Acute Cervicitis
1. Definition
Cervicitis คือการอักเสบของ uterine
cervix โดยมักเกิดที่ columnar epithelium ของ
endocervix แต่อาจลุกลามถึง squamous
epithelium ของ ectocervix
- แบ่งเป็น infectious / noninfectious
- Acute
cervicitis มักเกิดจาก infection
- Chronic
cervicitis มักเป็น noninfectious
2. Epidemiology
- พบได้สูงถึง 30–45% ใน STI
clinics
- ปัจจัยเสี่ยงหลัก: sexual activity
- C.
trachomatis + N. gonorrhoeae รวมกัน ~50% ของ identifiable causes
3. Etiology
Infectious causes
Most common
- Chlamydia
trachomatis (D–K)
- Neisseria
gonorrhoeae
Common
- Trichomonas
vaginalis
- Mycoplasma
genitalium
- HSV
- BV (มักไม่ทำให้ isolated cervicitis)
- Group
A streptococcus
- TB
(rare, usually with endometritis)
Uncommon / unlikely
- Mycoplasma
hominis, Ureaplasma urealyticum, CMV, GBS
→ ไม่มีหลักฐานชัดว่าเป็น cause โดยลำพัง
Noninfectious causes
- Mechanical:
pessary, tampon, diaphragm, condom, cervical trauma
- Chemical:
douching, spermicides, latex, povidone-iodine
- Others:
radiation, Behçet disease, lichen planus, hypoestrogenism
- Rare:
malignancy, plasminogen deficiency, lymphoma
4. Clinical Presentation
May be asymptomatic
Hallmark
- Purulent
/ mucopurulent endocervical discharge
- Cervical
friability (bleeds easily on swab)
Associated symptoms
- Dysuria,
dyspareunia
- Postcoital
bleeding
- Vaginal
irritation
- Fever/pain
→ suggest PID or
HSV
5. Diagnostic Approach
History (5 Ps)
- Partners,
Practices, Protection, Pregnancy prevention, Past STI
Physical exam
- Speculum:
discharge, friability
- Look
for clues:
- Strawberry
cervix → T.
vaginalis
- Vesicles/ulcers
→ HSV
- Always
do bimanual exam to exclude PID
Laboratory evaluation (recommended for all suspected
cases)
- NAAT
for C. trachomatis + N. gonorrhoeae
- Test
for Trichomonas (prefer NAAT if wet prep negative)
- Evaluate
BV (pH, wet mount)
- Consider
M. genitalium NAAT if persistent/refractory
Not routinely useful
- Gram
stain
- Cervical
cytology/histopathology (unless malignancy suspected)
6. Diagnosis
Clinical diagnosis based on:
- Mucopurulent
discharge OR
- Easily
induced endocervical bleeding (friability)
7. Differential Diagnosis
- STIs:
chlamydia, gonorrhea, trichomoniasis, HSV, M. genitalium
- BV
- Cervical
ectropion
- Contact
dermatitis
- Lichen
planus
- DIV
(desquamative inflammatory vaginitis)
- Atrophic
vaginitis (postmenopause)
- Cervical
neoplasia (must exclude if erosive lesion)
8. Treatment Principles
Goals
- Symptom
relief
- Prevent
PID
- Prevent
transmission
- Reduce
HIV acquisition risk
Empiric treatment (often preferred)
Indicated if:
- High
STI risk
- Follow-up
uncertain
- NAAT
unavailable
Empiric coverage
- Chlamydia
± Gonorrhea
9. Targeted Treatment
Chlamydia
- Preferred:
Doxycycline 100 mg PO BID × 7 days
- Alternative:
Azithromycin 1 g PO once
Gonorrhea
- Ceftriaxone
IM single dose
- <150
kg: 500 mg
- ≥150
kg: 1 g
- Add
doxycycline if chlamydia not excluded
Trichomoniasis
- Metronidazole
500 mg PO BID × 7 days
→ treat sexual partners
M. genitalium
- Two-stage
therapy, ideally resistance-guided
HSV
- Acyclovir
/ Valacyclovir / Famciclovir × 7–10 days
BV
- Oral
or topical metronidazole or clindamycin
→ no partner treatment
10. No Identified Pathogen
- Persistent
cervicitis without prior antibiotics →
trial doxycycline 7 days
- Persistent
despite treatment →
repeat testing + exclude noninfectious causes
- 3
months → chronic
cervicitis
11. Special Populations
- Pregnancy:
avoid doxycycline/fluoroquinolones →
use azithromycin
- HIV:
same regimens; treatment reduces cervical HIV shedding
- IUD:
usually can remain; remove if actinomyces or refractory symptoms
12. Sexual Partners
- Treat
partners for confirmed chlamydia, gonorrhea, trichomoniasis
- Abstain
from sex until treatment completed + symptoms resolved
13. Follow-up
- Symptoms
improve in 1–2 weeks
- Retest
chlamydia/gonorrhea/trichomonas at 3 months
- Screen
for HIV + syphilis
14. Chronic Cervicitis
- Usually
noninfectious
- Consider:
- Silver
nitrate cauterization
- Hormonal
therapy
- Ablative
procedures (after exclude malignancy)
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