Endocervicitis (mucopurulent cervicitis or MPC)-Standard Treatment Guidelines

Ministry of Health and Family Welfare, Government of India has issued the Standard Treatment Guidelines for Endocervicitis (mucopurulent cervicitis or MPC).

Following are the major recommendations :

Introduction

Symptoms

• Asymptomatic in majority


• Abnormal vaginal discharge in some


• Post coital and intermenstrual vaginal bleed

Case definition

An inflammation of the cervical mucosa characterized by two major diagnostic signs.

• Purulent or mucopurulent endocervical exudate (mucopurulent cervicitis).


• Sustained endocervical bleeding easily induced by gentle passage of a cotton swab through the cervical os.


• Either or both signs might be present.

Causative organisms

• C. trachomatis


• N. gonorrhoeae


• Mycoplasma genitalium

INCIDENCE OF THE CONDITION IN OUR COUNTRY
No institutional data available in the Indian scenario.

DIFFERENTIAL DIAGNOSIS

• Cervical ectopy (seen in adolescents)


• Ectropion (patulous parous cervix)


• Ectocervicitis caused by HSV, T. vaginalis, CMV, C. albicans


• Endocervical inflammation associated with oral contraceptive use

PREVENTION AND COUNSELING

General measures as applicable to all patients with suspected STIs

• Educate and counsel patient and sex partner(s) regarding RTIs/STIs, genital cancers, safer sex practices and importance of taking complete treatment.


• Treat partner(s) for the suspected organisms.


• Advise sexual abstinence during the course of treatment to minimize transmission.


• Promote the use of barrier contraception like condoms, educate about correct and consistent use.


• Refer for voluntary counseling and testing for HIV, Syphilis and Hepatitis B.


• Consider immunization against Hepatitis B.


• Schedule return visit after 7 days to ensure treatment compliance as well as to see reports of tests done.


• If symptoms persist, assess whether it is due to treatment failure or reinfection and advise prompt referral.

OPTIMAL DIAGNOSTIC CRITERIA, INVESTIGATIONS,
TREATMENT & REFERRAL CRITERIA

Situation 1: At Secondary Hospital/ Non-Metro situation: Optimal Standards of Treatment in Situations where technology and resources are limited

Clinical Diagnosis
Based on

• History of abnormal vaginal discharge, urinary burning or frequency, dysmenorrhoea, menorrhagia, irregular menstrual cycles.


• Speculum examination showing signs of cervical infection like yellowish discharge, redness with swelling, easy bleeding on probing cervix, cervical erosion to be assessed.


• Swab test: yellow colour of endocervical discharge visualized on a white swab.


• Bimanual pelvic examination: fornicial or cervical motion tenderness suggests PID.

Investigations

• Gram's stain of endocervical mucus: to document cervicitis and look for presence of GNID.


• Cervical Cytopathology: PAP smear can demonstrate characteristic cellularity.

Treatment

Provide presumptive therapy for cervicitis (not to await the results of diagnostic tests).

Treatment for cervical infection (chlamydia and gonorrhea)

• Tab cefixime 400 mg orally, single dose Plus.


• Tab Azithromnycin 1 gram, 1 hour before lunch. (If vomiting within 1 hour, give antiemetic and repeat).

Alternative regimes

• Inj Ceftriaxone 250 mg im stat Plus.


• Tab Doxycycline 100 mg orally twice a day for 7 days.

If Vaginitis also present

• treat for both vaginitis and cervicitis (refer to guidelines).


• Trichomoniasis and BV should be treated if detected.

Other measures to be advised

• Instruct client to avoid douching.


• Advise sexual abstinence during the course of treatment.

Follow-Up

• Followup after one week.


• Repeat testing of all women with chlamydia regardless of whether their sex partners were treated as there is high risk of reinfection.

Specific guidelines for partner management

• Treatment as for urethritis (refer to relevant guidelines).


• Provide condoms, educate about correct and consistent use.


• Schedule return visit after 7 days.

Special situations

• Pregnancy, diabetes, HIV may also be influencing factors and should be considered in recurrent infections.

Management in pregnant women

• Per speculum examination.


• In women with persistent symptoms attributable to cervicitis, refer to gynaecologist.

HIV Infection

• same treatment regimen as those who are HIV negative.

Recurrent and Persistent Cervicitis

• Reevaluate for possible reexposure to an STD as they have a high rate of reinfection within 6 months after treatment.


• Exclude BV.


• Sex partners to be evaluated and treated.


• Repeat alternative course of therapy.


• Revaluate to determine whether cervicitis has resolved.

Referral criteria

Gynecologic referral to rule out other causes in case of persistent, unresponsive or recurrent cervicitis.

Situation 2: At Super Specialty Facility in Metro location where higher-end technology is available

Clinical Diagnosis:
Same as above

Investigations:
Same as above

In addition

• Colposcopy.


• Cervical biopsy.


• Microbial etiology of cervicitis to be delineated (indicated in patients with recurrent or persistent cervicitis) as per relevance in a given clinical situation, any of the following tests may be done.
  o isolation of C. Trachomatis
  o culture for N. Gonorrhoeae
  o HSV culture: viral isolation
  o Isolation of T. Vaginalis
  o immunologic detection of microbial antigens
  o use of nucleic acid probes
  o DNA amplification / detection methods.


• NAAT should be used for diagnosing C. trachomatis and N. gonorrhoeae in women with cervicitis.

Treatment

• For reasons that are unclear, cervicitis can persist despite repeated courses of antimicrobial therapy.


• Most persistent cases not caused by relapse or reinfection with C. trachomatis or N. gonorrhoeae.


• Other factors like persistent abnormality of vaginal flora, douching, exposure to other types of chemical irritants or idiopathic inflammation in the zone of ectopy to be evaluated.

Guidelines by The Ministry of Health and Family Welfare :

Dr. M.K. Daga
Department of Medicine
Maulana Azad Medical College
New Delhi