Cervicitis
Overview
Cervicitis is defined clinically by the presence of cervical ectopy and/or a friable cervix with easily induced bleeding at the cervical os and/or mucopurulent (yellow coloured) discharge at the cervical os.
Possible causes
- Chlamydia trachomatis and Neisseria gonorrhoeae are the most common causes of cervicitis.
- Other organisms (not commonly tested for) include: Mycoplasma genitalium, herpes simplex virus (HSV) and Trichomonas vaginalis (so-called ‘strawberry cervix’).
- In women with a low risk of STIs, cervicitis is often not associated with an identifiable pathogen.
Clinical presentation
| Symptoms | Comments/Considerations |
|---|---|
| Vaginal discharge | Speculum examination to view cervix, +/- bimanual if complaining of pelvic pain or dyspareunia. Cervicitis may be a sign of an upper genital-tract infection making it important to assess for pelvic inflammatory disease (PID), particularly in the context of uterine tenderness, adnexal tenderness, or cervical motion tenderness on pelvic exam. |
| Intermenstrual or post-coital vaginal bleeding |
As above. May also require pregnancy test if at risk. |
| If cervicitis found incidentally on vaginal examination eg PAP smear consider testing for STIs | Especially if patient is <30 years old, has had a previous STI, is an Aboriginal or Torres Strait Islander, has had a recent new partner or >1 partner in last 12 months. |
Diagnosis
A speculum examination and cervical swab, at least, are required to diagnose cervicitis.
| Infection | Site/Specimen | Test |
|---|---|---|
| Chlamydia |
Endocervical swab |
NAAT |
| Gonorrhoea |
Endocervical swab |
NAAT. If positive, take swab at relevant site(s) for culture, before treatment. |
| Trichomoniasis |
High vaginal swab or FPU |
NAAT pH test |
| M. genitalium | Endocervical swab | NAAT |
|
Herpes (if cervical ulcers present) |
Cervical swab
|
NAAT |
|
NAAT - Nucelic acid amplification test |
||
Specimen collection
Urethral swabs for microscopy should be collected when the patient has not urinated for at least 1 hour and only if the patient has frank urethral discharge. Squeeze the urethra to express the discharge and collect on urethral swab. It is not necessary to insert the swab into the urethra. Vaginal swab: instruct the patient to insert the swab into the vagina like a tampon and then remove and place into the transport tube. Rectal swab: instruct the patient to insert the swab into the anal canal 2-4cms and then remove and place into the transport tube. FPU (First pass urine): Collect approximately 20 ml (1/3 of the standard urine jar) of the first part of the urine stream in a specimen jar at the time you are consulting the patient. The patient does not need to have held their urine for more than 20 minutes prior to specimen collection. A midstream urine (MSU) or early morning specimen (i.e. first void urine) are not required for NAAT. Click here for information on how to describe self-collection technique to a patient.Clinician collected for NAAT/culture/microscopy
Rectal swabs should be collected by inserting a sterile swab 2-4cms into the anal canal and moving the swab gently side to side for 10-20 seconds.
Pharyngeal swabs should be collected from the tonsils and oropharynx.
High vaginal swab of vaginal discharge smeared onto a glass slide, air dried and sent for microscopy. Swab inserted into transport medium for culture.Self-collection of samples for NAAT testing
Management
In the absence of a definitive causative organism, in a woman with increased risk of STI treat sydromically.
| Principal Treatment Options | ||
|---|---|---|
| Situation | Recommended | Alternative |
| Unknown organism |
Doxycycline 100mg PO, BD for 7 days |
Azithromycin 1g PO, stat
|
Consider treatment for gonorrhoea if patient is at risk, or in a community with high gonorrhoea prevalence.
If organism is known, see relevant STI guidelines for treatment recommendations:
Treatment advice
- Women with a clinical diagnosis of cervicitis who are at increased risk for STIs (as above) should be treated at initial assessment whether or not an STI pathogen is identified. Screening and treatment of regular male sexual partner/s should also occur.
- Cervicitis in women with low risk of exposure to STIs is often not associated with an identifiable pathogen. Cervicitis in this group may be due to exposure of large area of cervical ectropion to the vaginal environment or douching (or exposure to other types of chemical irritants such as spermicides and deodorants). Treatment is not recommended in this group unless subsequent STI is identified.
- Management options for persistent cervicitis are undefined, in the absence of STI reinfection, bacterial vaginosis and after treatment of partners.
Other immediate management
- Advise no sexual contact for 7 days after treatment is administered.
- Advise no sex with partners until 7 days after the partners have been tested and treated.
- Contact tracing.
Contact Tracing
- Treat sexual partner(s) as appropriate for the identified or suspected STI.
- Contact tracing is a high priority for chlamydia, gonorrhoea, trichomoniasis and M. genitalium and should be performed in all patients with confirmed infection.
- Contact tracing for herpes is not recommended.
See Australasian Contact Tracing Manual for more information.
Follow up
Review at day 7 with speculum, and/or bimanual, examination as required. Routine follow up is not required unless an STI has been identified or symptoms of PID.
If pelvic inflammatory disease (PID) diagnosed, assess response to antibiotics after 7 days.
If STI confirmed, follow up provides an opportunity to:
- Confirm patient adherence with treatment and assess for symptom resolution
- Confirm contact tracing procedures have been undertaken or offer more contact tracing support
- Provide further sexual health education and prevention counselling.
Mucopurulent cervicitis will often persist despite treatment if due to an ectropion, however no further treatment is required.
For test of cure (TOC) and retesting advice see:
Auditable outcomes
100% of patients diagnosed with cervicitis are treated with an appropriate antibiotic regime.
References
- British Association for Sexual Health and HIV (BASHH). UK National Guideline for the Management of Bacterial Vaginosis 2012: Clinical Effectiveness Group. BASHH, 2012. Available online [Accessed November 2013].
- Centers for Disease Control and Prevention (CDC). STD Sexually Transmitted Diseases Treatment Guidelines: Diseases characterised by urethritis and cervicitis. CDC, 2015. Available online at http://www.cdc.gov/std/tg2015/urethritis-and-cervicitis.htm#cervicitis [Accessed October 2015].
- Lusk MJ, Konecny P. Cervicitis: a review. Current Opinions in Infectious Diseases. 2008;21:49-55.
- Marrazzo JM, Martin DH. Management of women with cervicitis. Clinical Infectious Diseases. 2007;44(Suppl 3):S102-S110.
- M Josephine Lusk, Frances L Garden, Robert G Cumming, William D Rawlinson, , Zin W Naing, , Pam Konecny: Cervicitis: a prospective observational study of empiric azithromycin treatment in women with cervicitis and no Cervicitis: a prospective observational study of empiric azithromycin treatment in women with cervicitis and non-specific cervicitis International Journal of STD & AIDS Vol 28, Issue 2, pp. 120 - 126
- Lusk MJ, Garden FL, Rawlinson WD, et al Cervicitis aetiology and case definition: a study in Australian women attending sexually transmitted infection clinics Sex Transm Infect Published Online First: 19 November 2015