eMedicine Specialties > Obstetrics and Gynecology > Infections

Cervicitis: Differential Diagnoses & Workup

Author: Arthur T Ollendorff, MD, Associate Professor of Clinical Obstetrics and Gynecology, Residency Program Director, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine; Chief of Gynecology, Veterans Affairs Medical Center, Cincinnati
Contributor Information and Disclosures

Updated: Aug 3, 2009

Differential Diagnoses

Adnexal Tumors
Oophoritis
Benign Cervical Lesions
Ovarian Cancer
Benign Lesions of the Ovaries
Ovarian Cysts
Candidiasis
Pyelonephritis, Acute
Cervical Cancer
Radiation Cystitis
Cervicitis
Rectovaginal Fistula
Chancroid
Salpingitis
Chlamydial Genitourinary Infections
Threatened Abortion
Cystitis, Nonbacterial
Trichomoniasis
Ectopic Pregnancy
Trigonitis
Endometritis
Tuberculosis
Gonococcal Infections
Tuberculosis of the Genitourinary System
Gynecologic Pain
Urinary Tract Infection, Females
Herpes Simplex
Uterine Cancer
HIV Disease
Vaginitis
Human Papillomavirus
Vulvovaginitis
Malignant Vulvar Lesions

Other Problems to Be Considered

Retained foreign body (eg, tampon, condom)

Workup

Laboratory Studies

  • Because the causes of vulvovaginitis and cervicitis overlap, the initial diagnostic approaches to vulvovaginitis and cervicitis are identical. Appearance of vaginal secretions is assessed, pH of the secretions is measured, and microscopy with isotonic sodium chloride solution and 10% potassium hydroxide (KOH) is performed along with a whiff test.
  • Infection with T vaginalis usually produces a thin, purulent, frothy, and malodorous discharge and can cause vulvar erythema and edema. The cervix can be erythematous and may have punctate hemorrhages (ie, strawberry cervix). The diagnosis is suggested if microscopy of cervical secretions reveals 10-30 leukocytes per oil immersion field. The diagnosis is confirmed by observation of the motile flagellated protozoan on the normal saline wet mount under the microscope.
  • If cervicitis is suspected or mucopurulent cervicitis is observed, then cervical discharge is collected for culture and, optionally, for Gram stain.
    • The microscopic finding of gram-negative intracellular diplococci has a sensitivity of 60% and a specificity of more than 90% for gonorrhea.
    • The observation of more than 30 leukocytes per oil immersion field is highly suggestive of chlamydia and gonorrhea.
    • Although culture is still regarded as the criterion standard, many alternative techniques for the diagnosis of gonorrhea and chlamydia are available. They include enzyme immunoassay, direct fluorescent antibody staining, DNA probe, and polymerase chain reaction (PCR).
    • The advantages over conventional cultures include reduced turnaround time and lack of dependence on the complex and expensive systems needed to culture chlamydia and gonorrhea. It also possesses the ability to detect both organisms with the same sample. The main disadvantage of all the nonculture diagnostic techniques is the inability to assess microbial resistance. Nonetheless, many clinic- and hospital-based practices have already stopped using cultures and have switched to these alternative techniques.
  • If genital ulcer disease is observed, exclude the diagnosis of syphilis by serologic testing or consider performing a biopsy.
  • If typical grouped vesicles mixed with small ulcers are observed, in addition to a typical history, the diagnosis of HSV infection can be made on clinical grounds alone. For atypical ulcers or first infection, attempt definitive diagnosis by culture. Although culture is considered the criterion standard, alternative techniques (eg, cytology, antigen detection, DNA probe) are used. Serology currently has no role because of cross-reactivity between types 1 and 2 in the assays. Newer type-specific glycoprotein g1 and g2 serologic assays exist, but they are not yet for routine diagnostic use.
  • If genital warts are noted, subclinical lesions can be identified after applying a 3-5% solution of acetic acid and performing magnification with colposcopy.
  • While there have been more than 80 types of HPV identified, types 16, 18, 31, 33, 35, 45, 51, and 56 are associated with higher oncogenic risks, particularly cervical cancer. Currently, the United States Preventive Services Task Force (USPSTF) believes insufficient evidence exists to recommend HPV testing in women older than age 30 as an adjunct to Papanicolaou testing.4 However, the American College of Obstetrics and Gynecology (ACOG) and American Cancer Society (ACS) state that HPV testing can be a routine option for these women with the appropriate guidance from their health care provider.

