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 inflammation of the cervix. Patients usually present with cervical erythema and discharge.

Pathophysiology

Cervicitis is caused by a sexually transmitted bacterial infection. Infection of the cervix results in inflammation and may be accompanied by vulvovaginitis. Mucopurulent cervicitis is a clinical diagnosis, one typically characterized by friability of the cervix, mucopurulent discharge from the os, and increased numbers of polymorphs in endocervical secretions.¹ An ascending infection can cause endometritis, salpingitis, tuboovarian abscess, or perihepatitis.

Frequency

United States

In the United States, the prevalence of chlamydial infection is 5-15% in sexually active teenagers and young adults, who are asymptomatic.² The prevalence increases to almost 50% in symptomatic patients; however, the incidence of gonorrhea has declined steadily over the last 20 years.³ Adolescents and young adults continue to have the highest rates of infection, with a transmission risk of 20-50% per sexual contact. The incidence of co-infection with both gonorrheal and chlamydial organisms may be 15-20%.

International

Chlamydia trachomatis is the most prevalent bacterial pathogen that causes sexually transmitted infections worldwide. According to the World Health Organization (WHO), 50-70 million cases occur each year.

Mortality/Morbidity

Primary morbidity results from ascending infection to the uterus and fallopian tubes (pelvic inflammatory disease) that leads to chronic abdominal pain and infertility.

Age

Compared with older populations, sexually active adolescents and young adults have a higher incidence of both chlamydial and gonococcal cervicitis.

CLINICAL

Section 3 of 10  

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

History

Elicit the patient's history of sexual activity, number of sexual partners, and type of contraception used (if any). An increased incidence of chlamydial cervicitis in women has been associated with use of oral (PO) contraceptives.

• Most patients with cervicitis present with vaginal discharge or vaginal bleeding.
• Other associated symptoms include dyspareunia and dysuria.
• Abdominal pain and fever are associated with involvement of the upper genital tract.
• Patients with mild cervicitis may be asymptomatic, and many patients with chlamydial cervicitis are asymptomatic.

Physical

Upon physical examination, findings in the cervix include the following:

• Erythematous and inflamed cervix on speculum examination (Possible edema of the cervical ectropion may be noted.)
• Possible purulent discharge from the cervical os
• Cervix tender to palpation

Causes

• Gonorrheal and chlamydial infections
• • The most common causative organisms are Neisseria gonorrhea and C trachomatis.
  • Gonococcal and chlamydial cervicitis may be associated with upper genital tract infection.
  • Patients with gonorrhea may have associated urethritis.⁴
  • Patients with chlamydial infections are often asymptomatic.
• Other bacterial pathogens: Other bacterial pathogens implicated in cervicitis and upper genital infections include Mycoplasma genitalium, Ureaplasma urealyticum, and anaerobes, such as Streptococcus, Peptostreptococcus, and Bacteroides species. Other sexually transmitted infections, such as those caused by Trichomonas species and herpes simplex virus, also may be associated with cervicitis.
• • Trichomonas infection may result in a friable cervix with prominent papillae and punctate hemorrhages (ie, strawberry cervix). Although an uncommon finding, Trichomonas vaginalis is known to cause multiple punctate hemorrhages and swollen papillae in the cervix, giving it a strawberry appearance. This causes the cervix to become friable and bleed easily on touch.
  • Herpetic cervicitis may be associated with multiple ulcerations.

DIFFERENTIALS

Section 4 of 10  

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

Other Problems to be Considered

Other causes of vaginal discharge

Physiologic leukorrhea
Vaginitis
Vaginal foreign body
Cervical ectropion
Bacterial vaginosis

Consider associated pelvic inflammatory disease, perihepatitis, or both.

Consider sexual abuse if gonococcal or chlamydial cervicitis is detected in the prepubertal child.

WORKUP

Section 5 of 10  

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

Lab Studies

• Traditional tests
• • Wet mount of the discharge usually demonstrates more than 5 WBCs per high-power field. Most practice guidelines recommend a threshold of 10-30 polymorphonuclear (PMN) leukocytes per high-power field to support the diagnosis of mucopurulent cervicitis. However, inflammation alone is not considered presumptive evidence of chlamydial infection.
  • Gram stains of the cervical mucopus may reveal gram-negative intracellular diplococci in cases of gonorrhea. Culturing in modified Thayer-Martin medium is the criterion standard for confirming gonorrhea.
  • Enzyme-linked immunosorbent assay or direct fluorescent antibody testing is often used to detect chlamydial infection. DNA probes with 90-97% sensitivity are also available for the simultaneous detection of gonococcal and chlamydial organisms.
  • When indicated, chlamydial cultures are performed on McCoy cells (evaluations in prepubertal children in whom sexual abuse is suspected, testing response to therapy in a previously treated infection).
• Newer tests
• • Several highly specific and sensitive tests have been developed. These nucleic acid amplification tests (NAATs) include the polymerase chain reaction (PCR), the ligase chain reaction (LCR),⁵ and transcription-mediated amplification (TMA). Probes used in these tests are at least 20% more sensitive than the earlier DNA probes and are the tests of choice.
  • PCR and LCR testing consists of amplification of specific DNA sequences, while TMA testing is an RNA amplification assay.
  • Although endocervical specimens are preferred, these tests may be easily performed on first-void morning urine samples. Urine NAATs are highly sensitive for the diagnosis of endocervical chlamydial infection.

