Version May 2024
INTRODUCTION — Cervicitis refers to inflammation of the uterine cervix. The inflammation primarily affects the columnar epithelial cells of the endocervical glands but can also affect the squamous epithelium of the ectocervix. It may be due to an infectious or noninfectious etiology and may be acute or chronic. Acute cervicitis is often due to infection (eg, chlamydia, gonorrhea), although a specific infection cannot be determined in a large proportion of cases. Chronic cervicitis usually has a noninfectious source.
This topic will review the background, evaluation, diagnosis, and management of acute cervicitis in postpubertal and adult females. Related discussions of vaginitis (in adults and children) and endometritis are presented separately.
●(See "Vaginitis in adults: Initial evaluation".)
●(See "Vulvovaginitis in the prepubertal child: Clinical manifestations, diagnosis, and treatment".)
●(See "Endometritis unrelated to pregnancy".)
In this topic, when discussing study results, we will use "woman/en" as used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transgender and gender-diverse individuals.
EPIDEMIOLOGY AND ETIOLOGY
Prevalence estimates — The exact prevalence of cervicitis is difficult to define because there is no standard definition or case reporting among studies, and the prevalence likely varies by population. In sexually transmitted infection (STI) clinics, it may affect as many as 30 to 45 percent of patients [1,2]. Sexual activity is the main risk factor as it is a risk factor for the causative infections. It is helpful for clinicians to know the STI prevalence rates for their communities. (See 'Infectious etiologies' below.)
Infectious etiologies — An infectious etiology can be suspected when a specific organism associated with cervicitis, including sexually transmitted ones discussed below, is identified.
●Most common – When an infectious etiology can be documented, Chlamydia trachomatis (typically serovars D-K) and Neisseria gonorrhoeae are the most common organisms identified [3], even though only a relatively small proportion of individuals with these infections develops cervicitis. Chlamydial cervicitis occurs more often than gonococcal, and both primarily affect the columnar epithelium of the endocervix. Combined, these infections account for approximately 50 percent of cases of cervicitis [4-6].
●Common – Other infectious etiologies include herpes simplex virus (HSV), Mycoplasma genitalium, Trichomonas vaginalis, which primarily affect the squamous epithelium of the ectocervix [3,7-10]. Bacterial vaginosis (BV) and streptococci (group A) have also been implicated as causative agents of acute cervicitis [1,11,12]. BV is unlikely to be a cause of isolated cervicitis without concurrent vaginal findings. Tuberculosis involves the cervix in a small proportion of females with tuberculous endometritis [13,14] (see "Endometritis unrelated to pregnancy", section on 'Tuberculous endometritis').
●Uncommon – Case reports have described cervicitis associated with other infectious agents (bacteria, viruses, fungi, parasites) [2,15-23]. Although Mycoplasma hominis, Ureaplasma urealyticum, cytomegalovirus, and group B beta-hemolytic streptococci are commonly found in the genital tract, there is little evidence that they independently cause cervicitis [24-26].
There is no evidence that human papillomavirus infection induces cervical inflammation, but it can cause other histologic changes (eg, cervical intraepithelial neoplasia). However, organisms involved in cervicitis may act as potential cofactors (not direct cause) in development of cervical neoplasia (eg, U. urealyticum) [27].
•(See "Virology of human papillomavirus infections and the link to cancer".)
•(See "Cervical intraepithelial neoplasia: Terminology, incidence, pathogenesis, and prevention".)
Noninfectious causes — In cases where no infection is identified, cervicitis is usually caused by mechanical or chemical irritation.
●Common – Sources of mechanical irritation include trauma from surgical instruments or foreign objects (eg, pessary, diaphragm, tampon, cervical cap, or condom). Chemical irritation can be caused by exposure to latex, vaginal douches, spermicides, or contraceptive creams. Commercial products may also contain irritating ingredients such as povidone-iodine, surfactants, topical anesthetics, or cornstarch [28].
●Less common – Less common noninfectious causes include radiation therapy and systemic inflammatory diseases such as Behçet syndrome or lichen planus. In hypoestrogenic females, desquamative inflammatory vaginitis can cause inflammation of the cervix along with a more diffuse vaginal inflammation; in these cases, the purulent discharge comes from both the cervix and vagina. (See "Desquamative inflammatory vaginitis (DIV)".)
●Rare – Rare causes of noninfectious cervicitis documented in case reports include congenital plasminogen deficiency with resultant ligneous lesions of the cervix, cystic cervicitis, small cell carcinoma, and lymphoma [29-31].
