Cervicitis

Basics

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.

Risk Factors

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

Etiology

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

  • Chlamydia trachomatis
  • Neisseria gonorrhoeae
  • Herpesvirus hominis
  • Trichomonas vaginalis
  • Mycoplasma genitalium

Commonly Associated Conditions

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

  • Syphilis
  • Hepatitis B
  • HIV
  • Bacterial vaginosis

Diagnosis

History

  • Often asymptomatic
  • If symptomatic: The following symptoms are consistent with but not diagnostic of cervicitis:
    • Abnormal vaginal bleeding and/or discharge? Inflamed cervix may bleed spontaneously or following sexual intercourse.
    • Dysuria? May indicate urethritis or bladder infection
    • Vulvar itching? May be associated discharge from cervical inflammation or a coexisting vaginal infection
    • Dyspareunia? Common complaint owing to the sensitive cervix
  • 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
    • Gravity?
    • Parity?

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 herpes simplex virus (HSV).
  • Pelvic exam
    • Mucopurulent discharge from the cervical os or yellow exudative discharge present on a cotton-tipped swab from the endocervical canal: clinical evidence of cervical infection
    • No cervical motion or adnexal tenderness or masses: Pathology has not extended beyond the cervix to the upper genital tract.
    • Friability of the exocervix: easily induced bleeding from the cervical canal not to be confused with normal cervical ectopy (area of columnar epithelium around the cervical os presenting as a discrete, nonfriable, reddish circle)
ALERT
Pitfalls:
  • Failure to recognize the importance of evaluating the internal pelvic organs by physical examination with the presenting symptoms of dysuria, vaginal discharge, or abnormal menstrual bleeding in the postpubertal female
  • Imperative not to confuse normal cervical ectropion (i.e., cervical eversion) in an adolescent with cervicitis

Differential Diagnosis

  • It is helpful to consider cervicitis/vaginitis as a single disease in the evaluation process because the symptoms of these two entities are the same.
  • Inflammation of the vulva, urethra, and/or bladder, and vagina
  • In patients presenting with abnormal menstrual bleeding, these infectious causes are common.
  • 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 occurs and is primarily caused by mechanical or chemical irritation (foreign objects, latex, vaginal douches, contraceptive creams).

Diagnostic Tests and Interpretation

Initial Tests

  • Nucleic acid amplification tests done on the patient’s urine offers the least invasive method to detect Chlamydia, gonococcal, and Trichomonas infections. Cervical or vaginal swabs may also be used for nucleic acid amplification tests, provided that there is no bleeding:
    • Cervical swabs, vaginal swabs obtained by the health care provider, and urine have similar sensitivity and specificity.
    • Cervical cultures for chlamydia and gonorrhea will also identify the pathogen but require a speculum examination.
    • Identifies the pathogen, which is important for patient and partner treatment and disease surveillance
  • HSV culture if vesicular rash or ulcers are present: important to identify the cause of the ulcers for treatment and patient counseling
  • Wet preparation and vaginal pH may be helpful in diagnosing bacterial vaginosis.

Treatment

Medication (Drugs)

  • Gonorrhea
    • Ceftriaxone ≤45 kg: 50 mg/kg (max 125 mg) IM × 1, >45 kg: 250 mg IM × 1, PLUS azithromycin 20 mg/kg (max 1 g) PO, single dose or doxycycline 100 mg PO b.i.d. for 7 days. Oral cefixime is no longer recommended as first line due to resistance. If cefixime is used because ceftriaxone is not available, a test of cure is necessary.
    • Recently, noticed patterns of resistance to fluoroquinolones have caused the Centers of Disease Control and Prevention (CDC) to no longer recommend this class as first line of treatment of gonococcal cervicitis in the United States.
    • If fluoroquinolones are used, a test of cure is necessary.
  • C. trachomatis
    • Azithromycin ≥45 kg: 1 g PO, single dose, OR
    • Doxycycline 100 mg PO b.i.d. for 7 days, OR
    • Erythromycin <45 kg: 50 mg/kg/24 h (base or ethylsuccinate) PO divided q6h for 7 days; ≥45 kg: 500 mg (base) or 800 mg (ethylsuccinate) PO q.i.d. for 7 days
  • T. vaginalis
    • Metronidazole <45 kg: 45 mg/kg/24 h (max 2,000 mg/24 h) PO divided TID for 7 days; ≥45 kg: 2 g PO, single dose, OR 500 mg PO b.i.d. for 7 days, OR
    • Tinidazole >3 years old: 50 mg/kg (max 2 g) PO as a single dose
  • H. hominis
    • Acyclovir 400 mg PO t.i.d. for 7 to 10 days or until resolution, OR
    • Acyclovir 200 mg PO 5 times daily for 7 to 10 days or until resolution, OR
    • Famciclovir 250 mg PO t.i.d. for 7 to 10 days or until resolution, OR
    • Valacyclovir 1 g PO b.i.d. for 7 to 10 days or until resolution

