History

Fact Explanation
Vaginal discharge.[1] Usually grey to yellow in colour, mucopurulent discharge. [2]
Abnormal per vaginal bleeding: Post-coital bleeding, inter-menstrual bleeding.[1] Due to friability of the cervix due to underlying inflammation. [2]
Fever, headache, malaise, and myalgia These symptoms are seen in primary herpes simplex viral (HSV) infection, 15-20% of which are associated with cervicitis. [2]
The male partner having vesicular eruptions at or before the presentation of the female partner. [3] Presence of herpetiform lesions in the anogenital area. [3] Primary HSV infection results in vesicles in the anogenital region. [2]
Urethral discharge of partner or dysuria of the patient or partner. Various organism causing cervicitis such as Chlamydia, Gonorrhoea also cause urethritis. [7] HSV is known to cause severe dysuria in the patients. [8]
Urinary retention.[9] May occur in HSV infection due to severe vulval pain.[9]
Usage of pessaries, diaphragms, condoms, vaginal spermicides/ retained tampons [5] Pessaries and diaphragms may cause cervicitis, and some develop an allergy to latex condoms or to spermicides. These should be excluded by taking proper history.
Recent new sexual partner, multiple sexual partners within past 6 months, sexual contact with people who are known to have STI (Sexually Transmitted Infections), past history of STI, diagnosis of bacterial vaginosis. [4] Absence of H2O2-producing lactobacilli, as seen in bacterial vaginosis, is thought to be a contributory factor for cervicitis.[6] These are all known risk factors of cervicitis.
References
  1. Royal college of Obstetrics and Gynaecology. Faculty of Sexual & Reproductive Healthcare. Clinical Guidance. Management of Vaginal Discharge in Non-Genitourinary Medicine Settings Clinical Effectiveness Unit, February 2012 Viewed on-25/03/2014 http://www.fsrh.org/pdfs/CEUGuidanceVaginalDischarge.pdf
  2. MARRAZZO Jeanne M., MARTIN David H. Management of Women with Cervicitis. 2007. Oxford Journals. Clinical Infectious Diseases. Volume 44, Issue 3. Viewed on-25/03/2014 http://cid.oxfordjournals.org/content/44/Supplement_3/S102.full
  3. WILLCOZ R. R. Necrotic cervicitis due to primary infection with the virus of herpes simplex. British Medical Journal. Mar 9, 1968; Volume 1, Issue 5592, Pages 610–612. PMCID: PMC1985306 Viewed on-26/03/2014 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1985306/?page=3
  4. CHERNESKY Max A, PATRICK David. Syndromes associated with sexually transmitted infections Article information. Canadian Journal of Infectious Diseases & Medical Microbiology. 2005 Jan-Feb; Volume 16, Issue 1, Pages 13–14. PMCID: PMC2095003, Viewed on: 27/03/2014 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2095003/
  5. Canadian Guidelines on Sexually Transmitted Infections, Section 4 - Management and Treatment of Specific Syndromes, Vaginal Discharge. Viewed on: 25/03/2014 http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/section-4-8-eng.php
  6. MARRAZZO Jeanne M., WIESENFELF Harold C., MURRAY Pamela J., BUSSE Barbara, MEYN Leslie, KROHN Marijane, HILLIER Sharon L. Risk Factors for Cervicitis among Women with Bacterial Vaginosis. The Journal of Infectious Diseases. Volume 193, Issue 5Pp. 617-624. Viewed on: 27/03/2014 http://jid.oxfordjournals.org/content/193/5/617.short
  7. SHRESTHA Rabin K., ENGLUND Kristin, Sexually Transmitted Diseases, Medical Publications, Disease Management Project, Infectious Disease. The Cleveland Clinic Foundation. 2000. [Viewed on 27/03/2014], Available from: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/infectious-disease/sexually-transmitted-diseases/
  8. WILLCOZ R. R. Necrotic cervicitis due to primary infection with the virus of herpes simplex. British Medical Journal. Mar 9, 1968; Volume 1, Issue 5592, Pages 610–612. PMCID: PMC1985306 Viewed on-26/03/2014 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1985306/?page=1
  9. COLLINS Sally, ARULKUMARAN Sabaratnam, HAYES Kevin, JACKSON Simon, IMPEY Lawrence. Oxford handbook of obstetrics and gynaecology. 2nd edition. Oxford. Oxford university press. 2008.

