eMedicine Specialties > Pediatrics: Surgery > Gynecology

Cervicitis

Latha Chandran, MD, MPH, Associate Professor of Pediatrics, Associate Dean for Academic Affairs, Director, Division of General Pediatrics, State University of New York at Stony Brook School of Medicine

Updated: Mar 6, 2008

Introduction

Background

Cervicitis is inflammation of the cervix. Patients usually present with cervical erythema and discharge.

Pathophysiology

Cervicitis is caused by a sexually transmitted bacterial infection. Infection of the cervix results in inflammation and may be accompanied by vulvovaginitis. Mucopurulent cervicitis is a clinical diagnosis, one typically characterized by friability of the cervix, mucopurulent discharge from the os, and increased numbers of polymorphs in endocervical secretions.¹ An ascending infection can cause endometritis, salpingitis, tuboovarian abscess, or perihepatitis.

Frequency

United States

In the United States, the prevalence of chlamydial infection is 5-15% in sexually active teenagers and young adults, who are asymptomatic.² The prevalence increases to almost 50% in symptomatic patients; however, the incidence of gonorrhea has declined steadily over the last 20 years.³ Adolescents and young adults continue to have the highest rates of infection, with a transmission risk of 20-50% per sexual contact. The incidence of co-infection with both gonorrheal and chlamydial organisms may be 15-20%.

International

Chlamydia trachomatis is the most prevalent bacterial pathogen that causes sexually transmitted infections worldwide. According to the World Health Organization (WHO), 50-70 million cases occur each year.

Mortality/Morbidity

Primary morbidity results from ascending infection to the uterus and fallopian tubes (pelvic inflammatory disease) that leads to chronic abdominal pain and infertility.

Age

Compared with older populations, sexually active adolescents and young adults have a higher incidence of both chlamydial and gonococcal cervicitis.

Clinical

History

Elicit the patient's history of sexual activity, number of sexual partners, and type of contraception used (if any). An increased incidence of chlamydial cervicitis in women has been associated with use of oral (PO) contraceptives.

• Most patients with cervicitis present with vaginal discharge or vaginal bleeding.
• Other associated symptoms include dyspareunia and dysuria.
• Abdominal pain and fever are associated with involvement of the upper genital tract.
• Patients with mild cervicitis may be asymptomatic, and many patients with chlamydial cervicitis are asymptomatic.

Physical

Upon physical examination, findings in the cervix include the following:

• Erythematous and inflamed cervix on speculum examination (Possible edema of the cervical ectropion may be noted.)
• Possible purulent discharge from the cervical os
• Cervix tender to palpation

Causes

• Gonorrheal and chlamydial infections
  • The most common causative organisms are Neisseria gonorrhea and C trachomatis.
  • Gonococcal and chlamydial cervicitis may be associated with upper genital tract infection.
  • Patients with gonorrhea may have associated urethritis.⁴
  • Patients with chlamydial infections are often asymptomatic.
• Other bacterial pathogens: Other bacterial pathogens implicated in cervicitis and upper genital infections include Mycoplasma genitalium, Ureaplasma urealyticum, and anaerobes, such as Streptococcus, Peptostreptococcus, and Bacteroides species. Other sexually transmitted infections, such as those caused by Trichomonas species and herpes simplex virus, also may be associated with cervicitis.
  • Trichomonas infection may result in a friable cervix with prominent papillae and punctate hemorrhages (ie, strawberry cervix). Although an uncommon finding, Trichomonas vaginalis is known to cause multiple punctate hemorrhages and swollen papillae in the cervix, giving it a strawberry appearance. This causes the cervix to become friable and bleed easily on touch.
  • Herpetic cervicitis may be associated with multiple ulcerations.

Differential Diagnoses

Child Abuse & Neglect: Sexual Abuse
Chlamydial Infections
Gonorrhea

Other Problems to Be Considered

Other causes of vaginal discharge

Physiologic leukorrhea
Vaginitis
Vaginal foreign body
Cervical ectropion
Bacterial vaginosis

Consider associated pelvic inflammatory disease, perihepatitis, or both.

Consider sexual abuse if gonococcal or chlamydial cervicitis is detected in the prepubertal child.

