cervical infections Flashcards Preview

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Flashcards in cervical infections Deck (142):

most common causes of intectious cervicitis

Neisseria gonorrheoeae
Chlamydia trachomatis
herpes simples virus
human papilloma virus
mycoplasma genitalium
bacterial vaginosis


If untreated, cervicitis can lead to

Pelvic inflammatory disease
higher risk of infertility
ectopic pregnancy
chronic pelvic pain


methods for testing gonorrhea

urethral gram stain
culture on Thayer-Martin media
DNA probes
DNA amplification techniques on cervical or urine specimens


Testing for chlamydia

nucleic acid amplification techniques on cervical or urine specimens


HPV infection testing

cervical cytology (Pap test) and HPV testing are used with colposcopy and biopsy


The signs of cervicitis

edema and increased vascularity, making the cervix appear swollen and reddened.


Cervicitis can be diagnosed histologically when

polymorphonuclear leukocytes, lymphocytes, or histiocytes are noted


The cervix is in direct contact with the vagina and is exposed to

viral, bacterial, fungal, and parasitic agents


Cervical infections occur in the absence of

vaginal disease


Through sexual contact, the cervix may be infected with

N gonorrhoeae, C trachomatis, HSV, HPV, and Mycoplasma spp.


Why is screening high-risk populations important?

Because many women are asymptomatic


Patients diagnosed with gonorrhea or chlamydia are at risk for infection with other sexually transmitted diseases (STDs). Counseling and testing should be offered for

syphilis, hepatitis B, and HIV, as well as testing for HPV


Pathogenesis of C trachomatis

C trachomatis is often “silent,” an undiagnosed, ongoing infection may ascend into the endometrial cavity to the fallopian tubes, causing salpingitis as well as pelvic peritonitis.


Complications of chlamydia

With the cervix as a reservoir, the organism may infect the fetus during its passage through the birth canal. C trachomatis transmitted to the eyes causes trachoma and inclusion conjunctivitis or pneumonia of the newborn.


Pathogenesis of N. gonorrhoeae

Cervical infection which ascends to infect the endometrium and fallopian tubes.


At what time in a woman's cycle is she most at risk for cervicitis ascending into the upper reproductive tract?

at the end of menses when there is no protective mucus plug.


Fitz-Hugh-Curtis syndrome or perihepatitis

rare complication usually caused by C trachomatis and N gonorrhoeae and is characterized by adhesions between the liver and the parietal peritoneum.


2 types of HSV

herpes simplex virus type 1 (HSV-1) and herpes simplex virus type 2 (HSV-2)


Which HSV infection causes most of the genital herpes infections



When can HSV-1 cause genital herpes

oral-genital or genital-genital contact


HSV infection presentation

cervical lesions similar to those found on the vulva. First the lesion is vesicular and then becomes an ulcer. Primary infections may be extensive and severe, producing constitutional symptoms of low-grade fever, myalgia, and malaise lasting approximately 2 weeks. The ulcers heal without scarring. Once infection has occurred, even after healing, the virus continues to reside in the nerve cells of the affected area for life.


HSV recurrence

less severe in symptoms and duration


HSV is found in the lesions caused by HSV infection, but viral shedding can also occur

in asymptomatic patients without obvious lesions. Women with either active infection or asymptomatic HSV shedding from normal-appearing skin can infect their infants during vaginal delivery. Those with a positive HSV test near term are advised to undergo caesarean section.


HPV is spread by

skin-to-skin contact


Women with vulvar HPV lesions should be assessed for

cervical HPV lesions and infection


Appearance of cervical HSV lesions

The cervical lesions are flatter than typical genital warts (condylomata acuminata) seen on the vulva and perianal skin. In fact, they often are invisible to the naked eye, becoming visible only after application of a dilute solution of acetic acid (acetowhite epithelium) or by colposcopic examination (white epithelium, mosaicism, and coarse punctation).