Examination

Fact Explanation
Vaginal examination- Vaginal discharge maybe observed. Cervix will look erythematous and edematous. Contact bleeding maybe present. Mucopurulent vaginal discharge maybe seen. Due to inflammation of the cervix, it will be friable thus causing contact bleeding.
Vaginal examination- Petechial or punctuate hemorrhages of the cervix, giving rise to appearance of "strawberry cervix". [1][2] Trichomonas vaginalis produces cytotoxic agents which cause erosive type of inflammation resulting in "strawberry cervix" appearance. [1]
Vaginal examination- Small vesicles in vulval area. Cervix shows frank ulceration and white and necrotic areas especially around the os, and presence of prominent contact bleeding.[2][3] 15-20% of women with primary herpes simplex viral (HSV) infection are known to have cervicitis in which case primary vesicles will be visible in the genital area. Reactivation of latent HSV from the sacral ganglia results in recurrent HSV infection which has a shorter and less severe course than primary infection.[1][5][6] Reactivation maybe triggered by stress, menstruation or sexual intercourse itself.[5]
Tender lymphadenopathy. [6]Inguinal or local or generalized lymphadenopathy may occur. [7][8] HSV is associated with warm, erythematous, tender lymphadenopathy and in immuno-compromized patients generalized lymphadenopathy may occur. [7] Bilateral inguinal lymphnodes maybe palpable in tuberculous cervicitis. [4]
Vaginal examination- Vegetative and ulcerative growth patterns mimicking cervical cancer. [4] This is seen in tuberculous cervicitis which is now rare in western countries. Caseating granuloma will be visible microscopically. [4]
References
  1. MARRAZZO Jeanne M., MARTIN David H. Management of Women with Cervicitis. 2007. Oxford Journals. Clinical Infectious Diseases. Volume 44, Issue 3. Viewed on-25/03/2014 http://cid.oxfordjournals.org/content/44/Supplement_3/S102.full
  2. CASEY Petra M., LONG Margaret E., MARNACH Mary L. Abnormal Cervical Appearance: What to Do, When to Worry? Mayo Clin Proc. Feb 2011;Volume 86, Issue 2, Pages 147–151. Available from: doi: 10.4065/mcp.2010.0512 Viewed on-26/03/2014 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031439/
  3. WILLCOZ R. R. Necrotic cervicitis due to primary infection with the virus of herpes simplex. British Medical Journal. Mar 9, 1968; Volume 1, Issue 5592, Pages 610–612. PMCID: PMC1985306 Viewed on-26/03/2014 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1985306/?page=1
  4. AHMED SA, OGUNTAYO AO, ODOGWU K, ABDULLAHI K. Tuberculous cervicitis: A case report. Nigerian Medical Journal. 2011 Jan-Mar; Volulme 52, Issue 1, Pages 64–65. PMCID: PMC3180750 Viewed on-26/03/2014 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3180750/
  5. COLLINS Sally, ARULKUMARAN Sabaratnam, HAYES Kevin, JACKSON Simon, IMPEY Lawrence. Oxford handbook of obstetrics and gynaecology. 2nd edition. Oxford. Oxford university press. 2008.
  6. SHRESTHA Rabin K., ENGLUND Kristin, Sexually Transmitted Diseases, Medical Publications, Disease Management Project, Infectious Disease. The Cleveland Clinic Foundation. 2000. [Viewed on 27/03/2014], Available from: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/infectious-disease/sexually-transmitted-diseases/
  7. WITT Mallory D., TORNO Mauro S., SUN Nora, TOMIKO Stein. Herpes Simplex Virus Lymphadenitis: Case Report and Review of the Literature. Clinical Infectious Diseases Volume 34, Issue 1, Pages 1-6. Viewed on 27/03/2014 http://cid.oxfordjournals.org/content/34/1/1.full
  8. MILIAUSKAS JR, LEONG AS. Localized herpes simplex lymphadenitis: report of three cases and review of the literature. Histopathology. 1991 Oct. Volume 19. Issue 4, Pages 355-60. Viewed on 27/03/2014 http://www.ncbi.nlm.nih.gov/pubmed/1937414

