Section 4-2: Canadian Guidelines on Sexually Transmitted Infections - Management and treatment of specific syndromes - Cervicitis

This guidance document is about the management of cervicitis.

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1. Introduction

1.1 Key information

Public health importance
Cervicitis is a common clinical finding that can be caused by a sexually transmitted infection (STI). The most common STI causes are Chlamydia trachomatis and Neisseria gonorrhoeae; however, these account for up to 25% of cases (depending on the population) and most cases are of unknown etiology. The true incidence and prevalence of cervicitis are unknown because of its varied causes and lack of agreement in the case definition.

Note: Untreated cervicitis can result in pelvic inflammatory disease (PID) that may lead to chronic pelvic pain and infertility. Cervicitis also increases HIV shedding at the cervical canal which may increase the risk of HIV transmission.

Screening
Cervicitis is an indication for STI screening in sexually active individuals.
Diagnostic testing

Patients with cervicitis should be tested for Chlamydia trachomatis and Neisseria gonorrhoeae with a nucleic acid amplification test (NAAT) using a cervical swab. Vaginal swabs may also be used.

Testing for Mycoplasma genitalium is recommended in cases of persistent or recurrent cervicitis. Women with cervicitis should also be evaluated for bacterial vaginosis, trichomoniasis and herpes simplex virus (HSV) infection.

Treatment
  • Ceftriaxone 250 mg IM in a single dose in combination with Azithromycin 1 g PO in a single dose or Doxycycline 100 mg PO bid for 7 days

OR

  • Cefixime 800 mg PO in a single dose in combination with Azithromycin 1 g PO in a single dose or Doxycycline 100 mg PO bid for 7 days

Note: A test and wait approach (rather than empiric treatment) is appropriate if the patient is at low risk of STIs. This is because rates of antimicrobial resistance (AMR) are increasing and many cases are of unknown etiology.

Combination therapy is recommended for the empiric treatment of cervicitis due to ever-evolving AMR in N. gonorrhoeae and M. genitalium.

Follow-up
Follow-up will depend on etiology. Most patients treated for cervicitis do not require post-treatment follow-up unless there are recurrent or persistent symptoms. If an STI is suspected or confirmed, refer to the relevant guidelines for specific follow-up recommendations.
Partner notification
If an STI is suspected or confirmed, locate, evaluate and treat as appropriate all people who have had sexual contact with the index case within 60 days prior to symptom onset or date of specimen collection.

1.2 Definition

Since muco-purulent cervicitis was first described in 1984, there has been a lack of consensus about its definition in clinical and research studies. This has resulted in controversy about the interpretation and comparison of published studies.Footnote 1

Various definitions or combinations of clinical findings have been used across studies. The use of microscopic Gram stain for the diagnosis of cervicitis lacks clinical usefulnessFootnote 2, although this test is still done in some clinics.

The most consistent definition of cervicitis is: the presence of purulent or mucopurulent exudate visible in the endocervical canal or easily induced/sustained bleeding or friability at the endocervical os (e.g. with insertion of a swab into the endocervix).Footnote 1 Footnote 3 Footnote 4 Footnote 5

Note: This definition should be applied with caution during pregnancyFootnote 6 Footnote 7. Please refer to the section Diagnosis during pregnancy for more information.

The true incidence and prevalence of cervicitis are unknown because of its varied causes and lack of agreement in the case definition.

1.3 Etiology

There are many potential infectious causes for cervicitis and it may also be associated with non-infectious conditions.

The true etiology of cervicitis often remains undetermined despite thorough investigation.Footnote 6

The following findings have been reported regarding STI as a cause of cervicitis:

1.3.1 Other possible infectious causes

Although a causal role has not been determined, Cytomegalovirus (CMV), Epstein-Barr virus (EBV), adenoviruses and human T-cell lymphotropic virus (HTLV-1) have been isolated in secretions of women with cervical inflammationFootnote 6 Footnote 8.

2. Prevention and control

2.1 General STBBI prevention and control

Case finding, education, counselling, partner notification and treatment are critical to control infection.

Healthcare providers should offer screening for other sexually transmitted and blood-borne infections (STBBIs) as part of their prevention and control strategies. Since many STBBIs are frequently asymptomatic and can lead to serious complications if left untreated, offer STBBI screening during the course of routine medical care, with special attention to those with risk factors. Normalizing screening in this way can reduce barriers to testing and the stigma associated with STBBI.

Integrate STBBI prevention strategies such as counselling, vaccination and education on preventive practices in client care. Motivational interviewing techniques may be used to identify barriers to prevention practices and the means to overcome them.

Offer vaccination for hepatitis B (HBV), hepatitis A (HAV) and human papillomavirus (HPV) as per the Canadian Immunization Guide.

