eMedicine Specialties > Obstetrics and Gynecology > Infections

Cervicitis

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

Introduction

Background

Cervicitis is an inflammation of the uterine cervix. Infectious cervicitis might be caused by Chlamydia trachomatis, Neisseria gonorrhoeae, herpes simplex virus (HSV), or human papillomavirus (HPV). Trichomonas vaginalis, technically a vaginal infection, is commonly discussed when discussing cervicitis. Noninfectious cervicitis might be caused by local trauma, radiation, or malignancy. The infectious etiologies are significantly more common than the noninfectious causes, and all possible infectious causes of cervicitis are sexually transmitted infections (STIs). This article focuses on the infectious etiologies of cervicitis.

Pathophysiology

Because the female genital tract is contiguous from the vulva to the fallopian tubes, there is some overlap between vulvovaginitis and cervicitis. Vulvovaginitis and cervicitis are commonly categorized as lower genital tract infections. Infections involving the endometrium and fallopian tubes are commonly categorized as upper genital tract infections and are not discussed in this article.

Frequency

United States

The Centers for Disease Control and Prevention (CDC) estimates that over 19 million STI infections occur annually, almost half of them among those aged 15-24 years. In addition to potentially severe health consequences, STIs pose a tremendous economic burden, with direct medical costs as high as $16 billion in a single year.

Trichomonas is the most common curable STI in young, sexually active women. An estimated 7.4 million new cases occur each year in women and men. In 2007, 1.1 million chlamydial infections were reported to the CDC, up from 877,478 cases reported in 2003.¹ Because many cases are not reported or even diagnosed, 2.8 million new cases of chlamydia are actually estimated to occur each year. Gonorrhea is the second most commonly reported infectious disease in the United States, with 355,991 cases reported in 2007.¹ Much like chlamydia, gonorrhea is believed to be underreported.

The annual rates of infection by HSV and HPV are difficult to estimate because the vast majority of initial infections are asymptomatic or unrecognized.¹ In the United States, seroprevalence studies show that 22% of adults have HSV type 2 antibodies; currently, over 500,000 new cases of genital herpes are believed to occur annually. Approximately 20 million people are currently infected with HPV. At least 50% of sexually active men and women acquire a genital HPV infection at some point in their lives. By age 50 years, at least 80% of women will have acquired a genital HPV infection. About 6.2 million Americans get a new genital HPV infection each year.

International

Worldwide, more than 400 million adults become infected with an STI every year. Four STIs that are spread primarily through sexual contact are completely curable—trichomoniasis, chlamydia, syphilis, and gonorrhea. These infections account for 340 million STI infections, or about 80% of the worldwide total. Approximately 9% of all persons aged 15-44 years in North America contract 1 of these STIs annually, but the rate rises to 25% in sub-Saharan Africa.

Worldwide, over 170 million cases of trichomoniasis are reported each year. Infection rates have been reported as high as 67% in Mongolia in 1988, 40-60% in Africa, and 40% in indigenous Australians older than 40 years.

Chlamydia is the next most common STI, with approximately 92 million cases a year. Prevalence of chlamydia varies enormously across the world. In the 1990s, rates among pregnant women in Europe ranged from 2.7% in Italy to 8.0% in Iceland, while studies in South America found rates of 1.9% among teenagers in Chile and 2.1% among pregnant women in Brazil. In Asia, rates among pregnant women tend to be much higher: up to 17% in India and 26% in rural Papua New Guinea. In Africa, studies of pregnant women have revealed rates from 6% in Tanzania to 13% in Cape Verde.

HPV, HSV, and gonorrhea each account for roughly 20-60 million cases of STIs per year.

The prevalence of HPV, a cause of cervical cancer, varies roughly 20-fold internationally. An analysis of worldwide prevalence was published in 2005.² Among the countries evaluated, Spain had the lowest prevalence of HPV; only 1.4% of women in Spain tested positive for HPV. The highest prevalence of HPV was seen in sub-Saharan Africa; 26% of the women in Nigeria tested positive for HPV. South America tended to have rates that were in between those of Europe and sub-Saharan Africa, while rates in Asia varied widely (with the lowest rates in Hanoi, Vietnam, and the highest in India and Korea).

In various studies, the seroprevalence of HSV-2 is higher in the United States (13-40%) than in Europe (7-16%) and is highest in Africa (30-40%).

Studies of pregnant women in Africa have found rates for gonorrhea ranging from 0.02% in Gabon to 3.1% in Central African Republic and 7.8% in South Africa. In the Western Pacific in the 1990s, the highest prevalence rates (>3%) were in Cambodia and Papua New Guinea. Other areas such as China, Vietnam, and the Philippines had rates of 1% or less. Between 1995 and 1999, a significant increase in gonorrhea incidence occurred in Eastern Europe, with the highest rates in Estonia, Russia, and Belarus.

Mortality/Morbidity

Complications from untreated infectious cervicitis depend on the pathogen. Morbidity includes pelvic inflammatory disease (PID), infertility, ectopic pregnancy, chronic pelvic pain, spontaneous abortion, cervical cancer, premature rupture of membranes, and preterm delivery. Perinatal and neonatal infections can cause mental retardation, blindness, low birth weight, stillbirth, meningitis, and death. The social stigma is strong and might expose women to verbal, emotional, or physical abuse from others, particularly male partners.

Race

No racial predilection exists. Known risk factors include urban residence and low socioeconomic status.

Sex

Male urethritis is more often symptomatic; therefore, diagnosis is usually made earlier in males than in females. Females with cervicitis are most often asymptomatic, so they do not seek evaluation or treatment as readily.

Age

Age younger than 25 years, single marital status, and a new sexual partner within the past 6 weeks are risk factors for cervicitis. Both biological (eg, postulated immaturity of the female reproductive tract) and behavioral factors (eg, greater number of partners, low awareness of acquired immunodeficiency syndrome [AIDS] and other STIs, and limited use of protection against STIs) are thought to contribute to this risk. Routine screening of sexually active adolescents and young adults is therefore recommended.

Routine chlamydia screening of sexually active young women is recommended by the US Preventive Services Task Force to prevent consequences of untreated chlamydial infection (eg, pelvic inflammatory disease, infertility, ectopic pregnancy, chronic pelvic pain). Fewer than half of young, sexually active females in the United States are screened for chlamydia, according to the Morbidity and Mortality Weekly Report (MMWR). Nationally, the annual screening rate increased from 25.3% in 2000 to 43.6% in 2006, and then decreased slightly to 41.6% in 2007.¹

Clinical

History

• 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.

Physical

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.

Causes

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.

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