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Acute cervicitis

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.

INTRODUCTION — Cervicitis refers to inflammation of the uterine cervix. The


inflammation primarily affects the columnar epithelial cells of the endocervical glands,
but can also affect the squamous epithelium of the ectocervix. It may be due to an
infectious or noninfectious etiology and may be acute or chronic. Acute cervicitis is
usually due to infection (eg, chlamydia, gonorrhea), although a specific infection cannot
be determined in a large proportion of cases. Chronic cervicitis usually has a
noninfectious source.

SIGNIFICANCE — Cervical infection is clinically important because it can ascend and


cause endometritis or pelvic inflammatory disease (PID); the pathogens involved can
be transmitted to sexual partners; and, in pregnant women, it may cause
pregnancy and/or neonatal complications as a result of infection of the fetus, placenta,
amniotic fluid, decidua, or membranes. In addition, cervicitis appears to be associated
with a significant increase in risk of HIV-1 acquisition and shedding [1]. Sequelae of
PID include chronic pelvic pain, infertility, and an increased risk of ectopic pregnancy.
(See "Long-term complications of pelvic inflammatory disease".)

ETIOLOGY

Infection — When an infectious etiology can be documented, Chlamydia trachomatis


(typically serovars D-K) and Neisseria gonorrhoeae are the most common organisms
identified, even though a relatively small proportion of women with these infections
develop cervicitis. Chlamydial cervicitis occurs more often than gonococcal, and both
primarily affect the columnar epithelium of the endocervix.

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.

Mycoplasma hominis, Ureaplasma urealyticum, and group B beta-hemolytic


streptococci are commonly found in the genital tract, but there is little evidence that
they cause cervicitis [11,12]. Case reports have described cervicitis associated with
other infectious agents (bacteria, viruses, fungi, parasites).

There is no evidence that human papillomavirus infection (HPV) induces cervical


inflammation, but it can cause other histologic changes (eg, cervical intraepithelial
neoplasia).

Noninfectious causes — Noninfectious cervicitis is usually caused by mechanical or


chemical irritation. Sources of mechanical irritation include trauma from surgical
instruments or foreign objects (eg, pessary, diaphragm, tampon, cervical cap).
Chemical irritation can be caused by exposure to latex, vaginal douches, or
contraceptive creams. Radiation therapy and systemic inflammatory disease (Behçet's
syndrome) are other noninfectious sources of cervicitis.

CLINICAL FINDINGS

Signs and symptoms — A significant proportion of women with cervicitis are


asymptomatic. Cervicitis in these women may be detected incidentally during physical
examination.

When present, symptoms are often nonspecific. All women have:

●Purulent or mucopurulent vaginal discharge and/or


●Intermenstrual or postcoital bleeding

Some women also have one or more of the following:

●Dysuria, urinary frequency


●Dyspareunia
●Vulvovaginal irritation

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.

Physical examination — Purulent or mucopurulent discharge on the


ectocervix and/or exuding from the endocervical canal is a cardinal finding of acute
cervicitis (picture 1) [13]. Minor trauma from insertion of a cotton or Dacron swab
frequently precipitates bleeding (friability), and is another cardinal sign [13]. In addition,
the cervix may appear erythematous and edematous. On physical examination, the
cervix may be tender to motion (a nonspecific sign suggestive of coexistent PID).
The cervical appearance varies, depending upon the severity of infection and the
infecting organism. The quantity of cervical organisms correlates with the degree of
inflammation. Mucopurulent cervical discharge, cervical friability, and edema in the
zone of ectopy are characteristic of both gonococcal and chlamydial cervicitis. The
presence of one or more of these signs is more predictive of gonorrhea or chlamydia
infection in younger compared to older women (one in three women <25 years infected
versus 1 in 6 to 11 women >25 years) [13].

Diffuse vesicular lesions/ulceration suggest HSV infection, while punctate hemorrhages


("strawberry cervix" or colpitis macularis) are characteristic of T. vaginalis infection;
erosive inflammation and hemorrhagic lesions can occur with both infections. Primary
HSV infection is often associated with systemic symptoms, as well. Subclinical HSV
shedding is not typically associated with cervicitis [14]. (See "Epidemiology, clinical
manifestations, and diagnosis of genital herpes simplex virus
infection" and "Trichomoniasis".)