CLINICAL PRESENTATION — Cervicitis is diagnosed clinically. Individuals with cervicitis may have presenting symptoms or be asymptomatic, in which case the diagnosis is made at the time of physical examination for other indications. In an observational study that included 59 women presenting for routine cervical cancer screening, 24 percent had signs of cervicitis on examination, but only 5 percent had symptoms (vaginal discharge) [4].
●Characteristic symptoms include either or both [3,5]:
•Purulent or mucopurulent (yellow) endocervical exudate that is visible either in the endocervical canal or on an endocervical swab
•Endocervical bleeding that is easily caused by gently passing an endocervical swab through the cervical os
●Additional symptoms or signs can include [2,32]:
•Dysuria, urinary frequency
•Dyspareunia
•Vulvovaginal irritation
•Edema of the cervical ectropion
•Postcoital bleeding
Urinary symptoms are generally due to concomitant urethritis, which occurs in approximately 15 percent of females with cervical chlamydia infection. Pain and fever are atypical in the absence of upper tract infection (endometritis, pelvic inflammatory disease [PID]) or herpes simplex virus (HSV) infection.
DIAGNOSTIC EVALUATION
History — Evaluation of patient risk factors is important and should include a detailed discussion of sexual history (number of partners, condom use, type of sexual activity, new sex partner, sex partner with concurrent sex partners, sex partner with a sexually transmitted infection [STI]), vaginal hygiene (douching), and age (<25). Clinicians should be aware of STI prevalence in their communities. Factors associated with noninfectious cervicitis are listed above. (See 'Noninfectious causes' above.)
To generate a complete differential diagnosis, we also inquire about:
●Vaginal discharge – The typical discharge of cervicitis is purulent or mucopurulent (yellow). By contrast, the vaginal discharge usually associated with bacterial vaginosis (BV) is gray or off-white and malodorous, with vulvovaginal candidiasis scant and thick and with trichomoniasis brownish or bloody and malodorous.
●Vaginal bleeding – Patients with cervicitis often present with intermenstrual or postcoital vaginal bleeding. We ask about symptoms in relation to timing of vaginal sexual activity.
●Burning, irritation, or other local discomfort – Isolated cervicitis is typically painless. However, coexisting vaginal infections with Candida species may result in itching while BV may result in minor irritative symptoms.
●Abdominal or pelvic pain – Cervicitis alone generally does not cause pelvic or abdominal pain. However, patients with associated endometritis or pelvic inflammatory disease (PID) often complain of pain.
●Timing of symptoms – Symptoms of Candida vulvovaginitis often occur in the premenstrual period, while symptoms of trichomoniasis and BV often occur during or immediately after the menstrual period. Symptoms of cervicitis typically do not follow any specific time pattern.
●Estrogen status – Individuals with genitourinary syndrome of menopause (GSM) can present with symptoms similar to cervicitis. Common additional findings of GSM include tissue fragility, labial resorption, and decrease or loss of vaginal rugae and secretions. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Clinical manifestations and diagnosis", section on 'Clinical presentation'.)
Discussion of patient history that is suggestive of Candida vulvovaginitis, BV, and trichomoniasis is presented elsewhere.
●(See "Candida vulvovaginitis: Clinical manifestations and diagnosis", section on 'Symptoms'.)
●(See "Bacterial vaginosis: Clinical manifestations and diagnosis", section on 'Clinical features'.)
●(See "Trichomoniasis: Clinical manifestations and diagnosis" and "Trichomoniasis: Clinical manifestations and diagnosis", section on 'Female'.)
Physical examination — All patients with symptoms suggestive of cervicitis undergo a physical examination that includes pelvic and vaginal evaluations (algorithm 1).
Hallmark findings — The classic findings at the time of speculum examination are (1) a purulent/mucopurulent discharge on the ectocervix or exuding from the endocervical canal (picture 1) or (2) bleeding upon touching the cervix with a cotton or Dacron swab (ie, friability) [3]. However, these findings are not diagnostic of etiology [33].
In infection-related cases, the cervical appearance varies with the type of infecting organism and severity of infection. The quantity of cervical organisms correlates with the degree of inflammation.
●Mucopurulent cervical discharge, cervical friability, and edema in the zone of ectopy are characteristic of both gonococcal and chlamydial cervicitis (picture 2 and picture 1). The presence of one or more of these signs is more predictive of gonorrhea or chlamydia infection in younger compared with older women (1 in 3 women <25 years infected versus 1 in 6 to 11 women >25 years) [33].
●Punctate hemorrhages ("strawberry cervix" or colpitis macularis) are characteristic of T. vaginalis infection (picture 3). Erosive inflammation can also be present. (See "Trichomoniasis: Clinical manifestations and diagnosis", section on 'Female'.)