Partner notification has public health benefits (e.g. disease surveillance and control) and reduces the risk of reinfection for the index case.

2.2 Specific prevention and control

Measures to control the transmission of the sexually transmitted organisms causing cervicitis include prevention, prompt diagnosis and appropriate treatment of the patient and their sexual partners. If an STI is suspected or confirmed, refer to the relevant chapter of the Guidelines for specific follow-up recommendations.

3. Clinical manifestations

People who are diagnosed with cervicitis can be asymptomatic. Symptoms may include:

These symptoms may be seen with other conditions and are not diagnostic of cervicitis.

Note: Cervicitis may indicate upper-genital-tract infection and therefore those with a new episode of cervicitis should be assessed for signs of PID.

4. Assessment and diagnostic testing

4.1 Diagnostic testing

A speculum examination should be performed to evaluate the cervix and vaginal wall.

Note: Vaginal infections can cause symptoms that overlap with those of cervicitis. A diagnosis of vaginitis can be confirmed by laboratory testing of vaginal secretions to detect a change in vaginal flora consistent with BV, the parasite T. vaginalis and yeasts associated with vulvovaginal candidiasis.

The following suggest cervicitis:

Clinical findings of cervicitis have low positive predictive value (PPV) for the diagnosis of C. trachomatis or N. gonorrhoeae infections.

Endocervical swabs should be collected for:

Notes: Vaginal swabs for culture to detect N. gonorrhoeae are not recommendedFootnote 14.
Routine testing for M. genitalium is currently not recommended. Testing for M. genitalium is recommended only in cases of persistent or recurrent cervicitis. Refer to the Management of persistent /recurrent symptomatic cervicitis section for management considerations.
A bimanual examination should be performed to rule out PID. If PID is suspected, refer to the PID guidelines for recommendations.

Do not do a Pap test if cervical cancer is suspectedFootnote 15

4.2 Diagnosis during pregnancy

Consult an expert as needed for the diagnosis of cervicitis during pregnancy.

Use caution when applying the usual clinical criteria for the diagnosis of cervicitis during pregnancy for the following reasons.

4.3 Screening considerations for other STBBIs

For patients with cervicitis at risk for STIs who are being evaluated or treated for N. gonorrhoeae and C. trachomatis, consider:

4.4 Differential Diagnosis

Diagnostic criteria are included in the Assessment and diagnostic testing section above.

Cervical ectropion (or cervical eversion) is a particularly common finding in adolescents and may be misdiagnosed as cervicitisFootnote 17 Footnote 18.

The following non-infectious conditions can also cause cervicitis:

5. Management and treatment

5.1 When to treat

A "test and wait" approach (versus empiric treatment) may be best in certain circumstancesFootnote 5 Footnote 20. This is because most cases of cervicitis are of unknown etiology and rates of AMR are increasing.

5.1.1 High risk for STI

Consider factors associated with increased risk of C. trachomatis and N. gonorrhoeae when deciding whether to treat cervicitis empirically (e.g. sexual partner with a known STI; sexually active and under 25 years of age; new sexual partner or multiple sexual partners). Studies report that 20% to 24% of cases are associated with N. gonorrhoeae or C. trachomatis infectionFootnote 5 Footnote 6 Footnote 8 Footnote 9.

If the individual is at risk for an STI, specifically at an increased risk for C. trachomatis or N. gonorrhoeae and follow-up is not assured, consider empiric treatment.

Note: If empiric treatment is provided, patients should be advised to abstain from unprotected intercourse for seven days after treatment begins and until treatment of their partner(s) is complete.

If the patient is at low risk for an STI, consider a test and wait approach.

5.2 Treatment

5.2.1 Empiric treatment

Combination therapy is recommended for the empiric treatment of cervicitis. This is due to ever-evolving AMR in STIs. Refer to the Gonococcal infections guidelines for medication-specific considerations about penicillin allergy and cross-reactivity with cephalosporins.

Consider the following when selecting the second therapeutic agent (doxycycline or azithromycin) for empiric combination therapy of cervicitis:

Azithromycin

Note: Azithromycin may be preferred if the patient is unlikely to comply with a multiday treatment regimen.

There have been reports of QT prolongation in patients receiving therapeutic doses of azithromycin. Please refer to the Health Advisory issued by Health Canada about azithromycin and risk of cardiovascular complications and death.

Doxycycline

5.2.2 Treatment regimens

Refer to the complete product monograph for prescribing information including contraindications and adverse reactions.

Note: Encourage patients to use condoms consistently and correctly, as this may reduce cervicitis riskFootnote 2.

Refer to the alternative treatment options for N. gonorrhoeae if any of the above therapies are contraindicated.