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].

It is not generally possible to distinguish infectious from noninfectious acute cervicitis


by physical examination; the latter should be considered in women with persistent
cervicitis despite antibiotic therapy. (See 'Recurrent or persistent disease' below.)

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].

DETERMINING THE CAUSE — If cervicitis is suspected based on findings on cervical


examination, further evaluation should be performed to determine the cause and
exclude PID [6]. This evaluation includes:

●Testing for chlamydia and gonorrhea.


●Testing for bacterial vaginosis and trichomoniasis (table 1). Trichomonas
vaginalis may cause isolated cervicitis; bacterial vaginosis typically affects the
vagina. Either infection may occur concurrently with cervicitis. (See "Bacterial
vaginosis: Clinical manifestations and diagnosis" and "Trichomoniasis".)
●Excluding PID through bimanual examination of the pelvic organs. (See "Pelvic
inflammatory disease: Clinical manifestations and diagnosis", section on
'Diagnosis'.)

We suggest nucleic acid amplification testing (NAAT) for N. gonorrhoeae and C.


trachomatis. These assays can be performed on a swab of vaginal fluid, an
endocervical sample (cells are obtained by rotating a swab within the endocervical
canal while applying gentle lateral pressure) or, if a speculum examination is not
possible, on urine [6]. Application of NAAT to these samples has excellent performance
relative to that for direct endocervical sampling. A diagnostic test for M. genitalium is
not FDA-cleared; however, some laboratories are able to perform NAAT for this
organism (specifically transcription mediated amplification). (See "Clinical
manifestations and diagnosis of Chlamydia trachomatis infections", section on
'Diagnosis of chlamydial infections' and "Clinical manifestations and diagnosis of
Neisseria gonorrhoeae infection in adults and adolescents".)

Microscopy (wet prep) and vaginal pH are useful for identifying bacterial vaginosis.

The sensitivity of microscopy to detect T. vaginalis is relatively low (approximately 50


percent), therefore, symptomatic women with cervicitis and negative microscopy for
trichomonads should undergo further testing by culture, antigen-based methods, or
ideally NAAT. NAAT offers a more sensitive means of detection than the other options
and can be performed on the same screening specimen used for chlamydia and
gonorrhea testing. (See "Trichomoniasis", section on 'Rapid antigen and DNA
hybridization probes'.)

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.

Histopathology/cytology is unnecessary in diagnostic evaluation of cervicitis. If


performed, acute disease is characterized by stromal edema, vascular congestion, and
a predominance of neutrophils in the inflammatory infiltrate. Chronic disease is
characterized by an inflammatory infiltrate predominantly of round cells (lymphocytes,
plasma cells, histiocytes); squamous metaplasia is common and stromal fibrosis and
granulation tissue may be present.

Routinely testing for infections other than Trichomonas vaginalis, gonorrhea,


chlamydia, and bacterial vaginosis is not useful unless a specific organism, such as
herpes simplex virus, is suspected. There is generally no role for other bacterial
cultures or PCR, which can be very costly and often detect vaginal bacteria that are
unrelated to the cervical process.

TREATMENT — The goals of treatment are relief of symptoms and prevention of


infection of the upper genital tract.

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.)

Treatment of specific infections — Laboratory and microscopy findings guide


targeted therapy.

Gonorrhea, chlamydia, and mycoplasma — For women in whom empiric therapy of


chlamydia, gonorrhea, or both is deferred, the results of sensitive tests for C.
trachomatis and N. gonorrhoeae (eg, NAATs) should guide treatment subsequent to
the initial evaluation.

Treatment of these infections is indicated for relief of symptoms, to prevent


transmission to uninfected sexual partners, and to prevent upper genital tract disease
(endometritis, PID) and its sequelae. If more than one infection is identified (eg,
chlamydial cervicitis and bacterial vaginosis), all should be treated. (See "Endometritis
unrelated to pregnancy" and "Pelvic inflammatory disease: Treatment".)