●Diffuse vesicular lesions/ulceration, which may include sloughing of the epithelium, suggest herpes simplex virus (HSV) infection (picture 4). Erosive inflammation can occur as well. Primary HSV infection is often associated with systemic symptoms as well. Subclinical HSV shedding is not typically associated with cervicitis [34]. (See "Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection".)
The clinical features of cervicitis caused by M. genitalium are not well-defined; some studies suggest that the majority of cervical infections with this possible pathogen do not elicit visible signs of inflammation [9,35,36]. It is not generally possible to distinguish infectious from noninfectious acute cervicitis by physical examination. (See 'Recurrent or persistent disease' below.)
In any person with suspected cervicitis, visual evaluation of the cervix should be followed by bimanual examination of the pelvic organs to exclude PID. (See "Pelvic inflammatory disease: Clinical manifestations and diagnosis", section on 'Diagnosis'.)
Alarm findings — Patients meeting criteria for PID (cervical motion tenderness or uterine tenderness or_ adnexal tenderness) in addition to cervicitis should be evaluated and treated appropriately. Most patients with PID have either mucopurulent cervical discharge or leukorrhea on saline preparation of vaginal fluid [3].
●(See "Pelvic inflammatory disease: Clinical manifestations and diagnosis".)
●(See "Pelvic inflammatory disease: Treatment in adults and adolescents".)
Individuals with erosive cervical lesions suggestive of cancer should be further evaluated with Pap smear, colposcopy, cervical biopsy, and referral to a gynecologic oncologist as needed. (See "Invasive cervical cancer: Epidemiology, risk factors, clinical manifestations, and diagnosis".)
Laboratory evaluation — If cervicitis is suspected based on cervical examination findings, further evaluation should be performed to determine the cause and exclude STIs [3]. We routinely evaluate all patients with suspected cervicitis for C. trachomatis, N. gonorrhoeae, trichomoniasis, and BV [3].
●Vaginal pH and saline microscopy – As individuals with cervicitis may also have concurrent vaginitis, we perform vaginal pH and saline microscopy. Presence of polymorphonuclear cells on microscopy suggests of vaginal and/or cervical infection; absence of such cells suggests alternate etiologies (table 1). (See "Vaginitis in adults: Initial evaluation", section on 'Test vaginal discharge'.)
●Testing for chlamydia and gonorrhea – We advise nucleic acid amplification testing (NAAT) for N. gonorrhoeae and C. trachomatis. These assays can be performed on a swab of vaginal fluid, an endocervical sample (cells are obtained by rotating a swab within the endocervical canal while applying gentle lateral pressure), or, if a speculum examination is not possible, on urine [3]. Application of NAAT to these samples has excellent performance relative to that for direct endocervical sampling. (See "Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents", section on 'Nucleic acid amplification' and "Clinical manifestations and diagnosis of Chlamydia trachomatis infections", section on 'Nucleic acid amplification testing (test of choice)'.)
●Testing for BV and trichomoniasis – T. vaginalis may cause isolated cervicitis; BV typically affects the vagina (table 1). Either infection may occur concurrently with cervicitis. Microscopy (wet prep), the amine (whiff) test, and vaginal pH are useful for identifying BV. The sensitivity of microscopy to detect T. vaginalis is relatively low (approximately 50 percent); therefore, symptomatic individuals with cervicitis and negative microscopy for trichomonads should undergo further testing, preferably NAAT. NAAT offers a more sensitive means of detection than the other options and can be performed on the same screening specimen used for chlamydia and gonorrhea testing. (See "Bacterial vaginosis: Clinical manifestations and diagnosis", section on 'Diagnostic evaluation' and "Trichomoniasis: Clinical manifestations and diagnosis", section on 'Diagnostic evaluation'.)
●Testing for M. genitalium – Some experts suggest testing patients with cervicitis with an M. genitalium NAAT, if available, particularly in patients with cervicitis that does not respond to empiric treatment for gonorrhea and chlamydia. NAATs are the only clinically useful method of detecting M. genitalium on urogenital specimens. (See "Mycoplasma genitalium infection", section on 'Diagnosis'.)
Routinely testing for infections other than T. vaginalis, gonorrhea, chlamydia, M. genitalium, and BV is not useful unless a specific organism, such as HSV, is suspected. There is generally no role for other bacterial cultures (eg, general vaginal culture) or polymerase chain reaction, which can be very costly and often detects vaginal bacteria that are unrelated to the cervical process. (See "Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection".)
Unnecessary tests — While Gram stain and histopathology/cytology can be performed, we do not find these tests helpful in evaluating patients with findings of cervicitis on physical examination.