5.2.3 Management of persistent/recurrent symptomatic cervicitis

Patients with persistent/recurrent symptoms should be evaluated for the following:

Consider M. genitalium as a possible cause in patients with persistent symptoms following empiric treatment for cervicitis, when pre-treatment NAAT tests are negative for chlamydia and gonorrhea or follow-up test of cure is negative.

Repeated or prolonged administration of antibiotic therapy for persistent symptomatic cervicitis is not recommended because of limited evidence of effectiveness.

If cause remains undiagnosed, consider referral to an experienced colleague, or biopsy if clinically indicated.

6. Follow-up

Follow-up depends on etiology.

Patients treated for cervicitis do not usually require post-treatment follow-up unless there are recurrent or persistent symptoms. If an STI is confirmed, refer to the relevant chapter of the Guidelines for the specific follow-up recommendations.

7. Reporting and partner notification

7.1 National/provincial/territorial notification

Cervicitis is not a reportable condition in most jurisdictions, but may be caused by infections (e.g. C. trachomatis, N. gonorrhoeae) that are reportable by laboratories and clinicians to local public health authorities in all provinces and territories.

Where applicable, cervicitis should be reported as per jurisdictional regulations.

7.2 Partner notification

Case finding and partner notification are critical to the prevention and control of STIs.

Evaluate and treat partners depending on the suspected etiology.

Regardless of clinical findings, if an STI is suspected or confirmed, notify, evaluate, and treat all sexual partners from 60 days prior to symptom onset or date of specimen collection.

If an STI is not suspected and treatment of the index case is deferred, partner notification should be deferred until the index case results are available.

8. Acknowledgements

The Public Health Agency of Canada would like to thank the following individuals for their contribution to the development of this guideline.

Cervicitis Sub-Working Group
Dr. Ron Read
Dr. Annie-Claude Labbé
Dr. Ameeta Singh

External reviewers
Dr. Josephine Lusk
Senior Staff Specialist and Clinic Director, Short Street Centre, St George Hospital

Dr. Paul Nyirjesy
Professor of Obstetrics and Gynecology/Drexel University College of Medicine

9. References

Footnotes

Footnote 1

Brunham RC, Paavonen J, Stevens CE, Kiviat N, Kuo C, Critchlow CW, et al. Mucopurulent cervicitis-the ignored counterpart in women of urethritis in men. N Engl J Med 1984; 311(1):1-6.

Return to footnote 1 referrer

Footnote 2

Lusk MJ, Garden FL, Rawlinson WD, Naing ZW, Cumming RG, Konecny P. Cervicitis aetiology and case definition: a study in Australian women attending sexually transmitted infection clinics. Sex Transm Infect 2016 May; 92(3):175-181.

Return to footnote 2 referrer

Footnote 3

Schwebke JR, Weiss HL. Interrelationships of bacterial vaginosis and cervical inflammation. Sex Transm Dis 2002; 29(1):59-64.

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Footnote 4

Marrazzo JM. Mucopurulent cervicitis: no longer ignored, but still misunderstood. Infect Dis Clin North Am 2005 Jun; 19:333-349.

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Footnote 5

Taylor S, Lensing S, Schwebke J, Lillis R, Mena L, Nelson A, et al. Prevalence and treatment outcome of cervicitis of unknown etiology. Sex Transm Infect 2013; 40(5):379.

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Footnote 6

Marrazzo J, Martin D. Management of women with cervicitis. Clin Infect Dis 2007; 3(44):102.

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Footnote 7

Repke J, Berlin L, Spence M, Horn J, Niebyl J, Kanchanaraksa S, et al. Reproducibility of the diagnosis of cervicitis in pregnancy. 1988; 5(3):242.

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Footnote 8

Marrazzo JM, Handsfield HH, Whittington WLH. Predicting chlamydial and gonococcal cervical infection: implications for management of cervicitis. Obstet Gynecol 2002; 100(3):579-584.

Return to footnote 8 referrer

Footnote 9

Taylor SN. Cervicitis of unknown etiology. Curr Infect Dis Rep 2014;16(7).

Return to footnote 9 referrer

Footnote 10

Lis R, Rowhani-Rahbar A, Manhart L. Mycoplasma genitalium infection and female reproductive tract disease: a meta-analysis. Clin Infect Dis 2015; 61(3):418.

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Footnote 11

Manhart LE, Critchlow CW, Holmes KK, Dutro SM, Eschenbach DA, S tevens CE, et al. Mucopurulent cervicitis and Mycoplasma genitalium. J Infect Dis 2003; 187(4):650-657.

Return to footnote 11 referrer

Footnote 12

Corey L, Wald A. Genital herpes. In: Holmes K, Sparling P, Stamm W, Piot P, Wasserheit J, Corey L, et al, editors. Sexually Transmitted Diseases. 4th ed.: New York : McGraw-Hill, Medical; 2008. p. 399-437.