Workup

Laboratory Studies

• Traditional tests
  • Wet mount of the discharge usually demonstrates more than 5 WBCs per high-power field. Most practice guidelines recommend a threshold of 10-30 polymorphonuclear (PMN) leukocytes per high-power field to support the diagnosis of mucopurulent cervicitis. However, inflammation alone is not considered presumptive evidence of chlamydial infection.
  • Gram stains of the cervical mucopus may reveal gram-negative intracellular diplococci in cases of gonorrhea. Culturing in modified Thayer-Martin medium is the criterion standard for confirming gonorrhea.
  • Enzyme-linked immunosorbent assay or direct fluorescent antibody testing is often used to detect chlamydial infection. DNA probes with 90-97% sensitivity are also available for the simultaneous detection of gonococcal and chlamydial organisms.
  • When indicated, chlamydial cultures are performed on McCoy cells (evaluations in prepubertal children in whom sexual abuse is suspected, testing response to therapy in a previously treated infection).
• Newer tests
  • Several highly specific and sensitive tests have been developed. These nucleic acid amplification tests (NAATs) include the polymerase chain reaction (PCR), the ligase chain reaction (LCR),⁵ and transcription-mediated amplification (TMA). Probes used in these tests are at least 20% more sensitive than the earlier DNA probes and are the tests of choice.
  • PCR and LCR testing consists of amplification of specific DNA sequences, while TMA testing is an RNA amplification assay.
  • Although endocervical specimens are preferred, these tests may be easily performed on first-void morning urine samples. Urine NAATs are highly sensitive for the diagnosis of endocervical chlamydial infection.

Other Tests

• Because of the possible association between bacterial vaginosis and mucopurulent cervicitis, perform NAATs and look for Amsel criteria for the diagnosis of bacterial vaginosis
• Three of the following 4 criteria suffices:
  • Homogenous vaginal discharge
  • Vaginal fluid pH greater than 4.5
  • Clue cells greater than 20% of total vaginal epithelial cells on 100X magnification
  • Amine odor on addition of potassium hydroxide to vaginal fluid

Treatment

Medical Care

• Establishing the etiologic agent is a key to successful treatment (see Medication).
• Ensuring that the patient's sexual contacts receive the appropriate examination and treatment is also essential.
• Most treatment failures are actually reinfections from an untreated sexual partner.

Activity

Advise patients to abstain from sexual activity until test results after therapy are negative and partners are treated. Advise them to use condoms when they resume sexual activity.

Medication

The Centers for Disease Control and Prevention (CDC) revised their treatment guidelines for sexually transmitted diseases in 2006.⁶ Therapy for cervicitis depends on the etiologic agent. Ceftriaxone is the recommended drug for gonorrhea; doxycycline is recommended for chlamydial cervicitis. Other effective antibiotics for treatment of gonorrheal disease include cefixime 400 mg. All are administered as single PO doses. For chlamydial infections, azithromycin 1 g PO as a single dose is an acceptable alternative to doxycycline 100 mg PO bid for 7 days.

Alternatives for patients presenting with ceftriaxone allergy include spectinomycin, ciprofloxacin, or norfloxacin. Fluoroquinolones are not approved by the US Food and Drug Administration (FDA) for use in children younger than 18 years and are no longer recommended for gonorrhea in the United States because of increased resistance. Erythromycin is recommended for patients with chlamydial infections who are unable to take doxycycline. A single dose of azithromycin 1 g PO is also highly effective for treatment of chlamydial disease. If a patient has clinical cervicitis, both ceftriaxone and azithromycin are recommended as empirical treatment. Acyclovir may be used for primary herpes infection, but it is not curative, and recurrences are common. Metronidazole is the drug of choice for infection by Trichomonas organisms.

Antibiotics

Testing to determine the specific microorganism causing the infection is recommended because both chlamydial and gonococcal infections are reportable to state health departments. If diagnostic tools (eg, Gram stain, microscope) are unavailable, treat patients for both infections.

Ceftriaxone (Rocephin)

First choice for treatment for gonococcal cervicitis.

Dosing

Adult

125 mg IM as single dose

Pediatric

Administer as adults

Interactions

Concurrent use with furosemide or aminoglycosides may increase renal toxicity; decreases efficacy of PO contraceptives

Contraindications

Documented hypersensitivity; hyperbilirubinemic neonates

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution with history of penicillin allergy; mix with lidocaine 1% to decrease injection pain; reversible sonographic gallbladder anomalies reported

Doxycycline (Bio-Tab, Vibramycin, Doryx)

Treatment of choice for chlamydial cervicitis.

