Cervicitis Clinical Presentation

• Gonorrhea, chlamydia, and T vaginalis infections are often asymptomatic. When present, symptoms are often nonspecific. Symptoms include increased vaginal discharge, dysuria, urinary frequency, and intermenstrual or postcoital bleeding. If the infection has been long standing, symptoms can include low abdominal or low back pain.
• Infection with HPV is frequently asymptomatic because the genital warts are often flat and internal. When the warts are raised and on the labia, perineum, or perianal area, they are called condylomata acuminata and are easily visible.
• Similarly, most patients with HSV infection are asymptomatic. However, first episode genital herpes is frequently highly symptomatic and is marked by painful ulcerations associated with fever, myalgia, headache, and general malaise. Dysuria, vaginal discharge, and urethral discharge are also common symptoms. Recurrent outbreaks of HSV tend to be milder, but most patients have prodromal symptoms of itching or tingling followed by the appearance of vesicles.
• Because many causes of cervicitis are initially asymptomatic, ask all sexually active women for their complete gynecologic and sexual history at the initial evaluation and yearly thereafter. In addition to the basic gynecologic history (eg, age of menarche, date of last menstrual period, gravida, para, pregnancy or delivery complications, date of last Papanicolaou test [Pap smear]), a complete sexual history is needed. This information includes number of recent and current partners (in the last 3 months), condom use, nonbarrier contraception use, exchanging of sex for money or drugs, and previous diagnoses of STIs. A focused review of symptoms that asks about dyspareunia, vaginal discharge, genital skin lesions, abnormal vaginal bleeding, dysuria, genital burning, genital itching, genital malodor, and lower abdominal or pelvic pain is recommended.
• In high-risk populations (eg, women with multiple partners, adolescents, women with a history of previous STIs, pregnant women), screen for gonorrhea, chlamydia, and T vaginalis infections. Screening in this population has been proven to be cost effective. Screening can be performed annually in conjunction with the Pap smear. Pap smears are not an effective screening test for STIs, vaginitis, or cervicitis; however, a significant proportion of abnormal Pap smear results indicate subclinical HPV.
• New primary cervical screening guidelines from both the American Cancer Society (ACS) and the American College of Obstetricians and Gynecologists (ACOG) include the option to screen women aged 30 years and older with an HPV test plus cervical cytology.
• Persistent infection with oncogenic HPV is the primary cause of cervical cancer and its precursor lesions. Therefore, testing for HPV can detect cervical cancer risk at an early stage. However, the usefulness of the HPV DNA test result is dependent on the age of women being screened. In women younger than age 25, HPV infection is common but mostly transient and not associated with cervical cancer risk. Therefore, HPV screening is not recommended for women younger than age 25. In contrast, in women older than age 30, a positive HPV DNA test result is mostly indicative of persistent infection, and no more than 5% tend to have a positive test result. Also, about 95% of cervical cancers occur in this age group. Therefore, finding HPV infection in this age group is considered significant regardless of Papanicolaou test results, as this is known to be associated with an increased risk of cervical cancer.
• The application of the HPV DNA test as an adjunct test in Atypical Squamous Cells of Unknown Significance (ASC-US) triage has been well established.^[3] ASC-US Papanicolaou tests account for nearly two thirds of all Papanicolaou test abnormalities reported, but, in most patients this is not a predictor of cervical cancer risk. However, 5-17% in this group could have underlying HSIL and hence the indication for further follow-up. In this context, the HPV DNA test can identify women who are at risk for cervical cancer and allow for close surveillance of those testing HPV positive.
• General screening for HSV is not recommended because no evidence demonstrates that serological tests for HSV antibody improves health outcomes or symptoms or reduces transmission of disease. However, in individuals in partnerships with individuals infected with HSV-2, screening can be offered.

The physical examination should include a general survey; external inspection; and pelvic speculum, and bimanual examinations. In certain patients, a rectal examination should be performed.

• The physical examination is crucial to the evaluation and diagnosis of cervicitis, but do not limit the examination to the pelvic region. A survey for lymphadenopathy, skin lesions, oral lesions, joint redness or swelling, abdominal pain, and costovertebral angle tenderness can point to disseminated infection.
• The pelvic examination must be performed in a competent and sensitive manner. The presence of a nursing assistant is advised. A nursing assistant can help the examiner and act as chaperone. Always explain to the patient what is going to be done before proceeding. Begin with a neutral touch on the patient's thigh.

  • The pelvic examination begins by visually investigating the external genitalia in good lighting. Note any skin lesions (eg, warts, ulcers, vesicles, excoriations, erythema), inflammation of the Bartholin or Skene glands, or inguinal lymphadenopathy.
  • Perform the speculum examination with water or gel lubrication (eg, Surgilube or K-Y jelly), and include direct visualization of the vaginal walls and cervix. Remember that normal vaginal secretions are nonadherent to the vaginal walls, clear to white in color, and nonodorous. Normal vaginal secretions have an acidic pH of less than 4.5. Vaginitis is present if the vaginal discharge is copious, colored, and malodorous, or if the pH is greater than 4.5. Cervicitis is suspected if the cervix is erythematous, edematous, or easily friable. Classic mucopurulent cervicitis is present if thick yellow-green pus is visible in the endocervical canal (the cervical os) or on an endocervical swab specimen. Laboratory specimens are collected for study at this point. Note cervical warts or ulcerations.
  • After the speculum is removed, the bimanual examination is performed to assess tenderness or enlargement of the cervix, uterus, and adnexa. Cervicitis or pelvic inflammatory disease (PID) is suspected if the patient has cervical motion tenderness, ie, she experiences pain or tenderness while the examiner gently moves the cervix from side to side.

All of the infectious etiologies of cervicitis are STIs. Risk factors include multiple sex partners, young age, single marital status, urban residence, low socioeconomic status, and alcohol or drug use.

While its role in PID is unclear, Mycoplasma genitalium does not appear to be a significant etiologic agent for PID.^[4]