AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Cervicitis is an inflammation of the uterine cervix. Infectious cervicitis might be caused by Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, herpes simplex virus (HSV), or human papillomavirus (HPV). Noninfectious cervicitis might be caused by local trauma, radiation, or malignancy. The infectious etiologies are significantly more common than the noninfectious causes, and all possible infectious causes of cervicitis are sexually transmitted diseases (STDs). This article focuses on the infectious etiologies of cervicitis.

Pathophysiology

Because the female genital tract is contiguous from the vulva to the fallopian tubes, there is some overlap between vulvovaginitis and cervicitis. Vulvovaginitis and cervicitis are commonly categorized as lower genital tract infections. Infections involving the endometrium and fallopian tubes are commonly categorized as upper genital tract infections and are not discussed in this article.

Frequency

United States

The Centers for Disease Control and Prevention (CDC) estimates that 19 million STD infections occur annually, almost half of them among those aged 15-24 years. In addition to potentially severe health consequences, STDs pose a tremendous economic burden, with direct medical costs as high as $15.5 billion in a single year.

Trichomoniasis is the most common curable STD in young, sexually active women. An estimated 7.4 million new cases occur each year in women and men. In 2003, 877,478 chlamydial infections were reported to the CDC, up from 834,555 cases reported in 2002. Because many cases are not reported or even diagnosed, it is estimated that actually 2.8 million new cases of chlamydia occur each year. Gonorrhea is the second most commonly reported infectious disease in the United States, with 335,104 cases reported in 2003. Much like chlamydia, gonorrhea is believed to be underreported. An estimated 718,000 new infections occur each year.

The annual rate of infection by HSV and HPV is difficult to estimate because the vast majority of initial infections are asymptomatic or unrecognized. In the United States, seroprevalence studies show that 22% of adults have HSV type 2 antibodies, and currently, it is believed that over 500,000 new cases of genital herpes occurs annually. Approximately 20 million people are currently infected with HPV. At least 50% of sexually active men and women acquire a genital HPV infection at some point in their lives. By age 50 years, at least 80% of women will have acquired genital HPV infection. About 6.2 million Americans get a new genital HPV infection each year.

International

Worldwide, more than 400 million adults become infected with an STD every year. Four STDs that are spread primarily through sexual contact are completely curable—trichomoniasis, chlamydia, syphilis, and gonorrhea. These infections account for 333 million STD infections, or about 80% of the worldwide total. Approximately 9% of all persons aged 15-44 years in North America contract 1 of these STDs annually, but the rate rises to 25% in sub-Saharan Africa.

Worldwide, over 170 million cases of trichomoniasis are reported each year. Infection rates have been reported as high as 67% in Mongolia in 1988, 40-60% in Africa, and 40% in indigenous Australians older than age 40.

Chlamydia is the next most common STD with approximately 92 million cases a year. Prevalence of chlamydia varies enormously across the world. In the 1990s, rates amongst pregnant women in Europe ranged from 2.7% in Italy to 8.0% in Iceland, while studies in South America found rates of 1.9% amongst teenagers in Chile and 2.1% amongst pregnant women in Brazil. In Asia, rates among pregnant women tend to be much higher: up to 17% in India and 26% in rural Papua New Guinea. In Africa, studies amongst pregnant women have revealed rates from 6% in Tanzania to 13% in Cape Verde.

HPV, HSV, and gonorrhea each account for roughly 20-60 million cases of STDs per year.

The prevalence of HPV, a cause of cervical cancer, varies roughly 20-fold internationally. Among the countries evaluated, Spain had the lowest prevalence of HPV; only 1.4% of women in Spain tested positive for HPV. The highest prevalence of HPV was seen in sub-Saharan Africa; 26% of the women in Nigeria tested positive for HPV. South America tended to have rates that were in between those of Europe and sub-Saharan Africa, while rates in Asia varied widely (with the lowest rates in Hanoi, Vietnam, and the highest in India and Korea).

In a variety of studies, the seroprevalence of HSV-2 is higher in the United States (13-40%) than in Europe (7-16%), and the highest is in Africa (30-40%).

Studies of pregnant women in Africa have found rates for gonorrhea ranging from 0.02% in Gabon to 3.1% in Central African Republic and 7.8% in South Africa. In the Western Pacific in the 1990s, the highest prevalence rates (>3%) were in Cambodia and Papua New Guinea. Other areas such as China, Vietnam, and the Philippines had rates of 1% or less. Between 1995 and 1999, a significant increase in gonorrhea incidence occurred in Eastern Europe, with the highest rates in Estonia, Russia, and Belarus.