Low risk HPV types

6, 11, 42, 43, 44, 54, 55 (associated with benign lesions of the cervix)


High risk HPV types

16, 18, 31, 33, 35, 39, 46, 56 (associated with intraepithelial neoplasia and invasive cancers)


What percent of HPV infections resolve in 1 year?
In two years?

70% in one year
90% by 2 years


Persistent HPV infection may progress to

precancerous lesions and, over time, cervical cancer


Most important strategies for prevention of cervicitis

barrier methods


Which STIs should be screened for yearly in high risk populations, regardless of symptoms

gonorrhea and chlamydia--most prevalent in young adults aged 19-25
significant long-term complications


at risk populations for STI

multiple partners
inconsistent use of condoms or barrier
previous hx STI
current or prior drug abusers


when should pregnant women be screened for syphilis and HIV

at the first prenatal visit


Pregnant women with a history of HSV should be screened

near term


Women at high risk of premature delivery should be screened for

bacterial vaginosis


The prompt recognition and proper repair of cervical lacerations lessen the risk of

cervical stenosis and cervical incompetence in future pregnancies.


When hysterectomy is performed, if possible, the cervix should be

removed to minimize the risk of cervical diseases.


Common s/sx acute cervicitis

Purulent vaginal discharge
Some women have vaginal bleeding, most frequently after sexual intercourse, although intermenstrual bleeding and bleeding during examination can also occur.
burning and itching


In acute cervicitis, the pathogen may be determined by the appearance of

cervical discharge


thick and creamy discharge

gonorrheal infection


foamy and greenish-white discharge

trichomonal infection


white/curd-like discharge



thin and gray discharge

bacterial vaginosis


Amine or fishy odor when combined with KOH

bacterial vaginosis


purulent discharge from a reddened, congested cervix, or may be asymptomatic, without visible signs



acutely inflamed, edematous cervix with purulent discharge from cervical os

N. gonorrhoeae


strawberry-like appearance covers the ectocervix and may extend to the adjacent vaginal mucosa.

trichomonal infection


white cheesy exudate may be difficult to wipe away and once wiped off usually leaves punctate hemorrhagic areas



which organisms of cervicitis may be accompanied by urethritis with frequency, urgency, and dysuria

Gonorrheal or chlamydial


If any infection is associated with acute salpingitis, the symptoms and signs will include

pelvic peritonitis


Postcoital bleeding or intermenstrual spotting may occur because of

hyperemia of the infected cervix associated with freely bleeding areas. Cervical friability with bleeding occurs when endocervical smears are obtained.


Colposcopic findings of acute cervicitis reveal

an altered microangioarchitecture with marked increase in the surface capillaries, which when viewed end-on may show a pattern of diffuse “punctation.”


characteristic double-hairpin capillaries



Colposcopic picture in an inflammatory process

diffuse with ill-defined margins in contrast with the localized and sharply demarcated vascular changes associated with intraepithelial neoplasia


when colposcopic changes with malignancy are present alongside those associated with inflammation:

Invasive cancer with is secondarily infected


Chief sx of chronic cervicitis

Less diffuse as acute cervicitis, but may still cause vulvar irritation.


discharge in chronic cervicitis

The discharge may be frankly purulent and variable in color, or may simply be thick, tenacious, turbid mucus. Intermenstrual or postcoital bleeding may occur.


Associated sx of chronic cervicitis

lower abdominal pain, lumbosacral backache, dysmenorrhea, dyspareunia, urinary frequency, urgency, and dysuria.


Inspection of the chronically infected cervix often reveals

only abnormal discharge, with the upper vagina appearing normal.


Mucopurulent cervicitis is defined as

evidence of purulent material on inspection of an inflamed cervix along with 10 or more polymorphonuclear leukocytes per high-powered microscopic field seen on Gram's stain of the discharge.


In acute cervicitis with N gonorrhoeae, the sensitivity of Gram's stain for detection of diplococci is only



In symptomatic patients, with signs suggesting Trichomonas, further testing of

nucleic acid amplification, culture testing may be necessary


Bacterial vaginosis can be seen on saline wet mount by

the coating of epithelial cells with bacteria called “clue cells.”