●Gram stain – For Gram stain, while the presence of >10 polymorphonuclear cells per oil immersion field (ie, high power field) is indicative of mucopurulent cervicitis and suggests chlamydial or gonococcal infection, this information is of limited value since a specific diagnosis requires identification of an organism [33]. In addition, the criterion for elevated number of polymorphonuclear cells in cervical exudate has not been standardized [3]. While the absence of leukorrhea in vaginal fluid (ie, >10 polymorphonuclear cells per oil immersion field) may help exclude cervicitis, more data are needed [2].
●Histopathology or cytology – Histopathology/cytology is unnecessary in diagnostic evaluation of cervicitis, although cervical dysplasia can be associated with abnormal cervical bleeding. If performed, acute disease is characterized by stromal edema, vascular congestion, and a predominance of neutrophils in the inflammatory infiltrate. Chronic disease is characterized by an inflammatory infiltrate predominantly of round cells (lymphocytes, plasma cells, histiocytes); squamous metaplasia is common, and stromal fibrosis and granulation tissue may be present.
DIAGNOSIS — The diagnosis of acute cervicitis is clinical and, based upon the presence of purulent or mucopurulent cervical exudate or sustained endocervical bleeding (friability), easily induced by gently touching the area with a swab [2,3].
DIFFERENTIAL DIAGNOSIS — Individuals with signs or symptoms of cervicitis are evaluated for other processes that can present with cervicitis as one component.
●Most common – The most common differential diagnoses are sexually transmitted infections (STIs; gonorrhea, chlamydia, trichomoniasis, herpes simplex virus (HSV) 1 or 2 infection, M. genitalium) and bacterial vaginosis (BV) [18]. Cervical ectropion, commonly seen in adolescent females, individuals using estrogen-containing contraceptives, and pregnant persons, can mimic acute cervicitis. (See "Benign cervical lesions and congenital anomalies of the cervix", section on 'Ectropion'.)
●Less common – Those whose testing for infection is negative are evaluated for contact dermatitis, dermatoses such as lichen planus, and desquamatory inflammatory vaginitis (DIV). The approach to evaluation is the same for cervical presentations of these entities as vaginal/vulvar presentations.
•Contact dermatitis or allergy (See "Vaginitis in adults: Initial evaluation", section on 'No diagnosis after initial evaluation'.)
•Vulvar lichen planus – Lichen planus is an inflammatory dermatologic condition that most commonly occurs in females aged 50 to 60 years (picture 5). (See "Vulvar lichen planus".)
•Desquamative inflammatory vaginitis (DIV) – DIV is a noninfectious inflammatory vaginitis. Patients with DIV typically have a high vaginal pH, negative amine test, and saline wet mount microscopy shows an increased number of parabasal and inflammatory cells, with a leukocyte to epithelial cell ratio greater than 1:1 (picture 6) [37,38]. (See "Desquamative inflammatory vaginitis (DIV)".)
●Rare – Isolated cervicitis related to hypoestrogenism alone (ie, no infection) is unusual. Postmenopausal individuals may have cervicitis as a result of their hypoestrogenic status but typically have findings of atrophic vaginitis as well. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Clinical manifestations and diagnosis".)
TREATMENT — The goals of treatment are relief of symptoms and prevention of infection of the upper genital tract.
Rationale for treatment — Cervicitis is treated, often before test results are available, because infectious cervicitis can result in additional problems, including:
●Ascending infection – Some cervical infections can ascend and cause endometritis or pelvic inflammatory disease (PID) [3]. Sequelae of PID include chronic pelvic pain, infertility, and an increased risk of ectopic pregnancy.
●Sexual transmission – The pathogens can be transmitted to sexual partners.
●Increased susceptibility to HIV infection – Cervicitis appears to be associated with a significant increase in risk of HIV-1 acquisition and shedding [39].
•(See "Pelvic inflammatory disease: Long-term complications".)
●Pregnancy complications – In pregnant persons, it may cause pregnancy or neonatal complications, including preterm birth and low birth weight, as a result of infection of the fetus, placenta, amniotic fluid, decidua, or membrane (table 2) [24].
•(See "Spontaneous preterm birth: Overview of risk factors and prognosis", section on 'Infection'.)
•(See "Infants with fetal (intrauterine) growth restriction", section on 'Pathophysiology and etiology'.)
Treatment approaches — Individuals with clinically diagnosed cervicitis are offered treatment regardless of symptomatology. The goals of treatment are relief of symptoms and prevention of infection of the upper genital tract. Patients can be offered empiric therapy (ie, treat without waiting for test results), treatment based on the risk of having a sexually transmitted infection (STI), or targeted therapy (ie, infection-focused treatment as determined by test results). As studies comparing the approaches are lacking, all approaches are reasonable and patient preferences influence the decision.