Inpatient Consideratons

  • Patients meeting the criteria for the clinical diagnosis of cervicitis or those who have a high likelihood of infection should receive presumptive therapy for N. gonorrhoeae and C. trachomatis.
  • Treat other pathogens if clinically indicated or if documented by laboratory studies.

Ongoing Care

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 7 days after both partners have been treated to prevent reinfection.
  • Routine follow-up cultures are not necessary unless the patient remains symptomatic or in the case of pregnancy.
  • Nucleic acid amplification tests done <6 weeks following treatment may yield false-positive results because of persistence of dead organisms.
  • Detection of an STI at follow-up is most likely the result of reexposure and reinfection.

Patient Monitoring

  • Partners should be referred for evaluation and treatment if laboratory diagnosis of gonorrhea/chlamydia or Trichomonas is made.
  • Gonorrhea/chlamydia are reportable STIs.

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
  • Other STIs
  • Pregnancy
  • Symptomatic or asymptomatic upper genital tract disease (pelvic inflammatory disease), with all its sequelae:
    • Tuboovarian abscess
    • Infertility
    • Ectopic pregnancy
    • Chronic pelvic pain

Additional Reading

  1. American Academy of Pediatrics. Sexually transmitted infections in adolescents and children. In: Kimberlin DW, Brady MT, Jackson MA, et al, eds. Red Book: 2015 Report of the Committee on Infectious Diseases. 30th edition. Elk Grove, IL: American Academy of Pediatrics; 2015:177.
  2. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(RR-3):1–137.  [PMID:26042815]
  3. Centers for Disease Control and Prevention. Update to CDC’s sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR Morb Mortal Wkly Rep. 2007;56(14):332–336.  [PMID:17431378]
  4. Centers for Disease Control and Prevention. Update to CDC’s sexually transmitted diseases treatment guidelines, 2010: oral cephalosporins no longer a recommended treatment of gonococcal infections. MMWR Morb Mortal Wkly Rep. 2012;61(31):590–594.  [PMID:22874837]
  5. Committee on Adolescence and Society for Adolescent Health and Medicine. Screening for nonviral sexually transmitted infections in adolescents and young adults. Pediatrics. 2014;134(1):e302–e311.  [PMID:24982099]

Codes

ICD-9

  • 616.9 Unspecified inflammatory disease of cervix, vagina, and vulva
  • 098.15 Gonococcal cervicitis (acute)
  • 099.53 Other venereal diseases due to chlamydia trachomatis, lower genitourinary sites
  • 131.09 Other urogenital trichomoniasis

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

SNOMED

  • 37610005 inflammation of cervix (disorder)
  • 237083000 Gonococcal cervicitis (disorder)
  • 237084006 Chlamydial cervicitis (disorder)
  • 21955004 Trichomonal cervicitis (disorder)

FAQ

  • Q: How much cervical motion tenderness is present in patients with cervicitis?
  • A: None. Patients with cervicitis have inflammation and infection of the cervix only. They do not have any evidence of peritoneal inflammation on physical examination; therefore, patients with tenderness should be treated with the protocols recommended by the CDC for pelvic inflammatory disease. This does not include the use of a single dose of azithromycin.
  • Q: Which partners should be referred for treatment?
  • A: Sex partners from the preceding 60 days should be referred for evaluation and treatment. Treatment is based on documented or presumptive etiologies.
  • Q: What is the appropriate treatment for M. genitalium?
  • A: M. genitalium has clearly been implicated in the development of urethritis in males and is thought to play some role in the development of cervicitis in females (although that role is not entirely clear). Data suggests that azithromycin may be the best treatment for this infection.
  • Q: How often should asymptomatic sexually active adolescents be screened for STIs?
  • A: Sexually active men and women <25 years of age should be screened annually for STIs.

Authors

Camille Sabella, MD


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