Bacterial vaginosis is diagnosed by using

Amsel criteria:
thin homogeneous white, yellow discharge,
presence of the “clue cells” on microscopy,
vaginal pH >4.5,
and fishy odor on adding alkaline 10% potassium hydroxide solution.
Presence of 3 of these criteria will confirm the diagnosis of bacterial vaginosis.


Candidal infections can be seen on potassium hydroxide preparations, with the distinctive presence of



More recently, infection is detected more reliably than culture with

nucleic acid amplification methods such as polymerase chain reaction (PCR), transcription-mediated amplification, and strand displacement amplification.

high sensitivity and specificity (82–100%)

simultaneous detection of both N gonorrhoeae and C trachomatis from the same specimen.


Enzyme immunoassay and direct fluorescent antibody rely on

antigen detection and have a sensitivity ranging from 70–80%, but the specimen still requires invasive testing using a swab from the cervix or urethra.


HSV infection can be detected by

viral culture, PCR, and direct fluorescence antibody. Most laboratories are moving toward nonculture assays such as PCR, which offer high sensitivity and specificity.


Syphilis is detected by using

nontreponemal rapid plasma reagin (RPR) or Venereal Disease Research Laboratory (VDRL) tests and subsequent confirmation with microhemagglutination assay for Treponema pallidum (MHA-TP), fluorescent treponemal antibody-absorption (FTA-ABS) tests.


most effective strategy for detecting abnormal cervical pathology.

Combining HPV testing with cervical cytology


If cytology is abnormal

colposcopy with directed biopsy is advised.


In uncomplicated cervicitis not accompanied by salpingitis, the white count may be



With salpingitis, a leukocytosis is

common with an elevated white count. The erythrocyte sedimentation rate may be slightly elevated.


cytologic cervical testing may delineate

Cellular changes of mild dysplasia (low-grade squamous intraepithelial lesion [SIL]), moderate or severe dysplasia (carcinoma in situ [CIS], high-grade SIL), and invasive cancer


Nuclear enlargement, clumping of chromatin, hyperchromatism, and nucleoli, as well as cytoplasmic eosinophilia and poorly defined cell membranes, are nonspecific findings of

cytologic atypia.


large numbers of polymorphonuclear leukocytes or histiocytes indicate

acute cervicitis.


When the inflammatory cells are so dense that the epithelial cells are obscured

the smear should be repeated after the inflammatory process has been treated.


HPV infection is characterized histologically by

squamous epithelial cell enlargement, multinucleation, and the perinuclear “halo” effect of koilocytosis.


Enlarged, multinucleated cells with ground-glass cytoplasm and nuclei containing inclusion bodies are indicative of

HSV infection


Both N gonorrhoeae and C trachomatis infections produce a nonspecific acute inflammatory reaction of

nonspecific acute inflammatory reaction of edema and increased vascularity, and the cervix becomes swollen and reddened. Gross appearance of acute cervicitis must be distinguished clinically and histologically from cervical ectopy.


Histopathology of cervical infections
--visual inspection
--microscopic inspection
--post infection

Infection causes the glandular epithelium to hyperfunction, producing a copious purulent or mucopurulent exudate and mucus mixed with inflammatory cells.
Microscopically, stromal edema and infiltration by polymorphonuclear leukocytes are seen, and some mucous membrane may be denuded.
As the acute infection subsides, swelling and redness disappear, and polymorphonuclear leukocytes are replaced by lymphocytes, plasma cells, and macrophages—the histologic picture of chronic cervicitis.


Almost all parous women may have findings characteristic of chronic cervicitis on biopsy that are not significant unless

they also have clinical signs and symptoms of cervicitis.


Infectious cervicitis must be distinguished from

cervical intraepithelial neoplasia. Colposcopy is a useful adjunct. Cervical cytology and histologic examination by endocervical curettage and biopsy may help distinguish chronic cervicitis from cervical neoplasia.


N gonorrhoeae or C trachomatis cervicitis is often complicated by

salpingitis and pelvic inflammatory disease


salpingitis and pelvic inflammatory disease are associated with

an increased risk of
ectopic pregnancy,
and chronic pelvic pain.