Empiric therapy — We suggest that patients with cervicitis receive empiric antibiotic therapy at the time of initial evaluation, without waiting for results of laboratory tests, especially if demographic and/or behavioral risk is consistent with STI acquisition, follow-up is uncertain, if nucleic acid amplification testing (NAAT) is not available, or if a relatively insensitive diagnostic test is used in place of NAAT [3]. We provide empiric treatment that covers both gonorrhea and chlamydia infections because these are the most common infectious etiologies of cervicitis [3]. (See 'Targeted treatment of specific infections' below.)
Treatment based on STI risk — The decision for treatment can be made based on the individual's risk of acquiring an STI. While using STI risk assessment to influence treatment decision is common practice, solely using this approach to make treatment decisions has not been vetted with prospective trials. Limitations include potential limited accuracy of the patient's sexual history and the clinician's need to know local disease prevalence rates.
●High risk of STI acquisition – Treatment should be offered to individuals at high risk of STI acquisition [3]. High-risk status includes individuals age <25 years and/or those with a new sex partner, a sex partner with concurrent sex partners, or a sex partner with a known STI. Presumptive treatment includes coverage of both chlamydia and gonorrhea infections.
•Chlamydia – The minimum empiric regimen should include coverage of chlamydia, especially for females ≤25 years old, as the prevalence of this infection is highest in this age group. Other risk factors for chlamydia are history of a previous chlamydial infection in the prior several months, new or more than one sexual partner, and inconsistent use of condoms.
-(See 'Targeted treatment of specific infections' below.)
-(See "Epidemiology of Chlamydia trachomatis infections".)
•Gonorrhea – We follow the Centers for Disease Control and Prevention's (CDC) Sexually Transmitted Diseases Treatment Guidelines and add therapy for gonorrhea if either the patient's risk is high or if the local prevalence of gonorrhea infection is high [3,40]. The threshold prevalence that defines "high" is not clear, but most experts agree that >5 percent is reasonable, given the consequences of untreated infection and the ease with which treatment can be accomplished (ie, single-dose therapy) [2,3].
-(See 'Targeted treatment of specific infections' below.)
-(See "Epidemiology and pathogenesis of Neisseria gonorrhoeae infection".)
●Low risk of STI acquisition – Individuals at low risk for having an STI have the option of empiric treatment (coverage for both chlamydia and gonorrhea) or waiting for test results to determine treatment decisions. Even for those at low risk of STIs, empiric antibiotic therapy is reasonable if patient follow-up of test results is a concern or the local prevalence of gonorrhea or chlamydia infection is high [3]. We take this approach and generally treat low-risk individuals for both infections as well. We discuss that empiric treatment is not diagnostic for infection.
Targeted treatment of specific infections — In this approach, treatment decisions are deferred until the laboratory and microscopy results are available. Findings guide targeted therapy. Individuals who are diagnosed with chlamydia, gonorrhea, or trichomoniasis infection are also offered partner evaluation and/or therapy as well as reevaluated three months after treatment [3]. (See 'Sexual partners' below and 'Counseling and follow-up' below.)
Treatment of these infections is indicated for relief of symptoms, to prevent transmission to uninfected sexual partners, and to prevent upper genital tract disease (endometritis, PID) and its sequelae. If more than one infection is identified (eg, chlamydial cervicitis and bacterial vaginosis [BV]), all should be treated. (See "Endometritis unrelated to pregnancy" and "Pelvic inflammatory disease: Treatment in adults and adolescents".)
●Chlamydia – Treatment options include [3,32]:
•Preferred – Doxycycline 100 mg orally twice daily for seven days. This regimen is preferred for individuals with confirmed or suspected gonorrhea coinfection.
•Alternatives – If doxycycline is not available or not tolerated, alternative treatment options include azithromycin 1 g orally once or levofloxacin 500 mg orally daily for seven days.
Detailed discussion of chlamydia treatment, coinfections, and special populations is found separately. (See "Treatment of Chlamydia trachomatis infection".)
●Gonorrhea – We follow the CDC guidelines for treatment and use ceftriaxone as a single intramuscular dose determined by the patient's weight [3,40].
•Weight <150 kg – Ceftriaxone 500 mg intramuscularly once
•Weight ≥150 kg (300 lbs) – Ceftriaxone 1 g intramuscularly once
If chlamydia testing is positive or if chlamydia-specific test results are not available, the patient is also treated with doxycycline 100 mg orally twice a day for seven days [3,40]. If a chlamydia-specific test has been performed and is negative, then doxycycline treatment is not needed.
For treatment of gonorrhea, fluoroquinolones and doxycycline are not appropriate alternatives because of increasing resistance to these drugs, nor is therapy with oral azithromycin alone [3,40,41]. (See "Treatment of uncomplicated gonorrhea (Neisseria gonorrhoeae infection) in adults and adolescents", section on 'Preferred regimen'.)