Differential Diagnoses

Fact Explanation
Cervical carcinoma Chronic cervicitis, tuberculous, syphilitic cervicitis may resemble the appearance of cervical carcinoma. Microscopy will reveal granuloma in cases of tuberculous cervicitis. [3][4][5]
Cervical ectropion. This also results in vaginal discharge and post coital bleeding. Occurs due to exposure of columnar epithelium of endocervix usually due to pregnancy or use of oral contraceptive pill.[2]
Retained foreign body.[1][8] Usually retained tampons may cause vaginal discharge.
Bacterial vaginosis.[8] Also has white to gray per vaginal discharge. Can be excluded by alkaline pH, positive whiff test and presence of clue cells seen under microscopy.[6][7]
Vaginal candiasis.[8] Also results in vaginal discharge but the discharge is in consistent with cottage cheese appearance and pruritis maybe intense. [8]
Pelvic inflammatory disease.[8] This may occur in association with cervicitis as well. There will be associated fever, lower abdominal pain, adenexial tenderness elicited by vaginal examination. Full blood count will reveal leukocytosis.[8]
References
  1. Canadian Guidelines on Sexually Transmitted Infections, Section 4 - Management and Treatment of Specific Syndromes, Vaginal Discharge. Viewed on: 25/03/2014 http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/section-4-8-eng.php
  2. CASEY Petra M., LONG Margaret E., MARNACH Mary L. Abnormal Cervical Appearance: What to Do, When to Worry? Mayo Clin Proc. Feb 2011;Volume 86, Issue 2, Pages 147–151. Available from: doi: 10.4065/mcp.2010.0512 Viewed on-26/03/2014 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031439/
  3. AHMED SA, OGUNTAYO AO, ODOGWU K, ABDULLAHI K. Tuberculous cervicitis: A case report. Nigerian Medical Journal. 2011 Jan-Mar; Volulme 52, Issue 1, Pages 64–65. PMCID: PMC3180750 Viewed on-26/03/2014 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3180750/
  4. DOHERTY MG, VAN DINH T, PAYNE D, TYRING SK, HANNIGAN EV. Chronic plasma cell cervicitis simulating a cervical malignancy: a case report. Obstetrics and Gynecology. 1993 Oct; Volume 82, Pages 646-50. Viewed on-26/03/2014 http://www.ncbi.nlm.nih.gov/pubmed/8397360
  5. GUTMANN EJ. Syphilitic cervicitis simulating stage II cervical cancer. Report of two cases with cytologic findings. American Journal of Clinical Pathology. 1995 Dec; Volume 104, Issue 6, Pages 643-7. Viewed on-26/03/2014 http://www.ncbi.nlm.nih.gov/pubmed/8526206
  6. THULKAR J, KRIPLANI A, AGARWAL N. Utility of pH test & Whiff test in syndromic approach of abnormal vaginal discharge. Indian Journal of Medical Researches. 2010 Mar; Volume 131, Pages 445-8. Viewed on 27/03/2014. http://www.ncbi.nlm.nih.gov/pubmed/20418561
  7. HAPSARI ED, HAYASHI M, MATSUO H. Clinical characteristics of vaginal discharge in bacterial vaginosis diagnosed by Nugent's criteria. Clinical Experimental Obstetrics and Gynecology. 2006; Volume 33, Issue 1, Pages 5-9. Viewed on 27/03/2014. http://www.ncbi.nlm.nih.gov/pubmed/16761528
  8. In the clinic Vaginitis and Cervicitis. Annals of Internal Medicine. American College of Physicians. 2009. Viewed on 27/03/2014. Available from: http://www.med.unc.edu/medselect/resources/course%20reading/ITC%20vaginitis.full.pdf

