Cervicitis

Cervicitis (inflammation of the cervix) is considered the female equivalent of non-specific urethritis (NSU), although it may be a finding on clinical examination. Cervicitis is defined as >30 WBC/HPF, plus inflammation and/or a discharge. The cervix may be friable.

Cervicitis may be associated with pelvic inflammatory disease (PID) and an assessment for PID should occur, including a bimanual exam with testing to elicit cervical excitation and adnexal tenderness.

Organism
  • Common infective causes of cervicitis include Chlamydia trachomatis and Neisseria gonorrhoeae
  • Other possible STI’s may include Mycoplasma genitalium and Herpes Simplex Virus (HSV)
  • Non-STI causes for cervicitis can occur, and an organism may not be found.
  • Trichomoniasis can cause inflammation to the ectocervix and the appearance known as “strawberry cervix”
Clinical presentation

Symptoms

The symptoms of cervicitis are:

  • low abdominal pain
  • vaginal discharge
  • pain on sexual intercourse
  • a burning sensation on passing urine
  • intermenstrual bleeding of post-coital bleeding

Signs

The signs of cervicitis are:

  • endocervical discharge
  • contact bleeding from the cervix
  • cervical tenderness on examination
  • friable cervix.

STI Atlas (external site)

Investigations
  • Endocervical specimens are essential. A vaginal speculum and bimanual exam should be performed. Mop ectocervix with cotton wool prior to taking specimens to avoid contamination with vaginal flora.
  • Endocervical microscopy – >30 WBC/HPF in the absence of gonococci.
  • Endocervical culture for gonorrhoea and other organisms (glass slide and swab in charcoal [black] or non-charcoal [clear] agar gel transport medium. 
  • Endocervical NAAT for chlamydia (no transport medium). 
  • First void urine for NAAT for gonorrhoea and chlamydia.
  • Vaginal microscopy, and culture, to exclude other causes of discharge, eg candidiasis, bacterial vaginosis, T. vaginalis, anaerobes (Consider pH testing, elevated for BV and trichomoniasis). 
  • Consider HSV as a cause of cervicitis especially if ulceration present. 
  • Consider endocervical M. genetalium NAAT.
  • Added STI screen – treponemal serology, and HIV and HBV antibody.
  • Consider pregnancy testing in those at risk
  • Consider cervical cancer screening especially in those with abnormal bleeding. If not significantly overdue, may consider deferring pap smear if significant inflammation and patient likely to reattend.
Treatment

The following is for uncomplicated cervicitis, If PID is suspected clinically, treat accordingly. (see relevant PID section)

Adult

  • Azithromycin 1 g orally, as a single dose

OR

  • Doxycycline 100 mg orally, 12-hourly for 10 days
  • Consider treatment for gonorrhoea if:
    • Patient in at-risk population or in areas where this infection is common.
    • clinical exam reveals mucopurulent cervicitis
    • Treat with ceftriaxone 500mg IMI and azithromysin 1g oral as a single dose

Pregnancy or breastfeeding

Management of partners

No sexual contact for 7 days after treatment and avoid sexual contact with prior partners until 7 days after they have been tested and treated. 

Male sexual partners should be tested and treated for presumed NSU.

Follow up

Until post-treatment review ask patients to avoid unprotected sexual intercourse. Review at one week after cessation of treatment and:

  • assess resolution of signs and symptoms
  • review results of tests and manage appropriately 
  • review success of contact tracing.
Public health issues

This is not a notifiable disease, unless a specific cause is found.

Contact tracing and further counselling are important.

Always test for other STIs.