The occurrence of gonorrheal or chlamydial cervicitis in HIV-infected women has been reported to be associated with increased shedding of

HIV-1 that, in turn, increases the infectiveness of these women.


What is the risk of cancer in women with history of genital infection.

Not increased.

Although, hx of genital infection is more common among women with carcinoma of the cervix.


Considerations for treatment

Nature of infection
plans for future pregnancy
Severity of infection as indicated by: salpingitis/previous treatment


Instrumentation should be avoided during acute cervicitis to minimize the risk of

ascending infection.


Treatment for trichomoniasis

Metronidazole 2 grams PO, single dose
tinidazole 2 grams PO single dose
metronidazole 500 mg BID x 7 days.
Cure rate 90-95%.


What should be avoided while taking metronidazole or tinidazole?

alcohol--throughout treatment and for 24-72 hours afterward.


Treatment for pregnant/breastfeeding with thichomoniasis

Metronidazole 2 grams PO single dose.
If breastfeeding, stop breastfeeding for 12-24 hours after treatment.
Treat sex partners and avoid sex until both partners are cured.
Topical forms are available, but less efficacious.


Treatment for candidiasis

Topically applied azole drugs.
Course may be 1,3,or 7 days, depending on severity of infection.


Specific medications for candidiasis

butoconazole 2% cream 5 grams intravaginally for 3 days
clotrimazole 1% cream 5 grams intravaginally for 7-14 days
clotrimazole 100mg vaginal tab for 7 days
miconazole 25 cream 5 grams intravaginally for 7 days
Miconazole 200 mg vaginal suppository for 3 days, or 100mg for 7 days
Single dose 150mg fluconazole by mouth


most prevalent genital ulcerative lesions in the United States.

Genital herpes, syphilis, and, less commonly, chancroid


the workup for all genital ulcers should include

serologic screening for syphilis, culture/antigen testing for herpes simplex virus (HSV)-1 and HSV-2, and culture for Haemophilus ducreyi in areas where chancroid is prevalent. More than 1 infectious etiology may be present in a single lesion.


Herpes Simplex
Essentials of Diagnosis

Most commonly caused by HSV-2 but increasingly also caused by HSV-1
Painful genital ulcers
Chronic, lifelong, relapsing condition
Transmissible even in the absence of lesions
Antivirals improve symptoms, speed healing of lesions, and may decrease asymptomatic viral shedding


the majority of genital herpes infections are transmitted by persons

unaware that they have the infection or who are asymptomatic when transmission occurs.


Patients should be counseled that viral shedding

can occur during asymptomatic periods and that this can lead to transmission. Consistent condom use is associated with a decline in transmission of genital HSV infection.


For patients with symptomatic genital HSV-2 infection and an uninfected partner,

chronic suppressive therapy to reduce clinical recurrences and viral transmission should be considered.
Valacyclovir (500 mg daily) is the best-studied regimen for this specific indication and offers the convenience of once-daily dosing; however, acyclovir may be a reasonable alternative.


Symptoms and signs of genital herpes

Classically, patients present with multiple painful vesicular or ulcerative lesions on the genitals.
May be absent--especially if caused by HSV-1


Patients with a primary HSV infection may, in addition to painful ulceration, have

multiple constitutional symptoms such as fever, headaches, and malaise.


preferred tests for HSV in symptomatic patients

Cell culture and polymerase chain reaction (PCR)


Failure to detect HSV by culture or PCR does not indicate an absence of HSV infection, because

viral shedding is intermittent.


for serologically. Immunoglobulin (Ig)M testing for HSV is not useful, because

the IgM tests are not type-specific and might also be positive during recurrent episodes of herpes.


Type-specific HSV serologic assays may be useful in the evaluation of the following situations:

patients with recurrent genital symptoms or atypical symptoms with negative HSV cultures,
patients with a clinical diagnosis of genital herpes without laboratory confirmation,
and patients who have a partner with genital herpes.


during the first several weeks after HSV infection, what types of antibodies develop?

type specific and non-type specific
persist indefinitely
can be tested for serologically


The presence of type-specific HSV-2 antibody implies

anogenital infection


Lack of symptoms in an HSV-1 seropositive person does not distinguish

anogenital from orolabial or cutaneous infection.