●Gonorrhea – The Centers for Disease Control and Prevention (CDC)


recommend treatment with ceftriaxone 250 mg intramuscularly with azithromycin 1
gram orally (regardless of the results of chlamydia testing), both in a single dose
[6]. Fluoroquinolones and doxycycline are not appropriate alternatives because of
increasing resistance to these drugs, nor is therapy with oral azithromycin alone
[6,18]. (See "Treatment of uncomplicated gonococcal infections", section on
'Rationale for dual therapy'.)
The management of the penicillin allergic patient depends on the clinical suspicion
of true allergy and the type of allergy (eg, morbilliform rash versus IgE-mediated
reactions, such as urticaria). This is discussed separately. (See "Treatment of
uncomplicated gonococcal infections".)
●Chlamydia – Treatment options include azithromycin 1 g orally once
or doxycycline 100 mg orally twice daily for seven days [6]. (See "Treatment of
Chlamydia trachomatis infection", section on 'Treatment of uncomplicated genital
chlamydia infection'.)
●Mycoplasma genitalium – While routine testing for this pathogen is not yet
recommended, if the organism is identified, then azithromycinis the drug of choice.
Resistance to doxycycline is common. Resistance to azithromycin has also been
documented and associated with clinical failure. If this organism is suspected or
cannot be ruled out, the woman should be treated with one dose of azithromycin 1
g orally. As treatment failure appears to be increasingly common even with either
of these recommended agents, documentation of M. genitaliumby NAAT in the
setting of treatment failure should prompt treatment with moxifloxacin, 400 mg
once daily for 7 to 10 days. (See "Mycoplasma genitalium infection in men and
women", section on 'Cervicitis and pelvic inflammatory disease'.)

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".)

Trichomonas vaginalis — Treatment consists of metronidazole or tinidazole as a


single oral dose of 2 grams (four 500 mg tablets) [6]. An alternative regimen is
metronidazole 500 mg orally twice daily for seven days. Sexual partners should be
treated. (See "Trichomoniasis".)

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

Sex partners — Sex partners of women with chlamydia, gonorrhea, or trichomoniasis


should be treated for the sexually transmitted infection for which the woman received
treatment. To avoid reinfection, patients and their sex partners should abstain from
sexual intercourse until therapy is completed (seven days after a single-dose regimen
or after completion of a seven-day regimen).

Women with no identifiable pathogen — Management of cervicitis in which an


infectious agent has not been identified during the diagnostic evaluation is
controversial, although this is a common clinical scenario. Data are sparse and there is
no strong evidence to justify suggesting one treatment approach over another [19-21].
If the patient has not received any treatment, we recommend empiric treatment to
cover gonorrhea and chlamydia, as discussed above. (See 'Empiric therapy' above.)
Management of women with persistent disease after this therapy is discussed below.
(See 'Recurrent or persistent disease' below.)

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.

Asymptomatic women with inflammation on histology or cytology — Treatment is


not indicated for asymptomatic women who undergo cervical biopsy for the evaluation
of cervical intraepithelial neoplasia and are found to have histologic, but no clinical,
evidence of cervicitis. Histological inflammation is a poor indicator of a specific infection
[17]. Although follicular cervicitis (lymphoid follicles beneath the epithelium) suggests,
but is not pathognomonic of, chlamydial cervicitis [22-24], follicular cervicitis can also
occur with noninfectious cervicitis. Diagnostic testing is needed in these cases to
confirm or exclude a specific infection and to guide treatment.

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.

FOLLOW-UP — All patients being evaluated for chlamydia, gonorrhea, or


trichomoniasis should be offered counseling and testing for HIV and syphilis.
(See "Screening for sexually transmitted infections".)

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.