Dosing

Adult

100 mg PO bid for 7 d

Pediatric

<8 years: Contraindicated
>8 years: Administer as in adults

Interactions

Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate (administer doxycycline 1 h before or 2 h after); tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of PO contraceptives, causing breakthrough bleeding and increasing risk of pregnancy; barbiturates, rifampin, phenytoin, or carbamazepine induce metabolism of doxycycline; milk or dairy products, calcium, and iron may decrease doxycycline absorption; administer 1 h before or 2-3 h after milk, dairy products, or iron ingested

Contraindications

Documented hypersensitivity; severe hepatic dysfunction; pregnancy

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

May cause photosensitivity (avoid prolonged exposure to sunlight or tanning equipment); associated with retardation of skeletal development in infants; use during tooth development (last half of pregnancy through age 8 y) can permanently discolor teeth

Metronidazole (Flagyl)

Synthetic antimicrobial agent active against most obligate anaerobes. Used in Trichomonas infection.

Dosing

Adult

2 g PO as single dose

Pediatric

15 mg/kg/d PO divided q8h for 7 d; not to exceed 1 g/d

Interactions

May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity of metronidazole; disulfiram reaction may occur with PO ingested ethanol

Contraindications

Documented hypersensitivity; first trimester of pregnancy

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Pregnancy category X in first trimester; caution in breastfeeding and later stages of pregnancy; adjust dose in patients with hepatic disease; monitor for seizures and development of peripheral neuropathy; blood dyscrasias have been reported rarely

Azithromycin (Zithromax)

Macrolide antibiotic for treatment of C trachomatis infection.

Dosing

Adult

1 g PO as single dose 1 h ac or 2 h pc

Pediatric

10 mg/kg PO as single dose; not to exceed 1 g/dose

Interactions

May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine

Contraindications

Documented hypersensitivity; hepatic impairment; do not administer with pimozide

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution with hepatic dysfunction

Cefixime (Suprax)

Effective PO for treating gonococcal cervicitis. Arrests bacterial cell-wall synthesis and inhibits bacterial growth by binding to one or more penicillin-binding protein.

Dosing

Adult

400 mg PO as single dose

Pediatric

<45 kg: 8 mg/kg PO as single dose
>45 kg: Administer as in adults

Interactions

Coadministration of aminoglycosides increases nephrotoxicity; probenecid may increase effects of cefixime

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy; cross sensitivity exists with penicillins; administer with food to minimize adverse GI effects

Spectinomycin (Trobicin)

Inhibits protein synthesis in bacterial cells. Site of action is 30S ribosomal subunit and structurally different from related aminoglycosides. Alternative antimicrobial in to treat urethral, endocervical, or rectal gonococcal infections in patients who cannot take cephalosporins or fluoroquinolones. Can be administered to pregnant women allergic to cephalosporins.

Dosing

Adult

2 g IM as single dose

Pediatric

<45 kg and cannot tolerate ceftriaxone: 40 mg/kg IM as single dose; not to exceed 2 g/dose
>45 kg and cannot tolerate ceftriaxone: Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Benzyl alcohol used as diluent associated with fatal gasping syndrome in infants; antibiotics may mask or delay symptoms of incubating syphilis; perform serologic testing for syphilis in all patients with gonorrhea at time of diagnosis followed by additional testing after 3 mo; monitor clinical effects to detect resistance by N gonorrhea

Follow-up

Further Outpatient Care

• Gonococcal cultures are recommended 4-8 weeks after standard treatment or one week after alternative regimens are used.
• Routine testing for chlamydial eradication is not indicated after treatment; however, repeat testing may be worthwhile after 1-2 months in patients with a high risk of reinfection to identify inadequate treatment of their partners or new infections.
• Routine annual screening for chlamydial infection is recommended in all sexually active adolescents because of the high prevalence of asymptomatic females.
• Treat sexual partners.

Complications

• Ascending infection
• Arthritis, rash, or both (from disseminated gonorrhea)

Prognosis

• The prognosis is excellent when the patient is compliant.

