STI-associated syndromes guide: Cervicitis

On this page:

• Public health importance
• Common STI-associated etiology
• Clinical manifestations
• Diagnostic testing
• Empiric treatment and management
• Follow-up
• Reporting and partner notification
• References

Public health importance

If caused by a sexually transmitted infection (STI), undiagnosed or untreated cervicitis may result in pelvic inflammatory disease (PID) which can lead to chronic pelvic pain, ectopic pregnancy and infertility^{Footnote 1}.

Inflammation caused by cervicitis increases the risk of HIV acquisition. Cervicitis also increases human immunodeficiency virus (HIV) shedding at the cervical canal, which increases the risk of HIV transmission^{Footnote 2Footnote 3Footnote 4Footnote 5}.

Common STI-associated etiology

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) account for up to 25% of cervicitis cases, depending on population risk level, definition of cervicitis and detection methods used^{Footnote 6}.

Mycoplasma genitalium^{Footnote 7}, Trichomonas vaginalis and herpes simplex virus (both HSV- 1 and -2) are also associated with cervicitis^{Footnote 8}.

Up to 83% of cervicitis cases are of unknown etiology (no pathogen identified) and the cause often remains undetermined despite thorough investigation^{Footnote 8Footnote 9Footnote 10}.

Clinical manifestations

Symptoms and signs of cervicitis may include:

• Unusual vaginal discharge
• Vaginal bleeding during or after intercourse
• Purulent or mucopurulent endocervical exudate
• Glandular ectopy with friability

Notes:

• People with cervical infections can be asymptomatic
• Cervical ectropion is common among adolescents and does not indicate cervicitis
• Due to normal physiological changes, apply clinical diagnostic criteria for cervicitis cautiously in pregnancy^{Footnote 8Footnote 11}

Diagnostic testing

• Perform a speculum examination to evaluate the cervix and vaginal wall.
• Obtain endocervical swab for NAAT for CT and GC, plus culture for GC (where available).
  • Vaginal swabs or first-void urine (FVU) are also appropriate specimens for NAAT.
  • Vaginal swabs for culture for GC are not recommended^{Footnote 12}.
• Consider HSV testing when ulcerations or vesicles are present
• Consider testing for M. genitalium in persons with persistent or recurrent cervicitis following treatment for CT and GC when pre- or post-treatment NAAT tests are negative for CT and GC.

Assess for signs of PID as cervicitis may indicate upper genital tract infection. Refer to the PID section of this guide.

Vaginal infections can cause signs and symptoms that are similar to those of cervicitis. If vaginitis is suspected, refer to the vaginitis section of this guide.

Empiric treatment and management

The decision to treat empirically for CT and GC or to wait for test results should reflect the:

• Severity of the clinical condition
• Probability of infection
• Person's risk factors for a sexually transmitted or blood-borne infection (STBBI)
• Person's willingness to abstain from sex and to return for test results or follow-up

A "test and wait" approach (versus empiric treatment) may be best in certain circumstances. This is because most cases of cervicitis are of unknown etiology and rates of antimicrobial resistance (AMR) are increasing.

In people with HIV, treatment of cervicitis decreases the level of virus in cervical secretions and may therefore decrease risk of HIV transmission ^{Footnote 4Footnote 5}.

Empiric treatment for cervicitis
Ceftriaxone 250 mg IM in a single dose [C-III] or cefixime 800 mg PO in a single dose [C-III] plus Azithromycin 1 g PO in a single dose [C-III] or doxycycline 100 mg PO BID for 7 days [C-III]

Note: Azithromycin is preferred over doxycycline for the treatment of suspected or confirmed GC, due to significant rates of tetracycline-resistant GC and concerns about multiday treatment compliance^{Footnote 13Footnote 14Footnote 15Footnote 16}.

Follow-up

The need for test of cure (TOC) depends on which pathogen is confirmed by laboratory testing. Refer to the etiology-specific guide.

In the case of recurrent or persistent cervicitis,

• Assess the possibility of:
  • Poor adherence to treatment
  • Use of alternate rather than preferred (first-line) treatment
  • Reinfection
  • AMR
  • Presence of other pathogens that were not part of initial testing (e.g. M. genitalium)
  • Presence of other etiologies
• Consider:
  • If not done previously, NAAT testing for M. genitalium, including antibiotic susceptibility (where available). If testing is not available, consider empiric treatment for M. genitalium. Refer to Mycoplasma genitalium guide.
  • If the cause remains undiagnosed, consulting an experienced colleague or referring to a gynecologist.

Reporting and partner notification

When treatment is indicated for an STI: notify, evaluate, test and treat (as appropriate) sexual partners. Refer to the etiology-specific guide(s) for guidance on reporting and partner notification.