Investigations - for Diagnosis

Fact Explanation
Cervical smear gram stain and microscopy. Presence of more than 30 polymorphonuclear leukocytes per x1000 power demonstrated. [1][2] Gonoccocal infection will reveal gram negative intracellular diplococci.
Nucleic acid amplification test (NAAT) NAAT is performed in endocervical swab sample or in first catch urine sample to diagnose Chlamydial or gonococcal infections. [3]
Wet mount microscopy. Will help to visualise Trichomonas vaginalis if present. [4] Antigen based detection assay is also available to diagnose Trichomonas vaginalis.[1]
Cervical cytology/ biopsy, Zeil Neelsen stain, TB (tuberculous) culture, chest X ray Used if TB cervicitis is suspected. [5]
References
  1. MARRAZZO Jeanne M., MARTIN David H. Management of Women with Cervicitis. 2007. Oxford Journals. Clinical Infectious Diseases. Volume 44, Issue 3. Viewed on-25/03/2014 http://cid.oxfordjournals.org/content/44/Supplement_3/S102.full
  2. LUSK MJ, KONECNY P. Cervicitis: a review. Current Opinion on Infectious Diseases. 2008 Feb; Volume 21, Issue 1, Pages 49-55. Available from: doi: 10.1097/QCO.0b013e3282f3d988. Viewed on- 25/03/2014 https://45faa4ad-a-62cb3a1a-s-sites.googlegroups.com/site/gynonet/documents/Cervicitis-areview.pdf?attachauth=ANoY7cqO0CnelhPILkYd9c8yOX7v_nAtKvL_8mtqT6L_wgJSjRUGQnfaHXRjJcdOLC88JO3Kva39KtiCVWngxu6f1RHLMU-xAtv_yMeq5DlrNT6sVTg0wAofaV_vp4VmKMQyg18k3jyV_XZ4U8mDgQW45JXfpdvn_xbJE-4X3qJThQW4X4UedfL77JCcTMLAsKr1pmjVCxZGGNTTHHYtoaBZpiJuTI6EQIUfhY7_rM0rBFfDZJDTjSY%3D&attredirects=0
  3. SCHACHTER J., HOOK E. W. et al. Confirming Positive Results of Nucleic Acid Amplification Tests (NAATs) for Chlamydia trachomatis: All NAATs Are Not Created Equal. Journal of Clinical Microbiology. Mar 2005; Volume 43, Issue 3, Pages 1372–1373. Available from: doi: 10.1128/JCM.43.3.1372-1373.2005 Viewed on-25/03/2014 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1081269/
  4. SWYGARD H, SENA AC, HOBBS MM, COHEN MS. Trichomoniasis: clinical manifestations, diagnosis and management. Sexually Transmitted Infection 2004; Volume 80, Issue 2, pages 91-95. Available from: doi:10.1136/sti.2003.005124 Viewed on-25/03/2014 http://sti.bmj.com/content/80/2/91.full
  5. KALYANI R, SHEELA SR, RAJINI M. Cytological diagnosis of tuberculous cervicitis: A case report with review of literature Journal of Cytology. 2012 Jan-Mar; Volume 29, Issue 1, Pages 86–88. Available from: doi: 10.4103/0970-9371.93242 PMCID: PMC3307466 Viewed on-25/03/2014 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3307466/

Investigations - Screening/Staging

Fact Explanation
Screening in sexually active women Screening and treating chlamydial cervicitis has been recommended as a cost effective method when prevalence is more than 3.1%.[1][2] Also screening is recommended in women at high risk, such as women attending STD clinic. [3]
Screening in pregnant women. Screening and treating cervicitis in pregnant women is thought to decrease the incidence of premature delivery and screening for Chlamydial cervicitis is recommended in all pregnant mothers.[4][3]
References
  1. HONEY E, AUGOOD C, TEMPLETON A, RUSSELL I, PAAVONEN J, MARDH P, STARY A, STRAY-PEDERSEN B. Cost effectiveness of screening for Chlamydia trachomatis: a review of published studies. Sexually Transmitted Infection. Dec 2002; Volume 78, Issue 6, Pages 406–412. Available from: doi: 10.1136/sti.78.6.406 PMCID: PMC1758346 Viewed on: 25/03/2014 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1758346/
  2. MALOTTE C. Kevin, WIESMEIER Edward, GELINEAU J. Kristin. Screening for Chlamydial cervicitis in a sexually active university population. American Journal of Public Health. 1990 April; Volume 80, Issue 4, Pages 469–471. Viewed on: 25/03/2014 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1404587/?page=1
  3. PAAVONEN J, ROBERTS PL et al. Chlamydial cervicitis: complications and new treatment options. American Family Physician. 1994 Jun; Volume 49, Issue 8, Pages 1825-9, 1832. Viewed on: 25/03/2014 http://www.ncbi.nlm.nih.gov/pubmed/8203320
  4. BEGUM S, SAGAWA T, FUJIMOTO S. Screening for bacterial vaginosis and cervicitis aimed at preventing premature delivery. Journal of Obstetrics and Gynaecology. 1997 Feb; Volume 23, Issue 1, Pages 103-10. Viewed on: 25/03/2014 http://www.ncbi.nlm.nih.gov/pubmed/9094827