Mortality/Morbidity

Complications from untreated infectious cervicitis depend on the pathogen. Morbidity includes pelvic inflammatory disease (PID), infertility, ectopic pregnancy, spontaneous abortion, cervical cancer, premature rupture of membranes, and preterm delivery. Perinatal and neonatal infections can cause mental retardation, blindness, low birth weight, stillbirth, meningitis, and death. The social stigma is strong and might expose women to verbal, emotional, or physical abuse from others, particularly male partners.

Race

No racial predilection exists. Known risk factors include urban residence and low socioeconomic status.

Sex

Male urethritis is more often symptomatic; therefore, diagnosis is usually made earlier in males than in females. Females with cervicitis are most often asymptomatic, so they do not seek evaluation or treatment as readily.

Age

Individuals younger than age 25 and single marital status are both risk factors for cervicitis. Both biological (eg, postulated immaturity of the female reproductive tract) and behavioral factors (eg, greater number of partners, low awareness of acquired immunodeficiency syndrome (AIDS) and other STDs, and limited use of protection against STDs) are thought to contribute to this risk. Routine screening of sexually active adolescents and young adults is therefore recommended.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Gonorrhea, chlamydia, and T vaginalis infections are often asymptomatic. When present, symptoms are often nonspecific. Symptoms include increased vaginal discharge, dysuria, urinary frequency, and intermenstrual or postcoital bleeding. If the infection has been long standing, symptoms can include low abdominal or low back pain.
• Infection with HPV is frequently asymptomatic because the genital warts are often flat and internal. When the warts are raised and on the labia, perineum, or perianal area, they are called condylomata acuminata and are easily visible.
• Similarly, most patients with HSV infection are asymptomatic. However, first episode genital herpes is frequently highly symptomatic and is marked by painful ulcerations associated with fever, myalgia, headache, and general malaise. Dysuria, vaginal discharge, and urethral discharge are also common symptoms. Recurrent outbreaks of HSV tend to be milder, but most patients have prodromal symptoms of itching or tingling followed by the appearance of vesicles.
• Because many causes of cervicitis are initially asymptomatic, ask all sexually active women for their complete gynecologic and sexual history at the initial evaluation and yearly thereafter. In addition to the basic gynecologic history (eg, age of menarche, date of last menstrual period, gravida, para, pregnancy or delivery complications, date of last Papanicolaou test [Pap smear]), a complete sexual history is needed. This information includes number of recent and current partners (in the last 3 months), condom use, nonbarrier contraception use, exchanging of sex for money or drugs, and previous diagnoses of STDs. A focused review of symptoms that asks about dyspareunia, vaginal discharge, genital skin lesions, abnormal vaginal bleeding, dysuria, genital burning, genital itching, genital malodor, and lower abdominal or pelvic pain is recommended.
• In high-risk populations (eg, women with multiple partners, adolescents, women with a history of previous STDs, pregnant women), screen for gonorrhea, chlamydia, and T vaginalis infections. Screening in this population has been proven to be cost effective. Screening can be performed annually in conjunction with the Pap smear. Pap smears are not an effective screening test for STDs, vaginitis, or cervicitis; however, a significant proportion of abnormal Pap smear results indicate subclinical HPV.
• New primary cervical screening guidelines from both the American Cancer Society (ACS) and the American College of Obstetricians and Gynecologists (ACOG) include the option to screen women aged 30 years and older with an HPV test plus cervical cytology.
• Persistent infection with oncogenic HPV is the primary cause of cervical cancer and its precursor lesions. Therefore, testing for HPV can detect cervical cancer risk at an early stage. However, the usefulness of the HPV DNA test result is dependent on the age of women being screened. In women younger than age 25, HPV infection is common but mostly transient and not associated with cervical cancer risk. Therefore, HPV screening is not recommended for women younger than age 25. In contrast, in women older than age 30, a positive HPV DNA test result is mostly indicative of persistent infection, and no more than 5% tend to have a positive test result. Also, about 95% of cervical cancers occur in this age group. Therefore, finding HPV infection in this age group is considered significant regardless of Papanicolaou test results, as this is known to be associated with an increased risk of cervical cancer.
• The application of the HPV DNA test as an adjunct test in Atypical Squamous Cells of Unknown Significance (ASC-US) triage has been well established. ASC-US Papanicolaou tests account for nearly two thirds of all Papanicolaou test abnormalities reported, but, in most patients this is not a predictor of cervical cancer risk. However, 5-17% in this group could have underlying HSIL and hence the indication for further follow-up. In this context, the HPV DNA test can identify women who are at risk for cervical cancer and allow for close surveillance of those testing HPV positive.
• General screening for HSV is not recommended because no evidence demonstrates that serological tests for HSV antibody improves health outcomes or symptoms or reduces transmission of disease. However, in individuals with HIV or in partnerships with individuals infected with HSV-2, screening can be offered.