Regardless of site of infection, persons with HSV-1 are at risk for acquiring



Complications associated with HSV infection

Urinary retention due to severe dysuria with extensive genital lesions.
Rarely, can develop manifestations of disseminated infection, pneumonitis, hepatitis, or CNS complications such as meningoencephalitis.
Hospitalize for monitoring and IV antivirals.


Systemic treatment for herpes

help to control the symptoms of herpes episodes and may also be used as daily suppressive therapy.
Do not eradicate latent virus, nor affect the risk, frequency, or severity of recurrences after drug discontinued.


Medications for first episode of herpes

First clinical episode:
Choose one:
Acyclovir 400 mg orally 3 times a day for 7–10 days

Acyclovir 200 mg orally 5 times a day for 7–10 days

Famciclovir 250 mg orally 3 times a day for 7–10 days

Valacyclovir 1 g orally twice a day for 7–10 days

**May treat longer than 10 days if symptoms not resolved


Suppression therapy for genital herpes

Choose one of the following:

Acyclovir 200 mg orally twice a day

Famciclovir 250 mg orally twice a day

Valacyclovir 500 mg orally once a day (may be less effective than the other regimens in patients with >10 episodes per year)

Valacyclovir 1g orally once a day



Choose one of the following:

Acyclovir 400 mg orally 3 times a day for 5 days

Acyclovir 800 mg orally twice a day for 5 days

Acyclovir 800 mg orally 3 times a day for 2 days

Famciclovir 125 mg orally twice a day for 5 days

Famciclovir 1 g orally twice a day for 1 day

Famciclovir 500 mg once, followed by 250 mg twice daily for 2 days

Valacyclovir 500 mg orally twice a day for 3 days

Valacyclovir 1 g orally once a day for 5 days


HSV Recommendations to pregnant women

Abstain from sex during third trimester with partners who are HSV positive.
All should be asked about history of HSV
At onset of labor, all women should be questioned carefully and examined for herpetic lesions.
Women without symptoms or signs of genital herpes or its prodrome can deliver vaginally.
C-Section does not eliminate risk, but greatly reduces it.


Treatment of HSV-pregnancy

Acyclovir PO to pregnant women with first-episode genital herpes or severe recurrent herpes.
Reduces frequency of ceserean.
May be offered for suppression from approximately 36 weeks gestation


HSV with HIV treatment

Choose one of the following:

a. Suppression
Acyclovir 400–800 mg orally 2–3 times a day

Famciclovir 500 mg orally twice a day

Valacyclovir 500 mg orally twice a day

B. Episodic Infection
Acyclovir 400 mg orally 3 times a day for 5–10 days

Famciclovir 500 mg orally twice a day for 5–10 days

Valacyclovir 1 g orally twice a day for 5–10 days


Chancroid essentials of diagnosis

Caused by gram-negative rod Haemophilus ducreyi
Painful, tender genital ulcer
Suppurative inguinal adenopathy


Exposure to chancroid is usually through

coitus, but accidentally acquired lesions of the hands have been reported. The incubation period is typically 4–10 days. Chancroid is a reportable disease.


If patient is diagnosed with chancroid, how is partner treated

Treat regardless of symptoms if they have had sexual contact in the 10 days preceding partner's onset of symptoms.


chancroid lesion

begins as an erythematous papule that evolves into a pustule and ultimately degenerates into a saucer-shaped ragged ulcer circumscribed by an inflammatory wheal. Typically, the lesion is very tender and produces a heavy, foul discharge that is contagious. Patients typically have more than 1 ulcer, and these are almost exclusively confined to the genital region.


Painful inguinal adenitis related to chancroid

The nodes may undergo liquefaction, producing fluctuant buboes that may become necrotic and drain spontaneously.