The management of the penicillin-allergic patient depends on the clinical suspicion of true allergy and the type of allergy (eg, morbilliform rash versus immunoglobulin E [IgE]-mediated reactions, such as urticaria). Treatment of patients with drug allergies and antibiotic resistance is discussed separately. (See "Treatment of uncomplicated gonorrhea (Neisseria gonorrhoeae infection) in adults and adolescents", section on 'Alternate regimens'.)
●M. genitalium – If the organism is identified by laboratory testing, two-stage treatment is advised and is ideally based on results from drug-resistance testing, if available [3]. (See "Mycoplasma genitalium infection", section on 'Regimen selection for M. genitalium'.)
●Bacterial vaginosis – Oral or topical medication may be used (table 3). Treatment of sexual partners is not required. The presentation, diagnosis, and management of patients with BV is discussed in detail in related content.
•(See "Bacterial vaginosis: Clinical manifestations and diagnosis".)
•(See "Bacterial vaginosis: Initial treatment".)
●T. vaginalis – Females with T. vaginalis are treated with metronidazole 500 mg orally twice daily for seven days [3]. An alternative option is tinidazole as a single oral dose of 2 g (four 500 mg tablets). Sexual partners should be treated. (See "Trichomoniasis: Clinical manifestations and diagnosis".)
●Herpes simplex virus – Treatment options for the first episode of herpes simplex virus (HSV) infection include [3] (see "Treatment of genital herpes simplex virus infection"):
•Acyclovir – 400 mg orally three times per day for 7 to 10 days
•Famciclovir – 250 mg orally three times daily for 7 to 10 days
•Valacyclovir – 1000 mg orally twice daily for 7 to 10 days
No identifiable pathogen — Management of cervicitis in which an infectious agent has not been identified during the diagnostic evaluation is controversial, although this is a common clinical scenario. Data are sparse, and there is no strong evidence to justify suggesting one treatment approach over another [17,42,43].
We take the following approach:
●If testing for infectious etiologies is negative, the patient has not received any antimicrobial treatment, and the cervicitis has not resolved at a follow-up visit, we offer one course of antibiotic therapy with doxycycline 100 mg orally twice daily for seven days. (See 'Empiric therapy' above.)
●If antimicrobial therapy has been given but cervicitis symptoms persist, we repeat testing for infectious etiologies and exclude noninfectious causes. Noninfectious causes can include foreign body irritation (eg, diaphragm), chemical irritation (eg, douching), cervical dysplasia, and/or idiopathic inflammation of the cervical ectropion [3]. Any identified infections are treated as per guidelines. (See 'Targeted treatment of specific infections' above.)
●If symptoms and clinical findings of acute cervicitis persist for more than three months despite antibiotics and other causes have been excluded, the patient is diagnosed with persistent noninfectious cervicitis. Management of these patients is discussed below. (See 'Recurrent or persistent disease' below.)
Incidental finding on histology or cytology — Cervicitis can be diagnosed at the time of cervical biopsy or Pap testing. In general, these patients do not require antibiotic treatment.
●Histology – Treatment is not indicated for asymptomatic individuals who undergo cervical biopsy for the evaluation of cervical intraepithelial neoplasia and are found to have histologic, but no clinical, evidence of cervicitis. Histologic inflammation is a poor indicator of a specific infection [2]. Although follicular cervicitis (lymphoid follicles beneath the epithelium) suggests, but is not pathognomonic of, chlamydial cervicitis [5,44,45], follicular cervicitis can also occur with noninfectious cervicitis. Diagnostic testing is needed in these cases to confirm or exclude a specific infection and to guide treatment. (See 'Laboratory evaluation' above.)
●Cytology – Inflammation on cervical cytology is not an indication for treatment. The presence of a few lymphocytes on cytologic smears is normal and should not be misdiagnosed as inflammation.
Sexual partners — Sexual partners of patients with chlamydia, gonorrhea, or trichomoniasis should be treated for the STI for which the patient received treatment. The optimal approach for sexual partners of individuals with confirmed M. genitalium infection is less clear. (See "Mycoplasma genitalium infection", section on 'Partner management'.)
To avoid reinfection, patients and their sexual partners should abstain from sexual intercourse until antibiotic therapy is completed (seven days after a single-dose regimen or after completion of a seven-day regimen) and symptoms have resolved [3]. (See 'Targeted treatment of specific infections' above.)
Other populations
●Pregnant individuals – Diagnosis of cervicitis for pregnant persons is the same as above [3]. For treatment, azithromycin is preferred as doxycycline and fluoroquinolones are generally avoided in pregnancy.
