chlamydia and gonorrhea, with chlamydia accounting for the majority of cases. Trichomonas vaginalis and herpes simplex are less common causes of cervicitis. Non-infectious causes of cervicitis include: intrauterine devices, contraceptive diaphragms, and allergic reactions to spermicides or latex condoms

Differentiating Cervicitis overview from Other Diseases

Cervicitis must be differentiated from other diseases that cause vaginal discharge and/or pelvic pain, such as endometritis, salpingitis, vaginitis and vulvovaginatis.

Epidemiology and Demographics

The incidence and prevalence of cervicitis depends on the study population. The prevalence of cervicitis is estimated to be 18000 per 100000 women diagnosed of gonococcal infection.[16] The prevalence of cervicitis ranges from 7600 to 24900 per 100000 female sex workers. The broad range is due to variation in demographic location.[17][18] Cervicitis is relatively more prevalent in HIV-positive women than non-HIV positive women.[19]. Among this population, prevalence of cervicitis is estimated to be 7400 per 100000 women diagnosed of HIV infection.[20] Screening and treatment of M. genitalium among HIV-infected individuals may be needed to improve cervical health, and reduce mobidity.[20] The overall prevalence of nongonococcal cervicitis is higher than gonococcal cervicitis.[7]. Chlamydia cervicitis is four to five times more prevalent than gonococcal cervicitis.[21][7] However, coinfection of gonococcal and chlamydia cervicitis is higher in PID than in cervicitis.[21] Cervicitis commonly follows the pattern of age prevalence of sexually transmitted infections with highest incidence among women aged 15-24.[22][23][24] There is no racial predilection to developing cervcitis. The prevalence of cervicitis is higher in underserved communities and developing countries.[25][26]

Risk Factors

Common risk factors in the development of cervicitis include high-risk sexual behavior, history of sexually transmitted diseases, sexual intercourse at an early age, sexual partners who have engaged in high-risk sexual behavior or have previous history of STD, single marital status, urban residence, low socioeconomic status, smoking, alcohol or drug use , multiple sex partners, and bacterial vaginosis.[27][27][19][28][29]

Screening

Screening for the infectious causes of cervicitis is recommended according to the 2015 Sexually Transmitted Diseases Treatment Guidelines by the CDC.[30][31][23][32] Gonococcal and Chlamydial screening is recommended in sexually active women under 25 years of age, sexually active women aged 25 years and older if at increased risk, all pregnant women under 25 years of age and pregnant women aged 25 and older if at increased risk.

Natural History, Complications, and Prognosis

If left untreated, cervicitis may progress to PID with associated infectility especially in chronic cervicitis.[33][34] Untreated active HSV infections in the perinatal and neonatal period may lead to neonatal morbidity. Complications that can develop as a result of infectious cervicitis include:[35][33][36][14][25][37] pelvic inflammatory disease, infertility, chronic pelvic pain, ectopic pregnancy, spontaneous abortion, premature rupture of membranes and preterm delivery

Diagnosis

History and Symptoms

Mucopurulent cervicitis is often asymptomatic,[33][16] however, some patients may present with abnormal vaginal discharge, painful sexual intercourse and intermenstrual vaginal bleeding.[27][4]

Physical Examination

Two major diagnostic signs characterize cervicitis:[24][38]

1) a purulent or mucopurulent endocervical exudate visible in the endocervical canal or on an endocervical swab specimen (commonly referred to as mucopurulent cervicitis or cervicitis)
2) sustained endocervical bleeding easily induced by gentle passage of a cotton swab through the cervical os. Either or both signs might be present.

Laboratory Findings

Diagnosis of cervicitis is mostly clinical however, a finding of >10 WBC in vaginal fluid, in the absence of trichomoniasis, may indicate endocervical inflammation caused specifically by C. trachomatis or N. gonorrhea although culture is more accurate for gonococcal cervicitis.[39] The use of nucleic acid amplification tests is very helpful for the diagnosis of trichomoniasis.[40] Wet mount microscopy and direct visualisation have low sensitivity in detecting N. gonorrhea and T. vaginalis, because of this symptomatic women with cervicitis and negative microscopy should receive further testing (i.e., culture or other FDA-cleared method). Although HSV-2 infection has been associated with cervicitis, the utility of specific testing (i.e., culture or serologic testing) for HSV-2 is unknown. DNA amplification techniques has good sensitivity, but are not yet approved for diagnostic purposes of Trichomoniasis.[41] Microscopy (wet prep) and vaginal pH are useful for identifying bacterial vaginosis which may show clue cells.[42]

Ultrasound

Ultrasound is not needed in diagnosing cervicitis, however, when complicated by PID, it may be helpful.[21]

Other Diagnostic Studies

There are no other diagnostic studies for cervicitis.

Treatment

Medical Therapy

Antimicrobial therapy with adequate coverage against C. trachomatis should be provided for women at increased risk for C. trachomatis or if follow-up cannot be ensured and if a relatively insensitive diagnostic test is used in place of NAAT. Patients may also require concomitant therapy against N. gonorrhea. Medical therapies include either azithromycin, doxycycline, or a fluoroquinolone. Treatment of sexual partners is also indicated. Follow-up after completion of antimicrobial therapy regimen is required to evaluate for microbial resistance.[43]

Surgery

Surgical intervention is unnecessary in the management of cervicitis.

Prevention

Effective measures for the primary prevention of cervicitis include avoidance of the risk factors of cervicitis click here. Secondary prevention strategies of cervicitis include early diagnosis and treatment of patients with sexually treatment infections especially gonorrhea and chlamydia.

References

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  2. Anderson MT, Dewenter L, Maier B, Seifert HS (2014). "Seminal plasma initiates a Neisseria gonorrhoeae transmission state". MBio. 5 (2): e01004–13. doi:10.1128/mBio.01004-13. PMC 3958800. PMID 24595372.
  3. Paavonen J, Vesterinen E, Meyer B, Saksela E (1982). "Colposcopic and histologic findings in cervical chlamydial infection". Obstet Gynecol. 59 (6): 712–5. PMID 7078909.
  4. 4.0 4.1 Dunlop EM, Garner A, Darougar S, Treharne JD, Woodland RM (1989). "Colposcopy, biopsy, and cytology results in women with chlamydial cervicitis". Genitourin Med. 65 (1): 22–31. PMC 1196182. PMID 2921049.
  5. Dolgushin II, Kurnosenko IV, Dolgushina VF, Ugaĭ IIu, Abramovskikh OS, Gol'tsfarb VM (2004). "[Clinical and immunological aspects of cervicitis of chlamydial etiology]". Zh Mikrobiol Epidemiol Immunobiol (3): 48–52. PMID 15346950.
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  43. Diseases Characterized by Urethritis and Cervicitis. Centers for Disease Control and Prevention (2015). http://www.cdc.gov/std/tg2015/urethritis-and-cervicitis.htm Accessed on July 28, 2016


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