CervicitisZUrethritis
GENERAL PRINCIPLES
Cervicitis and urethritis are frequent presentations of infection with Neisseria gonorrhoeae or C. trachomatis, and occasionally Mycoplasma genitalium, Neisseria meningitidis, and T.
vaginalis. These infections often coexist, and clinical presentations can be identical.DIAGNOSIS
Clinical Presentation
• People with a vagina presenting with urethritis, cervicitis, or both complain of mucopurulent vaginal discharge, dyspareunia, and dysuria.
• People with a penis presenting with urethritis may have dysuria and purulent penile discharge.
• Most infections are asymptomatic.
• Disseminated gonococcal infection (DGI) can present with fever, tenosynovitis, vesicopustular skin lesions, and polyarthralgias. DGI may also manifest solely as septic arthritis of the knee, wrist, or ankle (see Chapter 25, Arthritis and Rheumatologic Diseases).
• If urethritis or cervicitis is persistent, consider M. genitalium.
Diagnostic Testing
• A NAAT performed on endocervical, vaginal, urethral (men), urine, or extragenital samples is recommended to make the diagnosis of C. trachomatis or N. gonorrhoeae infection. In the case of N. gonorrhoeae, a Gram stain of endocervical or urethral discharge with gram-negative intracellular diplococci can rapidly establish the diagnosis. Of note, N. meningitidis may appear similar on gram stain but will have negative NAAT for N. gonorrhoeae. Culture can be performed on urethral or endocervical swab specimens.
• Recommendations for testing include NAAT testing at extragenital sites of sexual contact (pharynx, rectum), especially in MSM and transgender persons. Not testing all exposed sites misses the majority of infections in certain populations.
• In addition to NAAT studies, patients with suspected DGI should have blood cultures drawn. In the setting of septic arthritis, synovial fluid analysis and culture is indicated.
• NAATs for M. genitalium are available and should be considered for persistent urethritis/cervicitis following proper testing and treatment for C. trachomatis.
TREATMENT
Because of increasing resistance concerns, treatment options for N. gonorrhoeae infection are reduced (see Table 16-1).