●Individuals living with HIV – No data suggest different treatment for this patient population [3]. Cervicitis is thought to increase HIV-1 shedding from the cervix in the presence of cervicitis; treatment reduces shedding. Women with HIV were observed to have a high prevalence of M. genitalium (7.4 percent), which was associated with increased cytokines in cervicovaginal fluid [46]. In this population, treatment that covers for M. genitalium may be important in decreasing the risk of HIV transmission to an HIV-negative sexual partner. (See 'Targeted treatment of specific infections' above.)
●Individuals with a foreign body/substance – For individuals with cervicitis that appears to be associated with a foreign body/substance, removal or avoidance of the foreign body/substance will often lead to resolution of inflammation. Therefore, chemical douches, vaginal contraceptives and deodorants, and pessaries should be discontinued and the patient reevaluated for therapeutic response. For those with mild to moderate symptoms and no purulent discharge, we remove the foreign body/substance and assess for symptom resolution before we treat with an antimicrobial drug such as topical metronidazole or clindamycin. For patients with severe purulent vaginitis associated with a foreign body, we remove the foreign body and treat with antibiotic treatment (oral amoxicillin or topical metronidazole or clindamycin), although there are no data to guide the choice of drug therapy. Unusual examples of retained foreign bodies an IUD with confirmed actinomyces infection or retained vaginal cerclage.
●Individuals with an intrauterine device (IUD) – Individuals with an IUD who also develop symptoms or signs of cervicitis can generally be treated for the cervicitis with the IUD in place. One exception is confirmed infection with actinomyces; in this setting the IUD is removed to facilitate treatment. If a patient has chronic cervicitis and other causes have been excluded, it may be reasonable to remove the IUD to assess for symptom resolution. In one trial of 132 women with copper IUDs and cervicitis, the cervicitis resolved in 131 women after treatment with daily oral estriol 0.25 mg for three months [47,48]. However, oral estriol is not universally available, and empiric estrogen treatment is not advised in the absence of established indications. Patients with an IUD and PID are treated as per PID guidelines [3]. (See "Intrauterine contraception: Management of side effects and complications", section on 'Infection and/or pelvic inflammatory disease'.)
COUNSELING AND FOLLOW-UP — Symptoms of cervicitis typically respond within a week or two of treatment. In general, patients and their sexual partners should abstain from sexual intercourse until treatment has been completed (seven days after a single-dose regimen or after completion of a seven-day regimen) [3].
Follow-up visits can be scheduled to confirm resolution of symptoms and discuss test results. Individuals with confirmed chlamydia, gonorrhea, or trichomonas infections should be retested three months after initial treatment because of high rates of reinfection [3]. Additionally, they should be offered counseling and testing for HIV and syphilis. (See "Screening for sexually transmitted infections".)
RECURRENT OR PERSISTENT DISEASE — Cervicitis can persist despite repeated courses of antimicrobial therapy.
●Our approach – Individuals who present with recurrent symptoms are reevaluated for possible re-exposure or treatment failure [3]:
•We repeat the diagnostic work-up and ensure that (1) nucleic acid amplification testing (NAAT) is negative for detection of C. trachomatis and N. gonorrhoeae, and (2) sexual partners have been appropriately treated, and (3) the patient has not been re-exposed to potential pathogens (ie, new sexual partner).
•Diagnostic testing is performed for trichomoniasis and bacterial vaginosis (BV). Some experts also suggest testing for M. genitalium, if available.
•Exposure to potential intravaginal irritants (lubricants, spermicides, douching) is reassessed.
•If possible, sexual partners should be examined and tested for chlamydia and gonorrhea, particularly if they were not treated presumptively at the time of the patient's initial treatment for cervicitis. (See 'Other populations' above.)
•If the above steps are completed and no cause of the persistent cervicitis has been identified, treatment can be considered for M. genitalium, as discussed below, particularly if NAAT for this infection is not available.
•Patients with recurrent or persistent cervicitis reflect a particular challenge. Those without a clear etiology of any sort whose symptoms persist for more than three months are diagnosed with chronic cervicitis. (See 'Chronic cervicitis' below.)
●M. genitalium –The role of M. genitalium in persistent cervicitis is unclear [3]. M. genitalium is very difficult to culture; most studies have used nucleic acid amplification (polymerase chain reaction or transcription-mediated amplification) for identification [2,9,35,36]. M. genitalium NAAT testing should be performed in patients with persistent cervicitis who have not yet been tested. Those who test positive receive targeted treatment. If M. genitalium NAAT cannot be performed, and thus resistance testing is not known, and the patient has persistent cervicitis despite prior antibiotic treatment, it is reasonable to treat empirically for M. genitalium. Treatment approaches for this population are discussed in related content.
