Cervicitis is an inflammation of the uterine cervix, primarily affecting the columnar epithelial cells of the endocervical glands. Acute cervicitis results from direct infection of the cervix secondary to a uterine or vaginal infection-most commonly chlamydia or gonorrhea-whereas chronic cervicitis is due to an exposure to a local irritant.

Endocervicitis

Ectocervicitis

Mucopurulent cervicitis

The published prevalence of cervicitis varies greatly, ranging from 8% to as high as 40% of women attending sexually transmitted disease (STD) clinics. Cervicitis is most common in women aged 15 to 24, but it can occur in any sexually active woman. Women who have had sex without condoms or sex with multiple partners are at increased risk of developing cervicitis as well as other STDs.

• Cervicitis is usually asymptomatic or associated with mild symptoms. Patients may complain of copious purulent or mucopurulent vaginal discharge, pelvic pain, postcoital or intermenstrual bleeding, vulvovaginal irritation, or dyspareunia.
• The CDC emphasizes that the two diagnostic signs of cervicitis are either mucopurulent discharge or sustained cervical bleeding with gentle trauma. On physical exam, the cervix can be erythematous and tender on palpation. The cervix may also bleed easily when obtaining cultures or a Pap smear. Yellow discharge will be seen on a Q-tip inserted into the cervix.

• Chlamydia trachomatis
• Neisseria gonorrhoeae
• Trichomonas vaginalis
• Herpes simplex
• Human papillomavirus
• M. genitalium
• Bacterial vaginosis

• Carcinoma of the cervix
• Cervical erosion (from tampons or other intravaginal devices)
• Cervical metaplasia
• Cervical ectropion
• Cervical and vaginal irritation due to chemicals or hormonal imbalance

If cervicitis is suspected, testing for infectious causes should be performed, and pelvic inflammatory disease (PID) should be excluded.

• A finding of leucorrhea (>10 WBC per high-power field on microscopic examination of vaginal fluid) has been associated with chlamydial and gonococcal infection of the cervix.
• Nucleic acid amplification tests (NAAT) should be used for diagnosing C. trachomatis and N. gonorrhoeae in women with cervicitis; this testing can be performed on vaginal, cervical, or urinary samples.
• Use a wet mount to look for evidence of bacterial vaginitis (BV) and trichomonads, but because the sensitivity of microscopy to detect T. vaginalis is relatively low (∼50%), symptomatic women with cervicitis and negative microscopy for BV and trichomonads should receive further testing with NAAT or culture if there is concern for resistant infection.
• HIV testing is recommended in all patients with suspected cervicitis.
• Although HSV-2 infection has been associated with cervicitis, the utility of specific testing (i.e., culture or serologic testing) for HSV-2 in this setting is not recommended unless there are clinical findings suggestive of herpes infection.

• The patient’s history of hygiene habits, which may increase her risk for cervicitis, should be obtained including history of douching, tampon usage, and other potential chemical exposures to vaginal irritants.
• Uncomplicated cervicitis is typically treated as an outpatient.
• Safe sex should be recommended including monogamous relationships and the consistent use of condoms (male and female).
• Sexual partners should be offered treatment in all cases of STD infection proven by culture.

• Because Chlamydia and N. gonorrhoeae cause 50% of cases of infectious cervicitis, if either of these infections is suspected, then treatment should be initiated without waiting for the test results. Administer ceftriaxone 500 mg IM as a single dose for persons weighing <150 kg (300 lb) or 1 g of IM ceftriaxone for persons weighing ≥150 kg (300 lb) followed by azithromycin 1 g single dose or doxycycline 100 mg PO bid for 7 days. If the patient is pregnant, treat with azithromycin 1 g single dose instead of using doxycycline, which is contraindicated in pregnant or nursing mothers. If Trichomonas is the etiologic agent, treat with metronidazole or tinidazole 2 g single dose, which is curative in 95% of cases. An alternative treatment option is metronidazole 500 mg twice daily for 7 days. Alcohol should be avoided during the treatment course.
• For herpes infection, treat with acyclovir, valacyclovir, or famciclovir.
• M. genitalium might be considered for cases of clinically significant cervicitis that persist after azithromycin or doxycycline therapy in which reexposure to an infected partner or medical nonadherence is unlikely. If M. genitalium infection is confirmed, treatment is with moxifloxacin.

Bacterial cervicitis responds well to antibiotics. Possible complications to watch for include subsequent PID and infertility (found in 5% to 10% of patients with increasing rates with repeat episodes of PID). Repeat cervical cultures are recommended after treatment in pregnancy or if there is concern of treatment failure. Screening for reinfection is recommended within 3 mo. Condoms should be recommended, and sexual relations should be resumed after negative cultures for both partners.

If subsequent PID develops, attempt outpatient therapy and consider hospital admission for IV antibiotics for severe or specialty cases as outlined in the CDC guidelines.

• Management of sex partners of women tested for cervicitis should be appropriate for the identified or suspected STD.
• Repeat testing 3 to 6 mo after treatment is recommended for all women diagnosed with chlamydia or gonorrhea, and all sex partners in the preceding 60 days should be evaluated and treated for the STDs for which the index patient received treatment.

Cervicitis (Patient Information)

Chlamydia Genital Infections (Related Key Topic)

Gonorrhea (Related Key Topic)

Urethritis, Nongonococcal (Related Key Topic)