Cervicitis

OVERVIEW: What every practitioner needs to know

Are you sure your patient has cervicitis? What should you expect to find?

Most patients with cervicitis are asymptomatic, however, a vaginal discharge may occur which tends to be malodorous and mucopurulent in nature.
When infection or inflammation is confined to the cervix, no symptoms or signs of vaginal inflammation or vulvar disease are evident.
The cervix is never sterile and therefore culture will always reveal organisms.

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Mucopurulent cervicitis is characterized by frankly purulent discharge originating from the endocervix.
The cervix as visualized reveals swelling, erythema, and alterations in the normal smooth appearance.
On Q-tip palpation, cervical friability is observed and bleeding is easily induced.
In the presence of complicating pelvic inflammatory disease, cervical excitation and adnexal tenderness are evident together with lower abdominal manifestations of pelvic peritonitis.

Beware: there are other diseases that can mimic cervicitis:

Noninfectious cervicitis- a physiologic alteration in the cervix occurs with cervical ectopy or cervical ectropium. Under these circumstances, the transition zone, which represents the junction between normal columnar epithelium lining the endocervical canal and stratified squamous epithelium that covers the rest of the ectocervix, undergoes transformation. Under these circumstances, the thin endocervical columnar lining migrates externally to cover areas of the visible cervix making it appear that the cervix is infected.

These patients receive repeated unnecessary courses of antibiotics.

Cervical ectopy in its mildest form is extremely common and is of unknown etiology although most frequently seen in women using oral contraceptives.

It is invariably asymptomatic, not associated with the cervical or vaginal discharge or any other symptoms.

There is no known treatment for cervical ectopy and even when extensive, is not amenable to antimicrobial therapy.

The extensive ectropion which is occasionally seen is often called pseudo-inflammatory cervicitis and is best treated by ablative techniques by gynecologists who specialize in cervical diseases.

What laboratory studies should you order and what should you expect to find?

Results consistent with the diagnosis

A Gram stain of the inflamed cervix reveals a marked increase in polymorphonuclear leucocytes (PMN).

Results that confirm the diagnosis

Mucopurulent cervicitis is diagnosed on the basis of its clinical appearance, and the purulent appearance on an endocervical swab. The two most common causes of mucopurulent cervicitis are chlamydia trachomatis and neisseria gonorrhoeae.
These two pathogens are easily diagnosed. Culture is no longer routinely used for diagnosis, but has been replaced by usually by DNA probes or polymerase chain reaction (PCR) technology.
For screening, urine can be used for PCR testing with a sensitivity of 98-100%. A positive screening test mandates treatment. Nevertheless, a positive screening test from urine does not replace evaluation of the cervix.

What imaging studies will be helpful in making or excluding the diagnosis of cervicitis?

No imaging is necessary

What consult service or services would be helpful for making the diagnosis and assisting with treatment?

Most patients are managed by emergency department physicians, primary care physicians, and gynecologists
More complicated or recurrent cases should be referred to an infectious diseases physician expert in these infections

If you decide the patient has cervicitis, what therapies should you initiate?

Most patients with symptomatic or asymptomatic cervicitis are seen and treated by gynecologists, primary care practitioners or sexually transmitted disease (STD) specialists who routinely and frequently treat women for cervicitis for Neisserria gonorrhoeae (GC), chlamydia and less frequently M. genitalium. Infectious disease specialists are likely to be consulted for antibiotic advice for M. genitalium and for persistent or recurrent cervicitis. In principle, these practitioners will, of necessity, institute antimicrobial therapy based upon clinical diagnosis of asymptomatic or symptomatic cervicitis before receiving laboratory diagnostic confirmation. CDC recommendations for aforementioned pathogens are described in the STD guidelines.
Management of recurrent disease invariably requires retesting and retreatment of GC and Chlamydia using conventional doses based upon high likelihood of reinfection, including treatment of sexual partners.
The majority of persistent cases of “cervicitis” is not caused by relapse or reinfection with Chlamydia or N. gonorrhoeae or other microbial pathogens but are the result of non-infectious idiopathic inflammation.

2. Other key therapeutic modalities.

Management of recurrent disease invariably requires retesting and retreatment of GC and Chlamydia using conventional doses based upon high likelihood of reinfection, including treatment of sexual partners.

What pathogens are responsible for this cervicitis?

The two most common causes of mucopurulent cervicitis are:

Chlamydia trachomatis

Neisseria gonorrhoeae
Genital herpes, HSV type 2 can cause acute cervicitis with local minor ulceration which although usually asymptomatic, may result in a vaginal discharge. As with other forms of genital herpes, local pathological involvement with signs of inflammation is usually self-limited lasting weeks for the first episode and days for subsequent recurrences. Genital herpes should not be considered a differential diagnosis of chronic cervicitis.
Another pathogen which is now being recognized as a cause of cervicitis is Mycoplasma genitalium. This recently recognized pathogen is capable of causing cervical disease and is now considered a pathogen in the development of pelvic inflammatory disease and urethritis. It is considered to be a less frequent causal pathogen and available testing is not widespread. Most testing today similarly relies on nucleic acid amplification methodology.
Rarely other viruses such as EBV, CMV virus can, in addition to HSV may be isolated from the cervix, but are not considered important causes of cervicitis.
In some cases an infectious agent cannot be identified indicating that there is an incomplete knowledge of the cause of cervical inflammation.

How can cervicitis be prevented?

There are no vaccines available
Prophylactic antibiotics play no role in preventing cervicitis

WHAT'S THE EVIDENCE for specific management and treatment recommendations?

Gaydos, C, Maldeis, NE, Hardick, A, Hardick, J, Quinn, TC. “Mycoplasma genitalium as acontributor to the multiple etiologies of cervicitis in women attending sexually transmitted disease clinics”. Sex Transm Dis. vol. 36. 2009. pp. 598-606.

Marrazzo, JM, Martin, DH. “Management of women with cervicitis”. Clin Infect Dis. vol. 44. 2007. pp. S102-10.

Mena, LA, Mroczkowski, TF, Nsuami, M, Martin, DH. “A randomized comparison of azithromycin and doxycycline for the treatment of Mycoplasma genitalium-positive urethritis in men”. Clin Infect Dis. vol. 48. 2009. pp. 1649-54.

Paavonen, J, Critchlow, CW, DeRouen, T, Stevens, CE, Kiviat, N, Brunham, RC, Stamm, WE, Kuo, CC, Hyde, KE, Corey, L. “Etiology of cervical inflammation”. Am JObstet Gynecol. vol. 154. 1986. pp. 556-64.

Rodrigues, MM, Fernandes, PÁ, Haddad, JP, Paiva, MC, Souza Mdo, C, Andrade, TC, Fernandes, AP. “Frequency of Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, Mycoplasma hominis, and Ureaplasma species in cervical samples”. J Obstet Gynaecol. vol. 31. 2011. pp. 237-41.

Schwebke, JR, Weiss, HL. “Interrelationships of bacterial vaginosis and cervical inflammation”. Sex Transm Dis. vol. 29. 2002. pp. 59-64.

Workowski, KA, Berman, S. “Centers for Disease Control and Prevention (CDC): Sexually transmitted diseases treatment guidelines”. MMWR Recomm Rep. vol. 59. 2010. pp. 1-110.

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