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Author:
Jeanne Marrazzo, MD, MPH, FACP, FIDSA
Section Editors:
Robert L Barbieri, MD
Noreen A Hynes, MD, MPH, DTM&H
Deputy Editor:
Kristen Eckler, MD, FACOG
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review
process is complete.
Literature review current through: Aug 2017. | This topic last updated: May 10,
2017.
ETIOLOGY
Herpes simplex virus (HSV) and Trichomonas vaginalis account for a few cases, but
primarily affect the squamous epithelium of the ectocervix. Tuberculosis involves the
cervix in a small proportion of women with tuberculous endometritis [2]
(see "Endometritis unrelated to pregnancy", section on 'Tuberculous
endometritis'). Mycoplasma genitalium may be an important pathogen, as well; a recent
meta-analysis reported that women with M. genitalium detected at the cervix had a
significantly increased risk of cervicitis [3-7]. Bacterial vaginosis and streptococci
(group A) have also been implicated as causative agents of acute cervicitis [8-10].
Bacterial vaginosis is unlikely to be a cause of isolated cervicitis, without concurrent
vaginal findings.
CLINICAL FINDINGS
Urinary symptoms are generally due to concomitant urethral infection, which occurs in
approximately 15 percent of women with cervical chlamydia infection.
Pain and fever are atypical in the absence of upper tract infection (endometritis, PID) or
herpes simplex virus infection.
The clinical features of cervicitis caused by M. genitalium are not well-defined; some
studies suggest that the majority of cervical infections with this possible pathogen do
not elicit visible signs of inflammation [5,15,16].
DIAGNOSIS — The diagnosis of acute cervicitis is clinical and based upon the
presence of (1) purulent or mucopurulent cervical exudate and/or (2) sustained
endocervical bleeding (friability) easily induced by gently touching the area with a swab
[6,17].
Microscopy (wet prep) and vaginal pH are useful for identifying bacterial vaginosis.
Less useful - unnecessary tests — A specimen for Gram's stain can be obtained by
inserting a swab into the cervix after cleaning the ectocervix of discharge and mucus.
The presence of >10 polymorphonuclear cells per oil immersion field (ie, high power
field) is indicative of mucopurulent cervicitis and suggests chlamydia or gonorrhea
infection. However, this information is of limited value since a specific diagnosis
requires identification of an organism [13]. Furthermore, sensitivity of Gram's stain for
diagnosis of chlamydia or gonorrhea is low, the definition of a positive test has not
been standardized, and it is difficult to ensure quality control. Sensitivity of Gram's stain
for detection of endocervical gonococcal infection detected by culture or NAAT is only
50 percent [6]. For these reasons, the Gram's stain is not recommended in routine
clinical practice for evaluation of cervicitis.
Empiric therapy — Most women with cervicitis should receive empiric antibiotic
therapy at the time of initial evaluation, without waiting for results of laboratory tests,
especially if follow-up is uncertain and if a relatively insensitive diagnostic test is used
in place of NAAT.
The empiric treatment regimen for cervicitis should include coverage of chlamydia at a
minimum (see 'Gonorrhea, chlamydia, and mycoplasma'below), especially for women
≤25 years old, as the prevalence of this infection is highest in this age group. Other risk
factors for chlamydia are history of a previous chlamydial infection in the prior several
months, new or more than one sexual partner, and inconsistent use of condoms.
The Centers for Disease Control and Prevention's Sexually Transmitted Diseases
Treatment Guidelines recommend adding therapy for gonorrhea (see 'Gonorrhea,
chlamydia, and mycoplasma' below), as well, if either the individual patient's risk is high
or if the local prevalence is high [6]. The threshold prevalence that defines "high" is not
clear, but most experts agree that >5 percent is reasonable, given the consequences of
untreated infection and the ease with which treatment can be accomplished (ie, single-
dose therapy) [6,17].
Even for women who are not at apparently high risk for sexually transmitted infection,
empiric antibiotic therapy for both chlamydia and gonorrhea is reasonable if patient
follow-up of test results is a concern; the patient has risk factors for, or a recent history
of, chlamydia or gonorrhea infection; or the local prevalence of gonorrhea or chlamydia
infection is high [6].
In general, patients and their sex partners should abstain from sexual intercourse until
treatment has been completed (seven days after a single-dose regimen or after
completion of a seven-day regimen) [6]. Treatment, follow-up, and management of sex
partners depend upon the results of the diagnostic tests. (See 'Sex partners' below.)
Bacterial vaginosis — Oral or topical medication may be used (table 2). Treatment of
sexual partners is not required. (See "Bacterial vaginosis: Clinical manifestations and
diagnosis".)
Herpes simplex virus — Treatment options for herpes simplex virus infection include
(see "Treatment of genital herpes simplex virus infection"):
●Acyclovir: 400 mg orally three times per day or 200 mg PO five times per day for
7 to 10 days
●Famciclovir: 250 mg orally three times daily for 7 to 10 days
●Valacyclovir: 1000 mg orally twice daily for 7 to 10 days
Women with a foreign body/substance — For women with cervicitis that appears to
be associated with a foreign body/substance,removal/avoidance of the
foreign body/substance will often lead to resolution of inflammation. Therefore,
chemical douches, vaginal contraceptives and deodorants, and pessaries should be
discontinued and the patient followed to see if there is a therapeutic response. For
women with mild to moderate symptoms and no purulent discharge, we remove the
foreign body/substance and assess for symptom resolution before we treat with an
antimicrobial drug such as topical metronidazole or clindamycin. For women with
severe purulent vaginitis associated with a foreign body, we remove the foreign body
and treat with antibiotic treatment (oral amoxicillin or topical metronidazole or
clindamycin), although there are no data to guide the choice of drug therapy.
Inflammation on cervical cytology is also not an indication for treatment. The presence
of a few lymphocytes on cytological smears is normal and should not be misdiagnosed
as inflammation.
Test of cure (performed at one month post-treatment) for chlamydia and gonorrhea is
not required unless symptoms persist or the woman is pregnant [6]. However, repeat
testing three to six months after a diagnosis of either of these sexually transmitted
infections is recommended, given high rates of recurrent infection documented in many
populations.
For women with persistent cervicitis, some experts also advise additional coverage
aimed at vaginal anaerobes (especially if bacterial vaginosis is present); one option
is metronidazole 500 mg orally twice daily for seven days. If cervicitis resolves, no
further treatment is required.
Women whose cervicitis persists after these measures may require referral for ablative
or excisional therapy. Some gynecologists have used electrocautery, laser, or shallow
loop excision successfully to reduce persistent mucopurulent discharge unresponsive
to prolonged antibiotic courses and for which an etiology has not been determined [22].
This is clearly a solution of last resort and it is imperative that malignancy be excluded
by biopsy before any ablative treatment is undertaken.