Cervicitis overview

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Overview

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:  Prince Tano Djan, BSc, MBChB [2]

## Overview

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Cervicitis means inflammation of the tissues of the cervix. Cervicitis may be classified according to the etiology, anatomical location and disease duration, such as infectious, non-infectious, acute, subacute and chronic cervicitis. C. trachomatis or N. gonorrhea is the most common etiology of cervicitis. Cervicitis must be differentiated from other diseases that cause vaginal discharge and/or pelvic pain, such as endometritis, salpingitis, vaginitis and vulvovaginitis. Mucopurulent cervicitis is often asymptomatic, however, some patients may present with abnormal vaginal discharge, painful sexual intercourse, and intermenstrual vaginal bleeding. Common risk factors in the development of cervicitis include high-risk sexual behavior, history of sexually transmitted diseases, sexual intercourse at an early age, sexual partners who have engaged in high-risk sexual behavior or have a previous history of STDs, single marital status, urban residence, low socioeconomic status, smoking, alcohol or drug use, multiple sex partners, and bacterial vaginosis. There is no single diagnostic study of choice for the diagnosis of cervicitis. There are two major diagnostic signs that characterize cervicitis, Purulent or mucopurulent endocervical exudate visible in the endocervical canal or on an endocervical swab specimen (commonly referred to as mucopurulent cervicitis) and sustained endocervical bleeding is easily induced by gentle passage of a cotton swab through the cervical os. Cervicitis is usually asymptomatic, symptoms observed include, abnormal vaginal discharge, and/or intermenstrual vaginal bleeding (e.g., especially after sexual intercourse). Diagnosis of cervicitis is mostly clinical however, a finding of >10 WBC in vaginal fluid, in the absence of trichomoniasis, may indicate endocervical inflammation caused specifically by C. trachomatis or N. gonorrhea although culture is more accurate for gonococcal cervicitis. If left untreated, cervicitis may progress to PID with associated infertility especially in chronic cervicitis. Untreated active HSV infections in the perinatal and neonatal period may lead to neonatal morbidity. Complications that can develop as a result of infectious cervicitis include, pelvic inflammatory disease, infertility, chronic pelvic pain, ectopic pregnancy, spontaneous abortion, premature rupture of membranes and preterm delivery. Antimicrobial therapy with adequate coverage against C. trachomatis should be provided for women at increased risk for C. trachomatis or if follow-up cannot be ensured and if a relatively insensitive diagnostic test is used in place of NAAT. Recommended regimen for cervicitis, doxycycline 100 mg PO bid for 7 days. The alternative regimen includes azithromycin 1 g PO in a single dose. Patients may also require concomitant therapy against N. gonorrhea. Medical therapies include either azithromycin, doxycycline, or a fluoroquinolone. Treatment of sexual partners is also indicated. Follow-up after completion of antimicrobial therapy regimen is required to evaluate for microbial resistance.

## Historical Perspective

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Cervicitis was first described formally by Dr. Voilet I. Russell and Dr. D. Cochrane Logan in 1926 during their addresses made before the Medical Society for the Study of Venereal Diseases on January 29, 1926. Before this time, no accurate record was made about the disease in the literature.

## Classification

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Cervicitis may be classified according to the etiology, anatomical location and disease duration, such as infectious, non-infectious, acute, subacute and chronic cervicitis. The infectious causes are gonococcal, C. trachomatis and herpes. Examples of the non-infectious causes are traumatic injury to the cervix, chemical exposure, douching, latex, contraceptive creams, systemic inflammation (e.g. Behcet syndrome), as well as radiation exposure.

## Pathophysiology

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The pathophysiology of cervicitis depends on the etiological agent and the physiological state of the patient. Under the influence of estrogen, the normal vaginal epithelium cornifies, making it somewhat resistant to infectious agents. The endocervix is lined by columnar epithelium which is susceptible to infectious agents leading to cervicitis. Gonococcal cervicitis results after the exposure of the cervix to N. gonorrhea in seminal fluid during sexual intercourse. N. gonorrhea infectivity is facilitated by type IV pilus-mediated motility of the bacterium. In the presence of seminal fluid, the bacterial motility is characterized by high velocity, low directional persistence and enhanced microcolony formation. Once the pili are attached, local inflammation results from the release of neutrophilic cytokines, leading to purulent or mucopurulent discharge. C. trachomatis infection is often associated with intense lymphocytic and neutrophilic inflammatory reactions in the affected areas, and is occasionally associated with follicular aggregation of lymphocytes. The chronic course of chlamydial cervicitis is associated with low content of cytokines, mainly IL-1α, IL-1β, and TNFα, and an elevated concentration of IL-8 in the pathogenesis.

## Causes

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Cervicitis is caused by infectious and non-infectious causes. The infectious causes are most commonly caused by chlamydia and gonorrhea, with chlamydia accounting for the majority of cases. Trichomonas vaginalis and herpes simplex (especially primary HSV-2 infection), or M. genitalium are less common causes of cervicitis. Non-infectious causes of cervicitis include: intrauterine devices, contraceptive diaphragms, and allergic reactions to spermicides or latex condoms.

## Differentiating Cervicitis from Other Diseases

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Cervicitis must be differentiated from other diseases that cause vaginal discharge and/or pelvic pain, such as endometritis, salpingitis, vaginitis and vulvovaginitis.

