Gonococcal Cervicitis

Gonococcal cervicitis is cervical infection with Neisseria gonorrhoeae. It causes mucopurulent cervicitis and may involve the urethra, Bartholin glands, rectum and pharynx.

• It often co-exists with chlamydia.
• Antibiotic resistance is rising, so treatment follows current susceptibility.
• Untreated infection leads to pelvic inflammatory disease, infertility, and disseminated infection.

Yellow-green mucopurulent discharge, dysuria, intermenstrual or post-coital bleeding, dyspareunia and lower abdominal pain; many women have no symptoms.

• Red, friable cervix with mucopus; Bartholin or Skene gland swelling.
• Differential diagnosis: chlamydial cervicitis, trichomoniasis, bacterial vaginosis, herpes cervicitis, pelvic inflammatory disease, urinary tract infection.
• Complications: pelvic inflammatory disease, tubal infertility, ectopic pregnancy, Bartholin abscess, disseminated gonococcal infection (arthritis, pustules), and neonatal ophthalmia.

Diagnosis is by NAAT, or Gram stain and culture, of cervical swabs.

• NAAT (Xpert CT/NG) on an endocervical or vaginal swab.
• Gram stain showing intracellular Gram-negative diplococci, and culture with susceptibility testing where available.
• Pharyngeal and rectal swabs if exposed.
• Test for chlamydia, HIV, syphilis, hepatitis B; pregnancy test.

Give ceftriaxone with cover for chlamydia, treat partners, and follow current susceptibility.

• Supportive: abstain from intercourse for 7 days after treatment; notify and treat all partners in the last 60 days; condoms.
• Pharmacological: ceftriaxone 500 mg IM single dose (1 g if body weight is above 150 kg). Add doxycycline 100 mg oral 12-hourly for 7 days to cover chlamydia unless chlamydia is excluded. Alternative when ceftriaxone is unavailable: cefixime 800 mg oral single dose, or spectinomycin 2 g IM single dose. In ceftriaxone allergy: gentamicin 240 mg IM single dose plus azithromycin 2 g oral single dose. Disseminated infection: ceftriaxone 1 g IV or IM daily for 7 days, with joint drainage. Paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours) for pain.
• Procedures: drain a Bartholin abscess; aspirate or wash out an infected joint.
• Special groups: in pregnancy give ceftriaxone 500 mg IM single dose plus azithromycin 1 g oral single dose; avoid doxycycline and gentamicin. In adolescents under 45 kg give ceftriaxone 125 mg IM single dose, and consider sexual abuse in children.
• Red flags: lower abdominal pain, fever, arthritis, skin pustules, endocarditis signs, treatment failure.
• Follow-up: review at 1 week; test of cure at 2 weeks if symptoms persist, with culture; retest at 3 months.