Physical

The physical examination should include a general survey; external inspection; and pelvic speculum, and bimanual examinations. In certain patients, a rectal examination should be performed.

• The physical examination is crucial to the evaluation and diagnosis of cervicitis, but do not limit the examination to the pelvic region. A survey for lymphadenopathy, skin lesions, oral lesions, joint redness or swelling, abdominal pain, and costovertebral angle tenderness can point to disseminated infection.
• The pelvic examination must be performed in a competent and sensitive manner. The presence of a nursing assistant is advised. A nursing assistant can help the examiner and act as chaperone. Always explain to the patient what is going to be done before proceeding. Begin with a neutral touch on the patient's thigh.
• • The pelvic examination begins by visually investigating the external genitalia in good lighting. Note any skin lesions (eg, warts, ulcers, vesicles, excoriations, erythema), inflammation of the Bartholin or Skene glands, or inguinal lymphadenopathy.
  • Perform the speculum examination with water or gel lubrication (eg, Surgilube or K-Y jelly), and include direct visualization of the vaginal walls and cervix. Remember that normal vaginal secretions are nonadherent to the vaginal walls, clear to white in color, and nonodorous. Normal vaginal secretions have an acidic pH of less than 4.5. Vaginitis is present if the vaginal discharge is copious, colored, and malodorous, or if the pH is greater than 4.5. Cervicitis is suspected if the cervix is erythematous, edematous, or easily friable. Classic mucopurulent cervicitis is present if thick yellow-green pus is visible in the endocervical canal (the cervical os) or on an endocervical swab specimen. Laboratory specimens are collected for study at this point. Note cervical warts or ulcerations.
  • After the speculum is removed, the bimanual examination is performed to assess tenderness or enlargement of the cervix, uterus, and adnexa. Cervicitis or pelvic inflammatory disease (PID) is suspected if the patient has cervical motion tenderness, ie, she experiences pain or tenderness while the examiner gently moves the cervix from side to side.

Causes

All of the infectious etiologies of cervicitis are STDs. Risk factors include multiple sex partners, young age, single marital status, urban residence, low socioeconomic status, and alcohol or drug use.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Pubic lice
Scabies
Retained foreign body (eg, tampon)

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Because there is overlap between the causes of vulvovaginitis and cervicitis, the initial diagnostic approaches to vulvovaginitis and cervicitis are identical. Appearance of vaginal secretions is assessed, pH of the secretions is measured, and microscopy with isotonic sodium chloride solution and 10% potassium hydroxide (KOH) is performed along with a whiff test.
• Infection with T vaginalis usually produces a thin, purulent, frothy, and malodorous discharge and can cause vulvar erythema and edema. The cervix can be erythematous and may have punctate hemorrhages (ie, strawberry cervix). The diagnosis is suggested if microscopy of cervical secretions reveals 10-30 leukocytes per oil immersion field. The diagnosis is confirmed by observation of the motile flagellated protozoan on the normal saline wet mount under the microscope.
• If cervicitis is suspected or mucopurulent cervicitis is observed, then cervical discharge is collected for Gram stain and culture.
• • The microscopic finding of gram-negative intracellular diplococci has a sensitivity of 60% and a specificity of more than 90% for gonorrhea.
  • The observation of more than 30 leukocytes per oil immersion field is highly suggestive of chlamydia and gonorrhea.
  • Although culture is still regarded as the criterion standard, many alternative techniques for the diagnosis of gonorrhea and chlamydia are available. They include enzyme immunoassay, direct fluorescent antibody staining, DNA probe, and polymerase chain reaction (PCR).
  • The advantages over conventional cultures include reduced turnaround time and lack of dependence on the complex and expensive systems needed to culture chlamydia and gonorrhea. It also possesses the ability to detect both organisms with the same sample. The main disadvantage of all the nonculture diagnostic techniques is the inability to assess microbial resistance. Nonetheless, many clinic- and hospital-based practices have already stopped using cultures and have switched to these alternative techniques.
• If genital ulcer disease is observed, exclude the diagnosis of syphilis by serologic testing.
• If typical grouped vesicles mixed with small ulcers are observed, in addition to a typical history, the diagnosis of HSV infection can be made on clinical grounds alone. For atypical ulcers or first infection, attempt definitive diagnosis by culture. Although culture is considered the criterion standard, alternative techniques (eg, cytology, antigen detection, DNA probe) are used. Serology currently has no role because of cross-reactivity between types 1 and 2 in the assays. Newer type-specific glycoprotein g1 and g2 serologic assays exist, but they are not yet for routine diagnostic use.
• If genital warts are noted, subclinical lesions can be identified after applying a 3-5% solution of acetic acid and performing magnification with colposcopy.
• While there have been more than 80 types of HPV identified, types 16, 18, 31, 33, 35, 45, 51, and 56 are associated with higher oncogenic risks, particularly cervical cancer. Currently, the United States Preventive Services Task Force (USPSTF) believes insufficient evidence exists to recommend HPV testing in women older than age 30 as an adjunct to Papanicolaou testing. However, the American College of Obstetrics and Gynecology (ACOG) and American Cancer Society (ACS) state that HPV testing should be a routine option for these women with the appropriate guidance from their health care provider.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

