Acute Cervicitis

Acute cervicitis is sudden inflammation of the cervix, usually from sexually transmitted infection.

• Common causes are Chlamydia trachomatis and Neisseria gonorrhoeae; others are Mycoplasma genitalium, Trichomonas vaginalis and herpes simplex virus.
• Many women have no symptoms.
• Untreated infection ascends to cause pelvic inflammatory disease, infertility and ectopic pregnancy.

Mucopurulent vaginal discharge, intermenstrual or post-coital bleeding, dyspareunia, dysuria and lower abdominal discomfort.

• The cervix is red, oedematous, friable, and bleeds on touch with mucopus at the os.
• Differential diagnosis: bacterial vaginosis, trichomoniasis, cervical ectropion, herpes cervicitis, cervical cancer, pelvic inflammatory disease, endometritis.
• Complications: pelvic inflammatory disease, tubal infertility, ectopic pregnancy, chronic pelvic pain, preterm birth and neonatal infection.

Diagnosis is by speculum examination and testing for sexually transmitted infection.

• Speculum examination for mucopus and friability.
• NAAT (Xpert CT/NG where available) from an endocervical or self-collected vaginal swab; otherwise Gram stain showing more than 10 white blood cells per high-power field.
• Wet mount for trichomonads and clue cells; vaginal pH.
• HIV, syphilis and hepatitis B tests; pregnancy test.
• HSV PCR when ulcers or vesicles are present.

Treat promptly for chlamydia and gonorrhoea, add cover for other causes when likely, and treat partners.

• Supportive: abstain from intercourse until the woman and partners have completed treatment and for 7 days afterwards; partner notification and treatment; condom use; adequate fluids.
• Pharmacological: ceftriaxone 500 mg IM single dose plus doxycycline 100 mg oral 12-hourly for 7 days, plus metronidazole 400 mg oral 12-hourly for 7 days when trichomoniasis or bacterial vaginosis is likely. Alternative to doxycycline: azithromycin 1 g oral single dose. Herpes cervicitis: aciclovir 400 mg oral 8-hourly for 7 to 10 days. Paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours) for pain.
• Procedures: none.
• Special groups: in pregnancy replace doxycycline with azithromycin 1 g oral single dose, and repeat testing 4 weeks after treatment. In HIV infection give the full regimen without dose change and check that cervical screening is up to date. In ceftriaxone allergy give gentamicin 240 mg IM single dose plus azithromycin 2 g oral single dose.
• Red flags: lower abdominal pain, fever, cervical motion tenderness (pelvic inflammatory disease): give ceftriaxone 500 mg IM single dose, doxycycline 100 mg oral 12-hourly for 14 days and metronidazole 400 mg oral 12-hourly for 14 days. Also watch for joint swelling or skin lesions (disseminated gonococcal infection).
• Follow-up: review at 1 week if symptoms persist; retest at 3 months; test of cure at 4 weeks in pregnancy.