Cervicitis

Cervicitis is the inflammation of the cervix. Cervicitis is most commonly caused by infection (e.g., with Chlamydia trachomatis or Neisseria gonorrhoeae); noninfectious causes include cervical dysplasia and mechanical or chemical irritation. Patients are often asymptomatic but may present with vaginal discharge, abnormal vaginal bleeding, dyspareunia, or pelvic pain. Cervicitis is a clinical diagnosis, based on gynecologic examination findings of mucopurulent or purulent endocervical discharge and a friable cervix. In isolated cervicitis, clinical features of pelvic inflammatory disease (PID) and diagnostic criteria for PID are absent. Initial diagnostic studies include evaluation for STIs. Treatment consists of empiric antibiotic therapy for individuals with risk factors for STIs; individuals without risk factors for STIs are treated with antibiotics if diagnostic testing confirms an infectious cause. Patients with no evidence of infection should be referred to gynecology for further evaluation. Untreated cervicitis can lead to PID, in which the infection spreads beyond the cervix to the upper female reproductive tract (i.e., the uterus, fallopian tubes, and ovaries) and/or peritoneal cavity.

• Infectious: (most common): C. trachomatis, N. gonorrhoeae, HSV-2 , Trichomonas vaginalis ^[1]
• Noninfectious ^[1][2]
  • Mechanical irritation (e.g., cervical caps, contraceptive diaphragms, tampons)
  • Chemical irritation (e.g., contraceptive creams, latex exposure)
  • Cervical dysplasia or polyps

Risk factors ^[1]

• Young age (< 25 years)
• Multiple sexual partners
• New sexual partner
• Unprotected intercourse

Cervicitis is often asymptomatic. Clinical features may include: ^[1][3]

• Vaginal discharge: may be purulent, blood-tinged, and/or malodorous
• Postcoital or intermenstrual bleeding
• Dyspareunia
• Lower abdominal or pelvic pain
• Symptoms of the underlying condition (e.g., genital lesions in HSV infections)

Fever is not a typical symptom of cervicitis; presence of fever should raise suspicion for PID. ^[1]

Clinical evaluation ^[1]

Isolated cervicitis is diagnosed clinically, based on both of the following.

• Presence of ≥ 1 of the following findings on speculum examination:
  • Mucopurulent or purulent discharge in the endocervical canal or on an endocervical swab
  • Erythematous, edematous, friable cervix
• Absence of both:
  • Clinical features of PID
  • Diagnostic criteria for PID (e.g., cervical motion tenderness) on bimanual pelvic exam

Abdominal tenderness and cervical motion tenderness are not characteristic of isolated cervicitis and suggest that infection has ascended, causing concomitant PID.

Laboratory studies ^[1]

• Vaginal or cervical swab testing
  • NAAT for N. gonorrhoeae and C. trachomatis
  • Wet mount preparation to evaluate for:
    • WBCs (leukorrhea)
    • Trichomoniasis
    • Bacterial vaginosis
  • If wet mount is negative for Trichomoniasis, obtain NAAT or culture for Trichomoniasis. ^[1]
  • Consider diagnostics for Mycoplasma genitalium infection.
• Test all patients with cervicitis for HIV and syphilis.

Cervicitis is unlikely if < 10 WBCs/HPF are seen on microscopic evaluation of vaginal fluid (wet mount). ^[1]

Approach ^[1]

If presentation is concerning for PID, provide treatment for PID.

• Treat with empiric antibiotic therapy for cervicitis if:
  • Patient has risk factors for STIs
  • There is concern for poor follow up
  • NAAT testing could not be done
• All other patients: Consider waiting for diagnostic test results.
  • If positive, treat with appropriate therapy based on the causative agent. See:
    • “Treatment of genital chlamydia”
    • “Treatment of gonorrhea”
    • “Treatment” in “Trichomoniasis”
  • If negative, refer to gynecology for evaluation for non-infectious causes.
• For patient's sexual partners from the preceding 60 days, recommend:
  • STI testing
  • Presumptive treatment for chlamydia, gonorrhea, and/or trichomoniasis based on patient's test results
• Advise abstinence from sexual intercourse until patient and partner have completed treatment and are asymptomatic.
• After completion of treatment, follow up to evaluate for symptom resolution.

Cervicitis is not an indication for IUD removal, but a new IUD should not be placed in patients with active cervicitis. ^[1]

Empiric antibiotic therapy for cervicitis ^[1]

• Doxycycline (preferred) OR azithromycin (alternative)
• Consider empiric coverage for N. gonorrhoeae with ceftriaxone based on community prevalence and patient risk factors.

Further management ^[1]

• If the patient tested positive for chlamydia, gonorrhea, and/or trichomoniasis, repeat testing in 3 months.
• For persistent symptoms or recurrent cervicitis:
  • Evaluate for:
    • New exposures (reinfection)
    • Treatment nonadherence
    • Treatment failure (check cultures for antimicrobial resistance).
  • Consider diagnostics for Mgen infection and treat appropriately (see “Treatment of Mgen infection”).
  • If no infectious cause is identified, refer to gynecology to evaluate for noninfectious causes (e.g., cervical dysplasia, polyps).

Pathogens that cause cervicitis can ascend to the upper female reproductive tract and result in PID.

We list the most important complications. The selection is not exhaustive.