## Epidemiology and Demographics

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The incidence and prevalence of cervicitis depends on the study population.The prevalence of cervicitis is estimated to be 18,000 per 100,000 women diagnosed with gonococcal infection. The prevalence of cervicitis ranges from 7,600 to 24,900 per 100,000 female sex workers. The broad range is due to variation in demographic location. Cervicitis is relatively more prevalent in HIV-positive women than non-HIV positive women. Among this population, the prevalence of cervicitis is estimated to be 7,400 per 100,000 women diagnosed with HIV infection. Screening and treatment of M. genitalium among HIV-infected individuals may be needed to improve cervical health and reduce morbidity. The overall prevalence of nongonococcal cervicitis is higher than gonococcal cervicitis. Chlamydia cervicitis is four to five times more prevalent than gonococcal cervicitis. However, co-infection of gonococcal and chlamydia cervicitis is higher in PID than in cervicitis. Cervicitis commonly follows the pattern of age prevalence of sexually transmitted infections with the highest incidence among women aged 15-24. There is no racial predilection to developing cervicitis. The prevalence of cervicitis is higher in under-served communities and developing countries.

## Risk Factors

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Common risk factors in the development of cervicitis include high-risk sexual behavior, history of sexually transmitted diseases, sexual intercourse at an early age, sexual partners who have engaged in high-risk sexual behavior or have a previous history of STDs, single marital status, urban residence, low socioeconomic status, smoking, alcohol or drug use, multiple sex partners, and bacterial vaginosis.

## Screening

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Screening for the infectious causes of cervicitis are recommended according to the 2015 Sexually Transmitted Diseases Treatment Guidelines by the CDC. Screening for chlamydia and gonorrhea is recommended in sexually active women under 25 years of age, sexually active women aged 25 years and older if at increased risk, all pregnant women under 25 years of age, and pregnant women aged 25 and older if at increased risk.

## Natural History, Complications, and Prognosis

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If left untreated, cervicitis may progress to PID with associated infertility especially in chronic cervicitis. Untreated active HSV infections in the perinatal and neonatal period may lead to neonatal morbidity. Complications that can develop as a result of infectious cervicitis include, pelvic inflammatory disease, infertility, chronic pelvic pain, ectopic pregnancy, spontaneous abortion, premature rupture of membranes and preterm delivery.

## Diagnosis

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### Diagnostic Study of Choice

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There is no single diagnostic study of choice for the diagnosis of cervicitis. There are two major diagnostic signs that characterize cervicitis, Purulent or mucopurulent endocervical exudate visible in the endocervical canal or on an endocervical swab specimen (commonly referred to as mucopurulent cervicitis) and sustained endocervical bleeding is easily induced by gentle passage of a cotton swab through the cervical os. Cervicitis is usually asymptomatic, symptoms observed include, abnormal vaginal discharge, and/or intermenstrual vaginal bleeding (e.g., especially after sexual intercourse).

### History and Symptoms

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Mucopurulent cervicitis is often asymptomatic, however, some patients may present with abnormal vaginal discharge, painful sexual intercourse, and intermenstrual vaginal bleeding.

### Physical Examination

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Two major diagnostic signs that characterize cervicitis, include, a purulent or mucopurulent endocervical exudate visible in the endocervical canal or on an endocervical swab specimen (commonly referred to as mucopurulent cervicitis or cervicitis) and sustained endocervical bleeding easily induced by gentle passage of a cotton swab through the cervical os. Either or both signs might be present.

### Laboratory Findings

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Diagnosis of cervicitis is mostly clinical however, a finding of >10 WBC in vaginal fluid, in the absence of trichomoniasis, may indicate endocervical inflammation caused specifically by C. trachomatis or N. gonorrhea although culture is more accurate for gonococcal cervicitis. The use of nucleic acid amplification tests is very helpful for the diagnosis of trichomoniasis. Wet mount microscopy and direct visualization have low sensitivity in detecting N. gonorrhea and T. vaginalis, because of this symptomatic women with cervicitis and negative microscopy should receive further testing (i.e., culture or other FDA-cleared methods). Although HSV-2 infection has been associated with cervicitis, the utility of specific testing (i.e., culture or serologic testing) for HSV-2 is unknown. DNA amplification techniques have good sensitivity but are not yet approved for diagnostic purposes of Trichomoniasis.

### Electrocardiogram

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There are no ECG findings specific for cervicitis.

### X Ray

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There are no x-ray findings associated with cervicitis.

### CT

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There are no CT scan findings associated with cervicitis.

### MRI

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There are no MRI findings associated with cervicitis.

### Ultrasound

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Ultrasound is not needed in diagnosing cervicitis, however, when complicated by PID, it may be helpful.

### Other Imaging Findings

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There are no other imaging findings of cervicitis.

### Other Diagnostic Studies

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There are no other diagnostic studies for cervicitis.

## Treatment

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### Medical Therapy

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Antimicrobial therapy with adequate coverage against C. trachomatis should be provided for women at increased risk for C. trachomatis or if follow-up cannot be ensured and if a relatively insensitive diagnostic test is used in place of NAAT. Recommended regimen for cervicitis, doxycycline 100 mg PO bid for 7 days. The alternative regimen includes azithromycin 1 g PO in a single dose. Patients may also require concomitant therapy against N. gonorrhea. Medical therapies include either azithromycin, doxycycline, or a fluoroquinolone. Treatment of sexual partners is also indicated. Follow-up after completion of antimicrobial therapy regimen is required to evaluate for microbial resistance.

### Surgery

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Surgical intervention is unnecessary in the management of cervicitis.

### Primary Prevention

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Effective measures for the primary prevention of cervicitis include avoidance of the risk factors of cervicitis click here.

### Secondary Prevention

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Secondary prevention strategies of cervicitis include early diagnosis and treatment of patients with sexually transmitted infections especially gonorrhea and chlamydia.

## References

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