More on Cervicitis

Overview: Cervicitis
Differential Diagnoses & Workup: Cervicitis
Treatment & Medication: Cervicitis
Follow-up: Cervicitis
References
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References

  1. Centers for Disease Control and Prevention. Chlamydia screening among sexually active young females enrollees of health plans - United States, 2000-2007. MMWR Weekly. April 17, 2009;58(14):362-365. [Full Text].

  2. Clifford GM, Gallus S, Herrero R, Munoz N, Snijders PJ, Vaccarella S. Worldwide distribution of human papillomavirus types in cytologically normal women in the International Agency for Research on Cancer HPV prevalence surveys: a pooled analysis. Lancet. Sep 17-23 2005;366(9490):991-8. [Medline].

  3. Wright TC Jr, Schiffman M, Solomon D, Cox JT, Garcia F, Goldie S. Interim guidance for the use of human papillomavirus DNA testing as an adjunct to cervical cytology for screening. Obstet Gynecol. Feb 2004;103(2):304-9. [Medline].

  4. Goldie SJ, Kim JJ, Wright TC. Cost-effectiveness of human papillomavirus DNA testing for cervical cancer screening in women aged 30 years or more. Obstet Gynecol. Apr 2004;103(4):619-31. [Medline].

  5. CDC. Update to CDC's sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR Morb Mortal Wkly Rep. Apr 13 2007;56(14):332-6. [Medline]. [Full Text].

  6. American College of Obstetricians and Gynecologists. Cervical Cytology and Screening. August 2003. ACOG Practice Bulletin.

  7. Anderson JR. Genital tract infections in women. Med Clin North Am. Nov 1995;79(6):1271-98. [Medline].

  8. CDC, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. Aug 4 2006;55(RR-11):1-94. [Medline]. [Full Text].

  9. Griffith WF, Stuart GS, Gluck KL, Heartwell SF. Vaginal speculum lubrication and its effects on cervical cytology and microbiology. Contraception. Jul 2005;72(1):60-4. [Medline].

  10. Katz VL, Lentz GM, Lobo RA, Gershenson DM. Comprehensive Gynecology. 5th ed. Mosby; 2007:598-600.

  11. Low N, Cowan F. Genital chlamydial infection. Clin Evid. Jun 2003;(9):1721-8. [Medline]. [Full Text].

  12. Schiffman M, Khan MJ, Solomon D, Herrero R, Wacholder S, Hildesheim A. A study of the impact of adding HPV types to cervical cancer screening and triage tests. J Natl Cancer Inst. Jan 19 2005;97(2):147-50. [Medline].

  13. Sexually Transmitted Disease Surveillance 2007. Centers for Disease Control and Prevention; December 2008. [Full Text].

  14. Soper DE. Sexually transmitted disease & pelvic inflammatory disease. Primary Care of Women. 1995:339-347.

  15. World Health Organization. Sexually Transmitted Infections. October 2007. WHO Fact Sheet. [Full Text].

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Further Reading

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Keywords

cervicitis, female lower genital tract infections, mucopurulent cervicitis, sexually transmitted diseases, STDs, vulvovaginitis, Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, human papillomavirus, HPV, herpes simplex virus, HSV, pelvic inflammatory disease, PID, infertility, ectopic pregnancy, spontaneous abortion, cervical cancer, preterm delivery, condylomata acuminata, Papanicolaou test, Pap smear

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Contributor Information and Disclosures

Author

Arthur T Ollendorff, MD, Associate Professor of Clinical Obstetrics and Gynecology, Residency Program Director, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine; Chief of Gynecology, Veterans Affairs Medical Center, Cincinnati
Arthur T Ollendorff, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists and American Public Health Association
Disclosure: Nothing to disclose.

Medical Editor

Jeffrey B Garris, MD, Chief, Assistant Professor, Department of Obstetrics and Gynecology, Division of Urogynecology and Reconstructive Pelvic Surgery, Tulane University School of Medicine
Jeffrey B Garris, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, American Urological Association, Association of Professors of Gynecology and Obstetrics, Louisiana State Medical Society, Royal Society of Medicine, and Sigma Xi
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

A David Barnes, MD, PhD, MPH, FACOG, Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, California), Pioneer Valley Hospital (Salt Lake City, Utah), Warren General Hospital (Warren, Pennsylvania), and Mountain West Hospital (Tooele, Utah)
A David Barnes, MD, PhD, MPH, FACOG is a member of the following medical societies: American College of Forensic Examiners, American College of Obstetricians and Gynecologists, American Medical Association, Association of Military Surgeons of the US, and Utah Medical Association
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD, Professor, Coordinator of Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

 
 
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