Cervicitis
Jill C. Cash and Rhonda Arthur
Definition
A.Cervicitis is acute or chronic inflammation of the cervix that is visible to the examiner.
Incidence
A.Incidence is unknown because of multiple etiologies.
Pathogenesis
A.Acute cervicitis is primarily due to infection from the following organisms:
1.Bacteria:
a.Chlamydia trachomatis (CT).
b.Neisseria gonorrhoeae.
c.Mycoplasma.
d.Ureaplasma.
2.Viruses:
a.Herpes simplex virus (HSV) type 2.
b.Human papillomavirus (HPV).
3.Trichomonas vaginalis (TV).
B.Chronic cervicitis is primarily due to the following:
1.Trauma occurring during childbirth or instrumentation.
2.Infection.
3.Presence of foreign bodies (i.e., intrauterine devices [IUDs]).
Predisposing Factors
A.Vaginal delivery.
B.Cervical procedures: Laser, loop, or other excision procedures.
C.IUD.
D.Sexually transmitted infections (STIs).
Common Complaints
A.Copious mucopurulent vaginal discharge.
B.Postcoital bleeding.
Other Signs and Symptoms
A.Asymptomatic; may be found on routine gynecologic exam.
B.Thick yellow vaginal discharge.
C.Dysuria.
D.Dyspareunia.
E.Vulvovaginal irritation or pruritus.
Subjective Data
A.Determine onset, duration, and course of symptoms. Is there any dyspareunia, pelvic pain, fever, or urinary symptoms?
B.Determine characteristics of the vaginal discharge.
C.Review the patient’s history of STIs.
D.Review the patient’s sexual history to include number of partners and partner symptoms (if any), use of sex toys, and sexual lifestyle.
E.Note last Pap smear and results. Has the patient ever had an abnormal Pap, and if so, how was it treated?
F.Note date of last menstrual period (LMP), use of contraception, and type(s) of contraception.
G.If the patient has recently been pregnant, review her records for cervical cerclage, vaginal delivery with cervical laceration, or other complications.
Physical Examination
A.Check temperature, pulse, and respirations.
B.Inspect: Observe generally for discomfort before, during, and after exam:
1.Observe the external vulva for Bartholin’s gland enlargement (Bartholin’s gland abscess is due primarily to infection by CT), lesions, irritation, fissures, and condyloma.
2.Note color, amount, and odor of vaginal discharge.
C.Palpate:
1.Back: Note costovertebral angle (CVA) tenderness.
2.Abdomen: Palpate for enlarged or tender inguinal lymph nodes.
D.Pelvic examination.
E.Speculum examination: Inspect cervix for inflammation and ectropion:
1.Cervical ectropion is found in 15% to 20% of healthy young women (especially in teens and with the use of oral contraceptives). It represents columnar epithelium that is found farther out on the ectocervix, causing the cervix to appear granular and red. Presence of cervical erosion, however, suggests advanced cervical pathology. A strawberry cervix
(petechiae) is highly suggestive of TV.
2.Check cervix for friability and bleeding when the cervix is touched with a cotton-tipped swab.
3.Assess the vagina and cervix for leukoplakia, lesions, polyps, and discharge. Assess vaginal walls for discharge and rugae.
4.Vesicular or ulcerated cervical lesions warrant testing for HSV, syphilis, and/or chancroid.
F.Bimanual examination: Check cervical motion tenderness (CMT); adnexal masses; uterine size, consistency, and tenderness:
1.Milk urethra for discharge.
2.Palpate Bartholin’s glands.
Diagnostic Tests
A.White blood cell (WBC), if indicated.
B.Consider testing for syphilis (rapid plasma reagin [RPR] or venereal disease research laboratory test).
C.Wet prep.
D.Cervical cultures for gonorrhea (GC) and CT.
E.Pap smear.
F.Urine culture and sensitivity, if indicated.
G.Herpes culture, if indicated.
Differential Diagnoses
A.Cervicitis.
B.CT.
C.GC.
D.Bartholin’s gland abscess.
E.Cervical neoplasm.
F.Cervical polyps.
G.HSV type 2.
H.Urinary tract infection (UTI).
I.Cervical ulceration, or erosion, from trauma: Fingernail, cervical biopsy, postpartum, or sex toys.
J.Pelvic inflammatory disease (PID).
Plan
A.General interventions: Patients whose culture is negative generally respond to a round of doxycycline therapy, which is the drug of choice for nonchlamydial, nongonorrheal cervicitis.
B.Patient teaching:
1.Women should be encouraged to obtain routine, annual examinations and Pap smears in accordance with Pap smear guidelines.
2.Patients should be cautioned to avoid alcohol consumption during and 24 hours after the completion of oral metronidazole due to a disulfiram-like reaction (nausea, vomiting, headache,
cramps, and flushing).
3.Patient should have no sexual intercourse for 1 week.
4.Avoid tampons and douches until antibiotics are completed.
5. 
See Section III: Patient Teaching Guide Cervicitis.
C.Pharmaceutical therapy:
1.Drug of choice for CT: Doxycycline 100 mg twice daily for 7 days or azithromycin 1 g orally in a single dose. Treat all partners.
2.Drug of choice for GC: Ceftriaxone (Rocephin) 125 mg by intramuscular (IM) injection plus either a single dose of azithromycin 1 g orally or doxycycline 100 mg orally twice a day for 7 days.
3.Drug of choice for HSV: Acyclovir 400 mg three times daily for 7 to 10 days for initial outbreak, acyclovir 400 mg three times a day for 5 days for recurrent outbreak, or acyclovir 400 mg twice a day for suppression.
4.Drug of choice for Trichomonas: Metronidazole 500 mg twice daily for 7 days (treat all partners), or 2 g orally in a single dose.
5.Drug of choice for UTI: See section Urinary Tract Infection (Acute Cystitis)
of Chapter 15.
Follow-Up
A.Recommend test of cure
: Reculture 1 to 2 weeks following completion of pharmacologic therapy.
B.Follow up with Pap smear as mandated by result.
Consultation/Referral
A.Refer the patient to a physician for suspected neoplasm and for cervicitis unresponsive to treatment.
B.If the cervix has a suspicious lesion, the patient should be referred for colposcopy and/or biopsy regardless of cytology results. On physical examination, the cervix may be edematous and erythematous and may show exposed columnar epithelium. It may be friable. Reddened areas of the cervix may be seen around the cervical os. The irregularity and friability sometimes differentiate them from eversion; other times, colposcopy is required to make the distinction.
Individual Considerations
A.Pregnancy: Cervical inflammation is common in early pregnancy. If an STI is diagnosed, nonteratogenic pharmacologic therapies must be implemented.
B.Partners: A positive STI result warrants treatment of each sexual partner in accordance with Centers for Disease Control and Prevention (CDC) STI treatment guidelines.