Treatment of all causes of cervicitis is medical. Treatment must include the patient's sexual partners to prevent reinfection. In cases of unclear diagnosis, pregnancy, or refractory infections or symptoms, consultation with an infectious disease specialist may be appropriate.

Activity

• No sexual activity for 7 days after initiating treatment
• No sexual activity until partner has been treated

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Oral antibiotics effectively cure gonorrhea, chlamydia, and T vaginalis infections. Oral antivirals reduce duration of symptoms, lesions, and viral shedding in the first and recurrent episodes of genital herpes infections. Initially, topical therapy is used for symptomatic genital wart removal. Other options include intralesional injection and surgery.

In April 2007, the Centers for Disease Control and Prevention (CDC) updated treatment guidelines for gonococcal infection and associated conditions. Fluoroquinolone antibiotics are no longer recommended to treat gonorrhea in the United States. The recommendation was based on analysis of new data from the CDC's Gonococcal Isolate Surveillance Project (GISP). The data from GISP showed the proportion of fluoroquinolone-resistant gonorrhea (QRNG) cases in heterosexual men reached 6.7%, an 11-fold increase from 0.6% in 2001. The data were published in the April 13, 2007 issue of the Morbidity and Mortality Weekly Report. This limits treatment of gonorrhea to drugs in the cephalosporin class (eg, ceftriaxone 125 mg IM once as a single dose). Fluoroquinolones may be an alternative treatment option for disseminated gonococcal infection if antimicrobial susceptibility can be documented. For more information, see the CDC's Antibiotic-Resistant Gonorrhea Web site; CDC Updated Gonococcal treatment recommendations (April 2007); or Medscape Medical News on CDC Issues New Treatment Recommendations for Gonorrhea.

Drug Category: Antibiotics

Therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting.

Drug Category: Antivirals

Nucleoside analogs are initially phosphorylated by viral thymidine kinase to eventually form a nucleoside triphosphate. These molecules inhibit HSV polymerase with 30-50 times the potency of human alpha-DNA polymerase.

Drug Category: Topical skin products

Indicated for genital/perianal warts.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Admit to hospital if disseminated infection is suspected, if the diagnosis is uncertain, or if the patient is unable to take oral medications.
• • If disseminated infection is suspected, then patients can quickly become unstable. These patients need intensive monitoring and parenteral medication.
  • If the diagnosis is uncertain, and competing diagnoses cannot be reliably excluded (eg, appendicitis, ectopic pregnancy), then further testing and monitoring is indicated.
• If the patient is unable to take oral medication because of intractable nausea, vomiting, or abdominal pain, then hospitalization for intravenous medication is warranted.

Further Outpatient Care

• In high-risk patients, consider screening for HIV, syphilis, and tuberculosis.
• In most cases, a test of cure is not necessary except in women with chlamydia. These women should be rescreened within 3 months. Also, in the case of persistent symptoms or pregnancy, follow-up testing is recommended.

