STI-associated syndromes guide: Cervicitis

This provides an overview of the management and empiric treatment of sexually transmitted infection (STI) - associated cervicitis, which is an inflammation of the cervix characterised by purulent or mucopurulent exudate visible in the endocervical canal or easily induced or sustained bleeding or friability at the endocervical os.

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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 infertilityFootnote 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 transmissionFootnote 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 usedFootnote 6.

Mycoplasma genitaliumFootnote 7, Trichomonas vaginalis and herpes simplex virus (both HSV- 1 and -2) are also associated with cervicitisFootnote 8.

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

Clinical manifestations

Symptoms and signs of cervicitis may include:

Notes:

Diagnostic testing

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:

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 complianceFootnote 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,

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.

References

Footnote 1

Aral SO. Sexually transmitted diseases: magnitude, determinants and consequences. Int J STD AIDS 2001;12(4):211-215.

Return to footnote 1 referrer

Footnote 2

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

Return to footnote 2 referrer

Footnote 3

Seck K, Samb N, Tempesta S, Mulanga-Kabeya C, Henzel D, Sow PS, et al. Prevalence and risk factors of cervicovaginal HIV shedding among HIV-1 and HIV-2 infected women in Dakar, Senegal. Sex Transm Infect 2001 Jun;77(3):190-193.

Return to footnote 3 referrer

Footnote 4

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;15(1):105-110.

Return to footnote 4 referrer

Footnote 5

Wright Jr TC, Subbarao S, Ellerbrock TV, Lennox JL, Evans-Strickfaden T, Smith DG, 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):279-285.

Return to footnote 5 referrer

Footnote 6

Taylor SN. Cervicitis of unknown etiology. Curr Infect Dis Rep 2014;16(7):409.

Return to footnote 6 referrer

Footnote 7

Lis R, Rowhani-Rahbar A, Manhart LE. Mycoplasma genitalium infection and female reproductive tract disease: a meta-analysis. Clin Infect Dis 2015;61(3):418-426.

Return to footnote 7 referrer

Footnote 8

Marrazzo JM, Martin DH. Management of women with cervicitis. Clin infect Dis 2007;44 Suppl 3:S102-S110.

Return to footnote 8 referrer

Footnote 9

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 9 referrer

Footnote 10

Taylor SN, Lensing S, Schwebke J, Lillis R, Mena LA, Nelson AL, et al. Prevalence and treatment outcome of cervicitis of unknown etiology. Sex Transm Dis 2013 May;40(5):379-385.

Return to footnote 10 referrer

Footnote 11

Repke JT, Berlin L, Spence M, Horn J, Niebyl J, Kanchanaraksa S, et al. Reproducibility of the Diagnosis of Cervicitis in Pregnancy. Am J Perinatol 1988;5(03):242-246.

Return to footnote 11 referrer

Footnote 12

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. 11th ed. Washington, DC: ASM Press; 2015. p. 635-651.

Return to footnote 12 referrer

Footnote 13

Lyss SB, Kamb ML, Peterman TA, Moran JS, Newman DR, Bolan G, et al. Chlamydia trachomatis among patients infected with and treated for Neisseria gonorrhoeae in sexually transmitted disease clinics in the United States. Ann Intern Med 2003 Aug 5;139(3):178-185.

Return to footnote 13 referrer

Footnote 14

Tapsall JW. What management is there for gonorrhea in the postquinolone era? Sex Transm Dis 2006 Jan;33(1):8-10.

Return to footnote 14 referrer

Footnote 15

Workowski KA, Berman S, Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep 2010 Dec 17;59(RR-12):1-110.

Return to footnote 15 referrer

Footnote 16

World Health Organization. Guidelines for the Management of Sexually Transmitted Infections. 2003.

Return to footnote 16 referrer

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