Management of Cervical Friability
Cervical friability should be evaluated for underlying causes, with testing for sexually transmitted infections being the first-line approach, as most cases of cervicitis with friability are of unknown etiology but require treatment of potential infectious causes.
Definition and Clinical Presentation
- Cervical friability refers to easy bleeding from the cervix when touched with a swab during examination
- Often presents as part of cervicitis, which may include:
- Mucopurulent discharge from the cervix
- Cervical ectopy (columnar epithelium visible on the ectocervix)
- Microscopic findings of >10 or >30 white blood cells per high-power field on Gram stain 1
Diagnostic Approach
Initial Evaluation
Visual inspection of the cervix to confirm friability and assess for:
- Mucopurulent discharge
- Cervical ectopy
- Polyps or other local causes
Microbiological testing for:
- Neisseria gonorrhoeae (GC)
- Chlamydia trachomatis (CT)
- Trichomonas vaginalis
- Bacterial vaginosis
- Candidiasis
Consider additional testing based on risk factors:
- HIV testing
- Syphilis serology
- HSV culture if vesicular lesions present
Risk Factors
While risk assessment has limited predictive value for cervical infections 2, consider:
- New sexual partner in past 3 months
- Partner with STD-related symptoms
- Multiple sexual partners
- Previous STIs
Management Algorithm
1. Local Causes (e.g., polyp)
- Treat or refer to gynecology for management 3
2. Infectious Etiology
Confirmed GC/CT Infection
- Treat according to current STI guidelines:
- For gonorrhea: Ceftriaxone 500mg IM single dose
- For chlamydia: Doxycycline 100mg twice daily for 7 days or Azithromycin 1g orally in a single dose
- Partner notification and treatment
- Test of cure as per local guidelines
Presumptive Treatment (When Testing Not Immediately Available)
- Consider empiric treatment for both GC and CT if:
- High-risk population
- Significant symptoms
- Partner with confirmed infection
- Unable to ensure follow-up
Other Vaginal Infections
- Treat bacterial vaginosis, trichomoniasis, or candidiasis according to identified pathogen
3. Non-Infectious Causes
- Hormonal influences (consider hormonal status)
- Mechanical trauma
- Inflammatory conditions
- Neoplastic processes (refer for colposcopy if suspicious lesions)
Follow-up Care
Schedule follow-up at 1-2 weeks after treatment to:
- Assess resolution of symptoms
- Review test results
- Ensure partner treatment if applicable
For persistent cervical friability despite appropriate treatment:
- Consider colposcopy to rule out cervical dysplasia or malignancy
- Consider biopsy for histological examination
Special Considerations
Pregnancy
- Cervical friability is more common in pregnancy due to increased vascularity
- Safe treatment options must be selected (avoid doxycycline)
- More vigilant follow-up may be required
Immunocompromised Patients
- Consider broader differential diagnosis including:
- CMV
- Mycobacterial infections
- Fungal infections
Pitfalls and Caveats
Not all cervical friability indicates infection
- Normal physiological changes, particularly in pregnancy or with hormonal contraceptive use, can cause increased friability
Beware of missed diagnoses
- Studies show that most cases of cervicitis are not caused by GC or CT 1
- Consider other infectious and non-infectious etiologies
Avoid overtreatment
- Empiric treatment should be guided by local epidemiology and risk factors
- Unnecessary antibiotics contribute to antimicrobial resistance
Don't miss cervical cancer
- Persistent friability warrants further investigation
- Consider age-appropriate cervical cancer screening
By following this structured approach to cervical friability, clinicians can ensure appropriate diagnosis and management while avoiding unnecessary treatments or missed diagnoses.