Deterrence/Prevention

• The most effective way to prevent the transmission of the infective agents that cause cervicitis is to avoid sexual intercourse with infected partners. Ideally, both partners should be tested for common STDs, including HIV, before initiating a sexual relationship. If the risk of infection is unknown by testing, then use a condom for all sexual acts. Condoms are available for men and women and have been proven to decrease the transmission of many STDs, including HIV, when used appropriately and consistently.

Complications

• Untreated gonorrhea and chlamydia infections can lead to PID, which can then lead to infertility and ectopic pregnancy. Untreated T vaginalis infections have been linked to spontaneous abortions, premature rupture of membranes, and preterm delivery. Certain subtypes of HPV are linked with the development of cervical cancer. Severe cases of condyloma may obstruct the birth canal during pregnancy, resulting in the need for cesarean section. Untreated active HSV infections can cause significant perinatal and neonatal complications such as mental retardation, blindness, meningitis, and death.

Prognosis

• Gonorrhea, chlamydia, and T vaginalis infections can be cured with antibiotic therapy.
• The number of HSV outbreaks, the duration of symptoms, and the severity of symptoms can be reduced with antiviral therapy.
• External genital warts caused by infection with HPV can be controlled but not always eradicated by topical therapy and surgical therapy.

Patient Education

• Patients must understand that their infection is a preventable STD. They must ensure that all their sexual partners are also treated, or they will become reinfected. Proper use of condoms reduces the risk of infection.
• For excellent patient education resources, visit eMedicine's Women's Health Center, Pregnancy and Reproduction Center. Also, see eMedicine's patient education articles Cervicitis, Ectopic Pregnancy, Female Sexual Problems, and Pap Smear.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• In women of childbearing age, always perform a urine pregnancy test before prescribing any medication.

Special Concerns

• In a pregnant patient, referral to an infectious disease specialist may be indicated.
• In a young adolescent or child, suspect abuse and notify the proper authorities.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Anderson JR. Genital tract infections in women. Med Clin North Am. Nov 1995;79(6):1271-98. [Medline].
• CDC, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. Aug 4 2006;55(RR-11):1-94. [Medline]. [Full Text].
• CDC. Update to CDC's sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR Morb Mortal Wkly Rep. Apr 13 2007;56(14):332-6. [Medline]. [Full Text].
• Clifford GM, Gallus S, Herrero R, Muñoz N, Snijders PJ, Vaccarella S. Worldwide distribution of human papillomavirus types in cytologically normal women in the International Agency for Research on Cancer HPV prevalence surveys: a pooled analysis. Lancet. Sep 17-23 2005;366(9490):991-8. [Medline].
• Goldie SJ, Kim JJ, Wright TC. Cost-effectiveness of human papillomavirus DNA testing for cervical cancer screening in women aged 30 years or more. Obstet Gynecol. Apr 2004;103(4):619-31. [Medline].
• Griffith WF, Stuart GS, Gluck KL, Heartwell SF. Vaginal speculum lubrication and its effects on cervical cytology and microbiology. Contraception. Jul 2005;72(1):60-4. [Medline].
• Low N, Cowan F. Genital chlamydial infection. Clin Evid. Jun 2003;(9):1721-8. [Medline]. [Full Text].
• Moran J. Gonorrhoea. Clinical Evidence. 2000;3:775-780. [Full Text].
• National Institute of Allergy and Infectious Diseases - National Institutes of H. Sexually transmitted infections. [Full Text].
• Schiffman M, Khan MJ, Solomon D, Herrero R, Wacholder S, Hildesheim A. A study of the impact of adding HPV types to cervical cancer screening and triage tests. J Natl Cancer Inst. Jan 19 2005;97(2):147-50. [Medline].
• Soper DE. Sexually transmitted disease & pelvic inflammatory disease. Primary Care of Women. 1995:339-347.
• Wald A. Genital herpes. Clinical Evidence. 2000;3:756-763. [Full Text].
• Wiley DJ, Beutner K. Genital warts. Clinical Evidence. 2000;3:764-774. [Full Text].
• Wright TC Jr, Schiffman M, Solomon D, Cox JT, Garcia F, Goldie S. Interim guidance for the use of human papillomavirus DNA testing as an adjunct to cervical cytology for screening. Obstet Gynecol. Feb 2004;103(2):304-9. [Medline].

Article Last Updated: May 3, 2007