Acute cervicitis

Neisseria gonorrhoeae is a gram-negative intracellular diplococcus that infects columnar and transitional epithelium of the cervix, urethra, rectum, pharynx, and conjunctiva, and disseminates hematogenously in 1% to 3% of infections to cause the arthritis-dermatitis syndrome or purulent monoarthritis; treatment is ceftriaxone-based because cephalosporin resistance is emerging and fluoroquinolones are no longer reliable.

Chlamydia trachomatis is the most commonly reported bacterial sexually transmitted infection in the United States, frequently asymptomatic, and diagnosed by nucleic acid amplification testing of urine or genital/rectal/oropharyngeal swabs. Uncomplicated genital infection is treated with a single dose of azithromycin or a course of doxycycline, complications include pelvic inflammatory disease and epididymitis, and LGV serovars require a 21-day course and are an increasing cause of proctitis.

Pelvic inflammatory disease is an ascending polymicrobial infection of the upper female genital tract, most often caused by Neisseria gonorrhoeae, Chlamydia trachomatis, or Mycoplasma genitalium, diagnosed clinically on uterine, adnexal, or cervical motion tenderness. Most women are treated as outpatients with a single dose of ceftriaxone plus 14 days of doxycycline, while parenteral cefotetan or cefoxitin plus doxycycline, or clindamycin plus gentamicin, is reserved for hospitalized patients, with tubo-ovarian abscess and infertility among the major complications of delayed treatment.

Bacterial vaginosis is a polymicrobial dysbiosis of the vagina caused by loss of lactobacilli and anaerobic overgrowth, diagnosed clinically by the Amsel criteria and treated with oral or intravaginal metronidazole or clindamycin.

Trichomonas vaginalis is a flagellated protozoan sexually transmitted infection that presents with malodorous frothy yellow-green discharge and a strawberry cervix but is frequently asymptomatic, especially in men. Diagnosis rests on nucleic acid amplification testing of vaginal secretions, and treatment is a single 2 g oral dose of metronidazole or tinidazole with partner treatment and retesting in 3 months for high reinfection rates.

Infectious urethritis is inflammation of the urethra from a sexually transmitted pathogen, most often Neisseria gonorrhoeae, Chlamydia trachomatis, or Mycoplasma genitalium, presenting with dysuria and urethral discharge. Diagnosis rests on urethral or urine leukocytes plus nucleic acid amplification testing, and empiric treatment covers gonorrhea with ceftriaxone and chlamydia with doxycycline while results are pending.

Herpes simplex virus type 1 or 2 establishes lifelong latency in sensory ganglia after mucocutaneous infection, causing painful vesicular-to-ulcerative outbreaks of the mouth or genitals with intermittent asymptomatic shedding; diagnosis is by NAAT of an ulcer swab and treatment is oral nucleoside analogues, escalating to intravenous acyclovir for encephalitis, severe mucocutaneous disease, or disseminated infection in immunosuppressed hosts.

Invasive cervical carcinoma is a human papillomavirus-driven squamous or glandular cancer staged by FIGO criteria, treated with fertility-sparing or radical surgery for early disease and cisplatin-based chemoradiation for locally advanced disease.

Persistent high-risk HPV infection drives squamous metaplasia at the cervical transformation zone into CIN 1/2/3, a histologic continuum staged by Pap cytology (Bethesda) and confirmed by colposcopic biopsy. Management follows ASCCP risk-based thresholds, from surveillance for CIN 1 to excisional or ablative treatment for CIN 2/3, to prevent progression to invasive cervical cancer.