Cervicitis: Etiology, Symptomatology, Diagnosis, Treatment

Cervicitis is a clinical syndrome characterized by inflammation of the cervical epithelium.

Acute or chronic forms are distinguished, with acute cervicitis having infectious causes, while chronic is caused predominantly by non-infectious sources.

The exact prevalence of cervicitis is difficult to determine due to the lack of standardized diagnostic criteria. Since sexual activity is a major risk factor for infectious diseases, the highest incidence is found in sexually active women between the ages of 15 and 24.

Etiology of cervicitis

According to etiology, cervicitis can be divided into infectious and non-infectious.

Infectious agents include:

• Neisseria gonorrhoea;
• Chlamydia trachomatis;
• Herpes simplex virus (HPV);
• Trichomonas vaginalis;
• Mycoplasma genitalium.

Neisseria gonorrhoea and Chlamydia trachomatis predominantly infect the prismatic epithelium of the endocervix, whereas HPV and trichomonads infect the squamous epithelium of the ectocervix. Bacterial vaginosis is also associated with cervicitis.

Non-infectious causes of cervicitis include:

• Mechanical irritants: surgical instruments or foreign objects such as pessaries, diaphragms, cervical caps, tampons, condoms, which may cause mechanical trauma;
• Chemical irritants cause allergic reactions and include soaps, laundry products, spermicides, latex, and vaginal sprays;
• Systemic inflammatory diseases such as red squamous lichen planus and Behçet’s syndrome can also be a cause of cervicitis;
• The hypoestrogenic state seen in natural or surgical menopause can mimic cervicitis. It occurs due to atrophy of the vaginal and uterine mucosa.

It is worth noting that in most cases the exact etiology cannot be established. It is clinically impossible to distinguish inflammation caused by mechanical or chemical stimuli from inflammation caused by infectious etiology.

Clinical manifestations of cervicitis

Patients present with nonspecific complaints, including purulent or purulent mucous discharge from the vagina and intermenstrual or postcoital bleeding. Patients may also present with dyspareunia or pulling pains in the lower abdomen.

History taking

History taking plays an important role in identifying risk factors. All women, regardless of symptoms, who come for a check-up should be asked about their sexual history in detail, using five key points:

• Partners;
• Practice;
• Pregnancy Prevention;
• Protection from STIs;
• Previous STIs.

Gynecological examination

The classic signs are yellow or mucous discharge from the pharynx and slight contact bleeding from the endocervix when touched with a cotton applicator. There may also be hyperemia of the mucosa.

In addition, visible pinpoint hemorrhages on the exocervix (so-called strawberry cervix) indicate trichomonad infection, and vesicles and ulcers indicate HPV infection. Many women are asymptomatic with mycoplasma cervicitis, so this infection is often missed.

Internal genital lesions should be suspected in the case of:

• High temperature;
• Bimanual examination pain;
• Soreness when moving the cervix.

Diagnosis of cervicitis

The initial investigation is aimed at identifying the causative agent. The most sensitive and specific test is the nucleic acid amplification test (NAAT). This NAAT test can be performed on samples of endocervical and vaginal secretions as well as urine.

The criteria for using an elevated leukocyte count in Gram staining of endocervical material for the diagnosis of cervicitis have not been standardized. This method has low sensitivity and low positive predictive value.

Methods of diagnosing cervicitis

Cervicitis treatment

Treatment tactics depend on the etiology of cervicitis and may vary depending on the cause of the disease.

Empirical treatment

According to CDC guidelines, empiric treatment is recommended for women at increased risk for sexually transmitted infections: girls younger than 25 years of age, women with a new sexual partner, a partner with a previously established sexually transmitted infection, and those who have multiple sexual partners at the same time.Such patients are prescribed antibiotic therapy for chlamydia and gonorrhea.

Empirical treatment is also recommended for women in whom testing fails to detect the causative agent. Treatment may be deferred until confirmatory test results are available in women at lower risk of sexually transmitted infections.

There are the following drugs for empiric therapy:

• Azithromycin – orally once a day;
• Ceftriaxone – intramuscularly once;
• Doxycycline – orally for 7 days;
• Cefixime – once orally.

For severe penicillin/cephalosporin allergies, it is recommended:

• Azithromycin – orally once a day.

Treatment based on laboratory results

If infectious agents are detected by laboratory tests, treatment is as follows:

• Chlamydia: single oral dose of azithromycin or doxycycline course;
• Gonorrhea: ceftriaxone intramuscularly once for those with body weight less than 150 kg and negative other infections;
• Mycoplasma: doxycycline for 3 days or azithromycin for 3 days;
• Trichomonads: single oral dose of metronidazole or tinidazole;
• Bacterial vaginosis: metronidazole oral course, metronidazole gel 0.75% vaginally, clindamycin cream 2% intravaginally, clindamycin in suppositories intravaginally;
• HPV: oral acyclovir, valacyclovir, famciclovir.

Contact tracking

Contact tracing is the first priority for chlamydia, gonorrhea, trichomoniasis and M. genitalium and should be performed in all patients with confirmed infection. Contact tracing for herpes simplex virus is not recommended. Sexual activity should be discontinued until completion of the therapeutic regimen. HIV-positive women with cervicitis receive the same treatment as HIV-negative women.

Timely treatment in these women reduces viral shedding and may reduce the risk of HIV transmission.

Chronic cervicitis

The term “chronic cervicitis” is used for women with persistent discharge persisting for three months despite exclusion of infection and empirical antibiotic therapy. Patients should be re-examined for possible re-exposure to an infectious agent. In the absence of infection, there is no evidence for the efficacy of repeated or prolonged antimicrobial therapy for persistent symptomatic cervicitis.

Complications

The spread of infection to the uterus, fallopian tubes and ovaries with the development of pelvic inflammatory disease (PID) is a dangerous complication of cervicitis. PID can lead to both an acute condition and have chronic consequences, including chronic pelvic pain, ectopic pregnancy and infertility.

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Pregnancy

The presence of cervicitis associated with sexually transmitted infections correlates with unfavorable pregnancy outcomes, especially premature rupture of the fetal membranes, premature delivery, and birth of low birth weight babies for gestational age. Untimely diagnosed chlamydial infection during pregnancy leads to perinatal exposure of the child to an infected maternal cervix. Primary neonatal C. trachomatis infection affects the mucous membranes of the eyes, oropharynx, urogenital tract and rectum.

The most severe manifestations of infection with N. gonorrhoeae infection in neonates are neonatal conjunctivitis and sepsis, which may include arthritis and meningitis. Less severe manifestations are rhinitis, vaginitis, urethritis and scalp infection.

Pregnant women, regardless of gestational age, should undergo mandatory prenatal infection screening and, if infection is detected, recommended treatment.