DESCRIPTION

Infection of the endocervix resulting in inflammation, leading to mucopurulent cervical discharge, edema, erythema, bleeding, and friability of the cervix and endocervical canal

EPIDEMIOLOGY

• The true incidence of cervicitis is unknown; however, the primary causes (gonorrhea/chlamydia) are more common in adolescents and young adults than any other age group.
• Because many patients are asymptomatic and the interpretation and presence of the clinical signs are quite variable, many cases are undiagnosed.

ETIOLOGY

In most cases of cervicitis, no pathogen is isolated. Common causes include the following:

• Chlamydia trachomatis
• Neisseria gonorrhoeae
• Genital herpes infection (especially herpes simplex virus [HSV]-2)
• Trichomonas vaginalis
• Mycoplasma genitalium

RISK FACTORS

• Early age of coitarche
• Multiple sexual partners
• Absent or inconsistent condom use

COMMONLY ASSOCIATED CONDITIONS

The presence of other sexually transmitted infections (STIs) must be considered, including the following:

• Syphilis
• Hepatitis B
• HIV
• Bacterial vaginosis

HISTORY

• Often asymptomatic
• If symptomatic, may have:
  • Abnormal vaginal discharge
  • Intermenstrual vaginal bleeding, especially after sexual intercourse
• Past medical history—important to evaluate risk factors related to sexual health but not diagnostic of cervicitis
  • Previous STI? Identifies patients at increased risk for reinfection
  • Last menstrual period? Symptomatic infection often occurs within 7 days of the last menstrual period because of loss of the protective endocervical mucous plug.
  • Birth control method? Condoms are protective.
  • Exposure to infected partner? Identifies patient at increased risk

PHYSICAL EXAM

• Abdominal exam
  • No tenderness on palpation of the abdomen suggests that infection is limited to the cervix.
• Vaginal exam
  • Assess for signs of vaginal/external lesions consistent with HSV.
• Pelvic exam
  • Purulent or mucopurulent discharge from the cervical os or yellow exudative discharge present on a cotton-tipped swab from the endocervical canal
  • Sustained endocervical bleeding easily induced by gentle passage of a cotton swab through the cervical os
  • No cervical motion or adnexal tenderness or masses: Pathology has not extended beyond the cervix to the upper genital tract.

DIFFERENTIAL DIAGNOSIS

Pelvic inflammatory disease (PID)/upper genital tract infection should always be ruled out.

• Bacterial vaginosis may accompany cervicitis and should be ruled out.
• Pregnancy is a frequent cause of abnormal vaginal bleeding.
• Foreign body can be associated with both discharge and bleeding.
• Polycystic ovary syndrome (PCOS), thyroid dysfunction, and hyperprolactinemia can all present with abnormal vaginal bleeding.
• Noninfectious cervicitis: primarily caused by mechanical or chemical irritation (foreign objects, latex, vaginal douches, contraceptive creams)

DIAGNOSTIC TESTS & INTERPRETATION

MEDICATION

• Presumptive treatment for cervicitis, including treatment of C. trachomatis and N. gonorrhoeae, should be provided for the following women:
  • Age <25 years
  • Those with a new sexual partner
  • Those with a sex partner with concurrent partners
  • Those with a sex partner who has an STI
  • If follow-up cannot be assured
  • If NAAT cannot be performed or not available
• Recommended regimen for cervicitis
  • Doxycycline (adolescent): 100 mg PO b.i.d. for 7 days
  • Alternative regimen: azithromycin ≥45 kg or ≥8 years old: 1 g PO, single dose
• Gonorrhea should be treated presumptively (see criteria above) and when detected.
  • Ceftriaxone >45 to <150 kg: 500 mg IM × 1; for those ≥150 Kg: 1 g IM × 1
  • Cefixime ≥45 kg: 800 mg PO × 1: should only be used if ceftriaxone is not available or not feasible
• T. vaginalis should be treated if detected
  • Metronidazole ≥45 kg and adolescent: 500 mg PO b.i.d. for 7 days
  • Alternative: Tinidazole (adolescent) 2 g PO as a single dose
• Bacterial vaginosis should be treated if detected
  • Metronidazole ≥45 kg and adolescent: 500 mg PO b.i.d. for 7 days or
  • Metronidazole gel 0.75% (adolescent): one full applicator (5 g) intravaginally, once a day at bedtime for 5 days, or
  • Clindamycin cream 2% (≥45 kg and adolescent): one full applicator (5 g) intravaginally once daily at bedtime for 7 days

FOLLOW-UP RECOMMENDATIONS

• The recommended treatment regimens have excellent cure rates.
• The patient should have resolution of symptoms 3 to 5 days after starting therapy.
• Patients should abstain from intercourse until both they and their partners have been treated (after completion of a 7-day course or 7 days after a single dose regimen) to prevent reinfection.
• Women who have a specific diagnosis of chlamydia, gonorrhea, or trichomoniasis should return 3 months after treatment for repeat testing because of high rates of transmission.
• NAATs done <6 weeks following treatment may yield false-positive results because of persistence of dead organisms.
• Patients diagnosed with cervicitis should be tested for syphilis and HIV.
• Detection of an STI at follow-up is most likely the result of reexposure and reinfection.

PROGNOSIS

If treated appropriately, patients are cured and have no sequelae from the infection.

COMPLICATIONS

The patient with endocervical infection is at risk for the following:

• Reinfection
• Persistent cervicitis (if specific infection has been excluded)
  • Not usually caused by reinfection and may be related to persistent abnormality of vaginal flora, douching, exposure to chemical irritants, dysplasia
  • Potential role of M. genitalium is unclear.
• Other STIs
• Pregnancy
• Symptomatic or asymptomatic upper genital tract disease (PID), with all its sequelae:
  • Tuboovarian abscess
  • Infertility
  • Ectopic pregnancy
  • Chronic pelvic pain

ICD 10

• N72 Inflammatory disease of cervix uteri
• A54.03 Gonococcal cervicitis, unspecified
• A56.09 Other chlamydial infection of lower genitourinary tract
• A59.09 Other urogenital trichomoniasis