RECURRENT OR PERSISTENT DISEASE — Cervicitis can persist despite repeated


courses of antimicrobial therapy. Women who present with recurrent symptoms are
reevaluated for possible re-exposure or treatment failure [6]. We repeat the diagnostic
work-up and ensure that (1) NAAT tests are negative for detection of C.
trachomatis and N. gonorrhoeae, and (2) sex partners have been appropriately treated
and the patient has not been re-exposed to potential pathogens. Diagnostic testing is
performed for trichomoniasis and bacterial vaginosis. Exposure to potential intravaginal
irritants (lubricants, spermicides, douching) is reassessed. If possible, sex partners
should be examined and tested for chlamydia and gonorrhea, particularly if they were
not treated presumptively at the time of the woman's initial treatment for cervicitis.
The role of M. genitalium in persistent cervicitis is unclear [6]. M. genitalium is very
difficult to culture; most studies have used nucleic acid amplification (PCR or, more
recently, transcription mediated amplification [TMA]) for identification [5,15-17]. Assays
for this organism are not yet commercially available, and no testing guidelines exist.
For these reasons, all women with persistent cervicitis should receive single-
dose azithromycin (1 g orally once) if they have not already been treated with this
agent, given its superiority over doxycycline for treatment of M. genitalium. The optimal
drug regimen for treatment of M. genitalium cervicitis that does not respond to
azithromycin is unknown, but moxifloxacin is recommended in European guidelines for
macrolide-resistant M. genitalium and by the United States Centers for Disease Control
and Prevention for urethritis that does not respond to presumptive treatment for
chlamydia and gonorrhea and may be due to M. genitalium [25-27]. Multiple studies
have suggested the potential for rapid emergence of macrolide resistance; thus
patients requiring treatment with moxifloxacin for macrolide-resistant M. genitalium may
become more common [28-33]. (See 'Gonorrhea, chlamydia, and mycoplasma'above.)

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.

CHRONIC CERVICITIS — Chronic cervicitis usually has a noninfectious source [34]. In


women with chronic cervicitis, the cervical mucosa is hyperemic and may be ulcerated.
Obstruction of the mucous glands may result in formation of nabothian cysts.

A minority of women have mucopurulent endocervical discharge, which is more typical


of acute infectious cervicitis, as described above. The term chronic in this context
generally refers to women in whom the usual infectious causes of acute cervicitis noted
above have been treated or excluded, yet abnormal physical signs persist.
(See 'Recurrent or persistent disease' above.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored


guidelines from selected countries and regions around the world are provided
separately. (See "Society guideline links: Bacterial vaginosis".)

SUMMARY AND RECOMMENDATIONS

●Cervicitis is an inflammatory disorder that primarily affects the endocervical


glands. Sexually transmitted infections are the most common cause; irritation from
foreign bodies is another etiology. (See 'Introduction' above.)
●Neisseria gonorrhoeae and Chlamydia trachomatis are the two most common
causes of acute cervicitis. It is uncertain how much Mycoplasma
genitalium contributes to cervicitis, but this organism is likely responsible for a
substantial minority of cases. (See 'Etiology'above.)
●The cardinal signs are purulent or mucopurulent discharge and easily induced
bleeding (friability) from the endocervix. Associated symptoms include abnormal
vaginal discharge, dysuria/urinary frequency, and intermenstrual or postcoital
bleeding. (See 'Clinical findings'above.)
●The clinical diagnosis of cervicitis is based upon the presence of mucopurulent
cervical discharge and friability. Diagnostic evaluation for potential causative
organisms includes assays for chlamydia and gonorrhea, as well as evaluation of
vaginal fluid for trichomonas vaginalis and bacterial vaginosis.
(See 'Diagnosis' above.)
●We suggest empiric therapy of cervicitis (Grade 2B). This should include
coverage for chlamydia and/or gonorrhea, depending on the patient’s risk factors.
(See 'Empiric therapy' above.)
●For women in whom empiric therapy of chlamydia, gonorrhea, or both is
deferred, the results of sensitive tests for C. trachomatis and N. gonorrhoeae (eg,
NAATs) should guide treatment. Testing for M. genitalium can be performed for
women with persistent symptoms in the absence of chlamydia, gonorrhea, and
trichomonas infections. (See 'Gonorrhea, chlamydia, and mycoplasma' above.)
●Treatment, follow-up, and management of sex partners depend upon the
causative organism. Treatment of sex partners is indicated for women with
chlamydia, gonorrhea, or trichomonas infections. (See 'Sex partners' above.)

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