Management - General Measures

Fact Explanation
Partner screening. Need for partner screening has been strongly recommended. [1]
References
  1. OH MK, BOKER JR, GENUARDI FJ, CLOUD GA, REYNOLDS J, HODGENS JB. Sexual contact tracing outcome in adolescent chlamydial and gonococcal cervicitis cases. Journal of Adolescent Health. 1996 Jan; Volume 18, Issue 1, Pages 4-9. Viewed on 26/03/2014. http://www.ncbi.nlm.nih.gov/pubmed/8750422

Management - Specific Treatments

Fact Explanation
Single dose of azithromycin 1 g po or doxycycline 100 mg po bd for 7 days To treat Chlamydial infection if diagnosed.[1]
Single dose of cefixime 400 mg po or ciprofloxacin 500 mg po or levofloxacin 250 mg po or ofloxacin 400 mg po or ceftriaxone 125 mg im To treat Gonorrhoea infection if diagnosed.
Single dose of metronidazole 2 g po or tinidazole 2 g po To treat Trichomonas vaginalis if diagnosed. [1]
Acyclovir 400 mg tds or famciclovir 250 mg tds or valacyclovir 1 g bd for 7-10 days. If HSV (Herpes simplex virus) infection is diagnosed. [1]
Emperic antiobiotics. Clinical cure rate for emperic antibiotic treatment given in cervicitis of unknown aetiology is low. And gasterointestinal side effect rate was high in treated group over placebo. [2]
Focused ultrasound therapy. This is effective in patients with high risk Human Papillomavirus cervicitis (HPV) and also used in recurrent cervicitis caused by HPV. [3]
Electrocautery, loop diathermy, cryotherapy or laser [4] Used in chronic cervicitis. [4]
References
  1. MARRAZZO Jeanne M., MARTIN David H. Management of Women with Cervicitis. 2007. Oxford Journals. Clinical Infectious Diseases. Volume 44, Issue 3. Viewed on-25/03/2014 http://cid.oxfordjournals.org/content/44/Supplement_3/S102.full
  2. TAYLOR SN, LENSING S et al. Prevalence and treatment outcome of cervicitis of unknown etiology. Sexually Transmitted Diseases. 2013 May, Volume 40, Issue 5, Pages 379-85. Available from: doi: 10.1097/OLQ.0b013e31828bfcb1. Viewed on-26/03/2014 http://www.ncbi.nlm.nih.gov/pubmed/23588127
  3. LI CZ, WANG ZB, YANG X, TANG Y, WANG D, HUANG Y, FAN XF. Feasibility of focused ultrasound therapy for recurrent cervicitis with high-risk human papillomavirus infection. Ultrasound in Obstetrics and Gynecology. 2009 Nov. Volume 34, Issue 5, Pages 590-4. Available from: doi: 10.1002/uog.7357. Viewed on-25/03/2014 http://www.ncbi.nlm.nih.gov/pubmed/19852044
  4. DALGIC H, KUSCU NK. Laser therapy in chronic cervicitis. Archieves of Gynecology and Obstetrics. 2001 May, Volume 265, Issue 2, Pages 64-6. Viewed on-26/03/2014 http://www.ncbi.nlm.nih.gov/pubmed/11409476