Patient Education

• Instruct patients to avoid sexual intercourse until treatment efficacy is confirmed.
• Instruct patients how to prevent reinfection by using condoms.
• Recommend prevention counseling to patients with sexually transmitted infections.
• Recommend that patients receive screening for other diseases, including HIV infection and syphilis.
• For excellent patient education resources, visit eMedicine's Women's Health Center. Also, see eMedicine's patient education article Cervicitis.

Miscellaneous

Special Concerns

• Adolescent compliance with the recommended regimen is a notable concern.
• A single dose of azithromycin 1 g PO is effective therapy for chlamydial infections and eliminates the need for ongoing treatment compliance.
• Isolation of gonococci in cervical or vaginal secretions in a child is definitive evidence of sexual abuse.

References

1. Marrazzo JM. Mucopurulent cervicitis: no longer ignored, but still misunderstood. Infect Dis Clin North Am. Jun 2005;19(2):333-49, viii. [Medline].

2. Darville T. Chlamydia. Pediatr Rev. Mar 1998;19(3):85-91. [Medline].

3. Darville T. Gonorrhea. Pediatr Rev. Apr 1999;20(4):125-8. [Medline].

4. Simpson T, Oh MK. Urethritis and cervicitis in adolescents. Adolesc Med Clin. Jun 2004;15(2):253-71. [Medline].

5. Smith KR, Ching S, Lee H, et al. Evaluation of ligase chain reaction for use with urine for identification of Neisseria gonorrhoeae in females attending a sexually transmitted disease clinic. J Clin Microbiol. Feb 1995;33(2):455-7. [Medline].

6. 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].

7. 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].

8. Sexually transmitted diseases: gonorrhea, Chlamydia trachomatis, pelvic inflammatory disease and syphilis. In: Emans SJ, Laufer MR, Goldstein DP, et al, eds. Pediatric and Adolescent Gynecology. 4^th ed. Philadelphia, PA: Lippincott-Raven; 1998:457-504.

9. Rome ES. Sexually transmitted diseases: testing and treating. Adolesc Med. Jun 1999;10(2):231-41, vi. [Medline].

10. Stuart GS, Castano PM. Sexually transmitted infections and contraceptives: selective issues. Obstet Gynecol Clin North Am. 30(4):795-808. [Medline].

Keywords

cervicitis, cervix, gonococcal cervicitis, chlamydial cervicitis, vaginal discharge, sexually transmitted disease, STD, cervical infection, cervical inflammation, cervical erythema, vulvovaginitis, endometritis, salpingitis, tubo-ovarian abscess, perihepatitis, gonorrhea, Neisseria gonorrhea, Chlamydia trachomatis, C trachomatis, Neisseria gonorrhea, N gonorrhea vaginal bleeding, PID, pelvic inflammatory disease

Contributor Information and Disclosures

Author

Latha Chandran, MD, MPH, Associate Professor of Pediatrics, Associate Dean for Academic Affairs, Director, Division of General Pediatrics, State University of New York at Stony Brook School of Medicine
Latha Chandran, MD, MPH is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Medical Editor

Elizabeth Alderman, MD, Director of Fellowship Training Program, Director, Adolescent Ambulatory Service, Clinical Professor, Department of Pediatrics, Division of Adolescent Medicine, Albert Einstein College of Medicine and Montefiore Medical Center
Elizabeth Alderman, MD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, North American Society for Pediatric and Adolescent Gynecology, and Society for Adolescent Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Wayne Wolfram, MD, MPH, Clinical Associate Professor, Departments of Pediatrics, Children's Hospital and University of Cincinnati
Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

Paul D Petry, DO, FACOP, FAAP, Consulting Staff, Freeman Pediatric Care, Freeman Health System
Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Chief Editor

Maureen Strafford, MD, Arnold P Gold Foundation Associate Professor, Departments of Anesthesiology and Pediatrics, Tufts University and Tufts-New England Medical Center
Maureen Strafford, MD is a member of the following medical societies: American Medical Women's Association, American Pain Society, American Society of Anesthesiologists, International Anesthesia Research Society, Society for Education in Anesthesia, Society for Pediatric Anesthesia, and Society of Cardiovascular Anesthesiologists
Disclosure: Nothing to disclose.

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