Abstract
Sir: The diagnosis and management of mucopurulent cervicitis (MPC) as a distinct entity is controversial. To investigate current practice in the UK and stimulate debate on whether guidance is needed and more evidence required, we asked the British Association for Sexual Health and HIV (BASHH) members via email to complete a short online questionnaire addressing their approach to MPC diagnosis and management.
The responses reflected a disparate approach. Of 133 respondents, 80/95 (84.2%) reported following BASHH guidelines for managing cervicitis; 45/133 (45%) had local guidelines. Out of 133, 105 (78.9%) actively look for cervicitis and 118/132 (89.4%) document if present. Diagnosis was made on cervical appearance alone by 76/117 (65%); 69/117 (59%) include the presence of cervical mucopus and 80/117 (68.4%) cervical friability. Out of 131, 115 (87.8%) laboratories routinely comment on pus cells, yet only 75/130 (57.7%) clinicians use this in reaching a diagnosis, with varying numerical cut-off. Other variables used to decide treatment include clinical appearance in 89/133 (66.9%), patient age 39/89 (43.8%) and sexual history 88/89 (98.9%). If reattendance is uncertain 47/89 (52.8%) treat empirically; 94/133 (79.7%) prescribe azithromycyn 1 g stat, 38/118 (32.2%) doxycycline, and 2/118 (1.7%) and 23/118 (19.5%) cefixime always and sometimes, respectively.
Our current practice in managing MPC in the UK clearly does not represent the ‘conscientious, explicit and judicious use of current best evidence’ expected in an era of evidence-based medicine. BASHH does not have any specific guidelines for the management of this condition. In the Centers for Disease Control and Prevention (CDC) guidelines, 1 the diagnosis is clinical, based on the finding of one or both of mucopurulent endocervical exudates and sustained bleeding on passage of a cotton swab through the endocervical os. Inflammation on endocervical Gram stain as presumptive evidence and indication for empirical treatment of chlamydial infection was dropped in 1993.
The diagnostic practice recommended by CDC was supported by the findings of a large US study carried out by Marrazzo et al. 2 in 2002. These were that signs of cervicitis should be interpreted in the context of age, with cervical signs having a higher predictive value in women under 25 years. In this study, 40% of young women with mucopus alone were infected with Chlamydia trachomatis (CT) compared with 16% with a normal cervical appearance. In contrast, a relatively small proportion of women older than 25 years with any cervical finding had CT or Neisseria gonorrhoeae (GC) documented.
The study also demonstrated the poor sensitivity (26%) of Gram-stained smear in the absence of clinical cervicitis supporting the findings of previous studies, 3,4 and highlighted the decreased utility if the cut-off for pus cell (polymorphonuclear [PMN]) count is reduced to less than 30.
In over 50% of cases of cervicitis, neither CT nor GC is detected, 2 yet there is evidence that this non-specific cervicitis may still confer an increased risk of poor pregnancy outcome 5 and predict upper genital tract disease. 6–8 Mycoplasma genitalium is increasingly implicated as a sexually transmitted cause, 9,10 and there is growing support for its role in upper genital tract disease and possibly as a predictor of poor pregnancy outcome.
So where do we go from here? Clearly more research is needed into this condition to provide a better evidence base. However, available evidence demonstrates the poor predictive value of cervical inflammation in the diagnosis of CT and GC, and by contrast the very high sensitivity and specificity of the now widely used non-invasive nucleic acid amplification tests. What has also been shown is the lack of benefit of counting pus cells in reaching a diagnosis, particularly when the cut-off used is less than 30 PMN. Should we therefore take the decision to amend practice? A better use of time would be for the National Chlamydia Screening Programme (NCSP) to harness the experienced workforce within genitourinary medicine services to focus on reaching the chlamydia targets of the NCSP.