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Footnote 13

Schwebke J, Schulien M, Zajackowski M. Pilot study to evaluate the appropriate management of patients with coexistent bacterial vaginosis and cervicitis. Infect Dis Obstet Gynecol 1995; 3(3):199.

Return to footnote 13 referrer

Footnote 14

Elias J, Frosch M, Vogel U. Neisseria. In: Jorgensen J, Pfaller M, Carroll K, Funke G, Landry M, Richter S, et al, editors. Manual of clinical microbiology, Volume 1. 11th ed.: Washington, DC : ASM Press, 2015; 2015. p. 635-651.

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Footnote 15

Steben M. Clinical manifestations and diagnosis of HPV-related disease. JOGC 2007; 29(8):S11.

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Footnote 16

Cunningham F, Leveno K, Bloom S, Spong C, Dashe J, Hoffman B, et al. Maternal Physiology. In: Cunningham F, Leveno K, Bloom S, Spong C, Dashe J, Hoffman B, et al, editors. Williams Obstetrics. 24 th ed.: McGraw-Hill Education / Medical; 2014.
http://accessmedicine.mhmedical.com/content.aspx?bookid=1057&sectionid=59789139. Accessed May 29, 2017.

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Footnote 17

Critchlow C, Wölner-Hanssen P, Eschenbach D, Kiviat N, Koutsky L, Stevens C, et al. Determinants of cervical ectopia and of cervicitis: age, oral contraception, specific cervical infection, smoking, and douching. Am J Obstet Gynecol 1995; 173(2):534.

Return to footnote 17 referrer

Footnote 18

Duarte K, MacNamara M. Cervicitis, Ectropion, and True Erosion. In: Domino F, editor. The 5 Minute Clinical Consult Standard 2015, The, 23rd Edition. 23 rd ed.: Lippincott Williams & Wilkins; 2014. p. 220.

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Footnote 19

Castle P, Hillier S, Rabe L, Hildesheim A, Herrero R, Bratti M, et al. An association of cervical inflammation with high grade cervical neoplasia in women infected with oncogenic human papillomavirus (HPV). Cancer Epidemiol Biomarkers Prev 2001; 10:1021.

Return to footnote 19 referrer

Footnote 20

Lusk M, Garden F, Cumming R, Rawlinson W, Naing Z, Konecny P. Cervicitis: a prospective observational study of empiric azithromycin treatment in women with cervicitis and non-specific cervicitis. Int J STD AIDS 2017; 28(2):120.

Return to footnote 20 referrer

Footnote 21

Cu-Uvin S, Hogan JW, Caliendo AM, Harwell J, Mayer KH, Carpenter CC, et al. Association between bacterial vaginosis and expression of human immunodeficiency virus type 1 RNA in the female genital tract. Clin Infect Dis 2001 Sep 15; 33(6):894-896.

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Footnote 22

Seck K, Samb N, Tempesta S, et al. Prevelance and Risk Factors of Cervicovaginal HIV-1 and HIV-2 infected women in Dakar, Senegal. Sexually Transmitted Infections 2001; 77:190-193.

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Footnote 23

Mcclelland RS, Wang CC, Mandaliya K, Overbaugh J, Reiner MT, Panteleeff DD, et al. Treatment of cervicitis is associated with decreased cervical shedding of HIV-1. AIDS 2001 Jan 5;15(1):105-110.

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Footnote 24

Wright TJ, Subbarao S, Ellerbrock T, Lennox J, Evans-Strickfaden T, Smith D, et al. Human immunodeficiency virus 1 expression in the female genital tract in association with cervical inflammation and ulceration. Am J Obstet Gynecol 2001; 184(3):279.

Return to footnote 24 referrer

Footnote 25

Gaydos C, Maldeis NE, Hardick A, Hardick J, Quinn TC. Mycoplasma genitalium as a contributor to the multiple etiologies of cervicitis in women attending sexually transmitted disease clinics. Sex Transm Dis 2009; 36(10):598-606.

Return to footnote 25 referrer

Footnote 26

Anagrius C, Lore B, Jensen J. Treatment of Mycoplasma genitalium. Observations from a Swedish STD clinic. PLoS ONE [Electronic Resource] 2013; 8(4):e61481.

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Footnote 27

Taylor-Robinson D. Diagnosis and antimicrobial treatment of Mycoplasma genitalium infection: sobering thoughts. Expert Rev Anti Infect Ther 2014 Jun; 12(6):715.

Return to footnote 27 referrer

Footnote 28

Horner PJ, Martin DH. Mycoplasma genitalium Infection in Men. J Infect Dis 2017 Jul 15; 216 (suppl 2): S396.

Return to footnote 28 referrer

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