Other Tests

• Because of the possible association between bacterial vaginosis and mucopurulent cervicitis, perform NAATs and look for Amsel criteria for the diagnosis of bacterial vaginosis
• Three of the following 4 criteria suffices:
• • Homogenous vaginal discharge
  • Vaginal fluid pH greater than 4.5
  • Clue cells greater than 20% of total vaginal epithelial cells on 100X magnification
  • Amine odor on addition of potassium hydroxide to vaginal fluid

TREATMENT

Section 6 of 10  

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

Medical Care

• Establishing the etiologic agent is a key to successful treatment (see Medication).
• Ensuring that the patient's sexual contacts receive the appropriate examination and treatment is also essential.
• Most treatment failures are actually reinfections from an untreated sexual partner.

Activity

Advise patients to abstain from sexual activity until test results after therapy are negative and partners are treated. Advise them to use condoms when they resume sexual activity.

MEDICATION

Section 7 of 10  

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

The Centers for Disease Control and Prevention (CDC) revised their treatment guidelines for sexually transmitted diseases in 2006.⁶ Therapy for cervicitis depends on the etiologic agent. Ceftriaxone is the recommended drug for gonorrhea; doxycycline is recommended for chlamydial cervicitis. Other effective antibiotics for treatment of gonorrheal disease include cefixime 400 mg. All are administered as single PO doses. For chlamydial infections, azithromycin 1 g PO as a single dose is an acceptable alternative to doxycycline 100 mg PO bid for 7 days.

Alternatives for patients presenting with ceftriaxone allergy include spectinomycin, ciprofloxacin, or norfloxacin. Fluoroquinolones are not approved by the US Food and Drug Administration (FDA) for use in children younger than 18 years and are no longer recommended for gonorrhea in the United States because of increased resistance. Erythromycin is recommended for patients with chlamydial infections who are unable to take doxycycline. A single dose of azithromycin 1 g PO is also highly effective for treatment of chlamydial disease. If a patient has clinical cervicitis, both ceftriaxone and azithromycin are recommended as empirical treatment. Acyclovir may be used for primary herpes infection, but it is not curative, and recurrences are common. Metronidazole is the drug of choice for infection by Trichomonas organisms.

Drug Category: Antibiotics

Testing to determine the specific microorganism causing the infection is recommended because both chlamydial and gonococcal infections are reportable to state health departments. If diagnostic tools (eg, Gram stain, microscope) are unavailable, treat patients for both infections.

FOLLOW-UP

Section 8 of 10  

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

Further Outpatient Care

• Gonococcal cultures are recommended 4-8 weeks after standard treatment or one week after alternative regimens are used.
• Routine testing for chlamydial eradication is not indicated after treatment; however, repeat testing may be worthwhile after 1-2 months in patients with a high risk of reinfection to identify inadequate treatment of their partners or new infections.
• Routine annual screening for chlamydial infection is recommended in all sexually active adolescents because of the high prevalence of asymptomatic females.
• Treat sexual partners.

Complications

• Ascending infection
• Arthritis, rash, or both (from disseminated gonorrhea)

Prognosis

• The prognosis is excellent when the patient is compliant.

Patient Education

• Instruct patients to avoid sexual intercourse until treatment efficacy is confirmed.
• Instruct patients how to prevent reinfection by using condoms.
• Recommend prevention counseling to patients with sexually transmitted infections.
• Recommend that patients receive screening for other diseases, including HIV infection and syphilis.
• For excellent patient education resources, visit eMedicine's Women's Health Center. Also, see eMedicine's patient education article Cervicitis.

MISCELLANEOUS

Section 9 of 10  

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

Special Concerns

• Adolescent compliance with the recommended regimen is a notable concern.
• A single dose of azithromycin 1 g PO is effective therapy for chlamydial infections and eliminates the need for ongoing treatment compliance.
• Isolation of gonococci in cervical or vaginal secretions in a child is definitive evidence of sexual abuse.

REFERENCES

Section 10 of 10

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

1. Marrazzo JM. Mucopurulent cervicitis: no longer ignored, but still misunderstood. Infect Dis Clin North Am. Jun 2005;19(2):333-49, viii. [Medline].
2. Darville T. Chlamydia. Pediatr Rev. Mar 1998;19(3):85-91. [Medline].
3. Darville T. Gonorrhea. Pediatr Rev. Apr 1999;20(4):125-8. [Medline].
4. Simpson T, Oh MK. Urethritis and cervicitis in adolescents. Adolesc Med Clin. Jun 2004;15(2):253-71. [Medline].
5. Smith KR, Ching S, Lee H, et al. Evaluation of ligase chain reaction for use with urine for identification of Neisseria gonorrhoeae in females attending a sexually transmitted disease clinic. J Clin Microbiol. Feb 1995;33(2):455-7. [Medline].
6. 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].
7. 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].
8. Sexually transmitted diseases: gonorrhea, Chlamydia trachomatis, pelvic inflammatory disease and syphilis. In: Emans SJ, Laufer MR, Goldstein DP, et al, eds. Pediatric and Adolescent Gynecology. 4^th ed. Philadelphia, PA: Lippincott-Raven; 1998:457-504.
9. Rome ES. Sexually transmitted diseases: testing and treating. Adolesc Med. Jun 1999;10(2):231-41, vi. [Medline].
10. Stuart GS, Castano PM. Sexually transmitted infections and contraceptives: selective issues. Obstet Gynecol Clin North Am. 30(4):795-808. [Medline].

Article Last Updated: Mar 6, 2008