CHRONIC CERVICITIS — The term "chronic" in this context generally refers to patients in whom the usual infectious causes of acute cervicitis described above have been treated or excluded, yet abnormal physical signs persist for at least three months. A minority of patients have persistent mucopurulent endocervical discharge. Chronic cervicitis usually has a noninfectious source [32]. In individuals with chronic cervicitis, the cervical mucosa is hyperemic and may be ulcerated. Obstruction of the mucous glands may result in formation of nabothian cysts. (See "Benign cervical lesions and congenital anomalies of the cervix", section on 'Nabothian cysts'.)
Patients with chronic cervicitis who fail to respond to antibiotics are a therapeutic challenge; there is no standardized approach for these patients [32]. Some may respond to two doses of depot medroxyprogesterone or cauterization of the bleeding points with silver nitrate, which can be applied repeatedly every two weeks until the cervicitis improves or fails to show a clinical response. As a last resort, electrocautery, laser, or shallow loop excision can successfully reduce persistent mucopurulent discharge unresponsive to other measures and for which an etiology has not been determined [5]. It is imperative that malignancy be excluded ( pap smear and/or by biopsy) before any ablative treatment is undertaken.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Sexually transmitted infections" and "Society guideline links: Bacterial vaginosis" and "Society guideline links: Gynecologic infectious diseases (non-sexually transmitted)".)
SUMMARY AND RECOMMENDATIONS
●Definition and etiologies – Cervicitis refers to inflammation of the uterine cervix that primarily affects the columnar epithelial cells of the endocervical glands. The squamous epithelium of the ectocervix can also be involved. (See 'Introduction' above.)
•Infectious – Sexually transmitted infections (STIs) are the most common cause with Neisseria gonorrhoeae and Chlamydia trachomatis being the two most common infections. It is uncertain how much Mycoplasma genitalium contributes to cervicitis, but this organism is likely responsible for a substantial minority of cases. (See 'Infectious etiologies' above.)
•Noninfectious etiologies – In cases where no infection is identified, cervicitis is usually caused by mechanical or chemical irritation such as from a diaphragm or vaginal douche, respectively. Often, there may be no clearly identified cause. (See 'Noninfectious causes' above.)
●Clinical presentation – The presenting symptoms are purulent or mucopurulent discharge and/or easily induced bleeding (friability) from the endocervix when touched with an endocervical swab. Associated symptoms include abnormal vaginal discharge, dysuria/urinary frequency, and intermenstrual or postcoital bleeding. (See 'Clinical presentation' above.)
●Evaluation – Diagnostic evaluation includes a history, physical examination, and testing for potential causative organisms (ie, chlamydia, gonorrhea, Trichomonas vaginalis, and bacterial vaginosis) (algorithm 1). (See 'Diagnostic evaluation' above.)
●Diagnosis – Cervicitis is a clinical diagnosis is based upon the presence of mucopurulent cervical discharge or friability. Infectious causes may be diagnosed by specific laboratory testing. (See 'Diagnosis' above.)
●Treatment – For individuals with physical examination findings of cervicitis, we suggest empiric therapy rather than treatment based on risk factors for STI acquisition or targeted test results. (Grade 2C). We offer treatment for chlamydia and gonorrhea infection as these are the most common infectious etiologies. As data directly comparing the strategies are lacking, all approaches are reasonable and patient preferences influence the decision.
•(See 'Empiric therapy' above.)
•(See 'Treatment based on STI risk' above.)
•(See 'Targeted treatment of specific infections' above.)
Individuals with clinically diagnosed cervicitis are offered treatment regardless of symptomatology. The goals of treatment are relief of symptoms and prevention of infection of the upper genital tract.
●Sexual partners – Treatment, follow-up, and management of sexual partners depends upon the test results. Treatment of sexual partners is indicated for patients with chlamydia, gonorrhea, or trichomonas infections. (See 'Sexual partners' above.)
●Recurrent symptoms – Individuals who present with recurrent symptoms are reevaluated for possible re-exposure or treatment failure. We treat patients with persistent cervicitis for presumed M. genitalium if they have not already been treated for this agent and NAAT-based testing has not excluded this organism. (See 'Recurrent or persistent disease' above.)
●Chronic cervicitis – Chronic cervicitis refers to those in whom the usual infectious causes of acute cervicitis have been treated or excluded, yet abnormal physical signs persist for at least three months. A minority of patients have persistent mucopurulent endocervical discharge. Chronic cervicitis usually has a noninfectious source. (See 'Chronic cervicitis' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Dr. Jeanne Marrazzo, MD, MPH, FACP, FIDSA who contributed to an earlier version of this topic review.
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