Cervical intraepithelial neoplasia (disordered growth)



Vaginal intraepithelial neoplasia



vulvar intraepithelial neoplasia



perianal intraepithelial neoplasia


5 categories of Pelvic infection

Pelvic inflammatory disease, including tubo-ovarian abscess (TOA)
Puerperal infections
Postoperative pelvic infection after gynecologic surgery
Abortion-associated infections
Secondary to other infections


Pelvic inflammatory disease essentials of diagnosis

Inflammation of upper female genital tract

usually polymicrobial

often diagnosed clinically based on the presence of cervical motion tenderness or uterine or adnexal tenderness

criteria exist to determine whether to manage patient as inpatient or outpatient

may result in pelvic scarring and infertility


Pathogenesis of PID

spectrum of inflammatory disorders of the upper female genital tract.
Any combination of:
salpingitis, tubo-ovarian abscess
pelvic peritonitis
STI (gonorrhoeae and trachomatis)
microorganisms from vaginal flora


normal vaginal flora

anaerobes, G vaginalis, Haemophilus influenzae, enteric gram-negative rods, and Streptococcus agalactiae


Prevention of PID

Screening and treatment of sexually active women and their partners. (60 days preceding onset of symptoms)

Early diagnosis and eradication to prevent salpingitis

abstain from sex until no symptoms


PID clinical findings


may be subtle or mild, though early diagnosis important
Clinical diagnosis is appropriate, but often imprecise
c/o insidious or acute onset lower abdominal/pelvic pain--usually bilateral
sensation of pelvic pressure or back pain
offten associated with purulent vaginal discharge
Nausea with or without vomiting
HA with general lassitude.
No fever required for Dx


PID clinical findings


Abdominal tenderness in both lower quadrants
somewhat distended abdomen
BS hypoactive or absent
Pelvic exam: inflammation of the periurethral (Skene) or Bartholin's glands as well as purulent cervical discharge.
Bimanual exam: extreme tenderness on cervical and uterine movement and palpation of the parametria.


CDC guidelines on when to start emperic tx of PID

sexually active young women and other woman at risk for STDs if
1. experiencing pelvic or lower abdominal pain
2. no cause other than PID can be identified
3. 1 of the following:
(a) cervical motion tenderness
(b) uterine tenderness
(c) adnexal tenderness


Labs for PID

Vaginal fluid: abundant WBC
Leukocytosis with shift to the left
ESR, CRP elevated
Endocervical swabs culture gonorrheoeae or trachomatis.
(BTW these might all be normal)
Endometrial biopsy is definitive, but hardly done.


Imaging for PID

Laparoscopy/salpingitis, endometriosis--useful adjuct



acute appendicitis
ectopic pregnancy
ruptured corpus luteum cyst with hemorrhage
infected septic abortion
torsion of an adnexal mass
degeneration of a leiomyoma
acute UTI
regional enteritis
ulcerative colitis


Complications of PID

pelvic or generalized peritonitis
prolonged ilius
septic pelvic thrombophlebitis
abscess formation with adnexal destruction/infertility
intestinal adhesions and obstruction
Rarely: dermatitis
gonococcal arthritis
bacteremia with septic shock



All regimens should be effective against gonorrhea and chlamydia.
Outpatient Therapy
Ceftriaxone 250 mg IM in a single dose (or other parenteral third-generation cephalosporin), plus
Doxycycline 100 mg orally twice a day for 14 days, with or without
Metronidazole 500 mg orally twice a day for 14 days

Cefoxitin 2 g IM in a single dose and probenecid 1 g orally in a single dose administered concurrently, plus
Doxycycline 100 mg orally twice a day for 14 days, with or without
Metronidazole 500 mg orally twice a day for 14 days


Hospitalize PID pt if:

Patient in whom surgical emergencies (eg, appendicitis) cannot be excluded
Patient who are pregnant
Patients who have not responded well to outpatient oral therapy
Patients who are unable to tolerate or comply with outpatient therapy
Patients who have severe illness, nausea and vomiting, or high fever
Patients with tubo-ovarian abscess