What are the signs of cervicitis?

Signs of Cervicitis

The two major diagnostic signs that characterize cervicitis are: 1) a purulent or mucopurulent endocervical exudate visible in the endocervical canal or on an endocervical swab specimen, and 2) sustained endocervical bleeding easily induced by gentle passage of a cotton swab through the cervical os. 1

Clinical Presentation

Cervicitis often presents with the following signs:

• Primary diagnostic signs:

  • Purulent or mucopurulent yellow endocervical exudate
  • Easily induced endocervical bleeding with gentle passage of a cotton swab

• Additional clinical findings:

  • Leukorrhea (>10 WBC per high power field on microscopic examination of vaginal fluid)
  • Presence of polymorphonuclear leukocytes on endocervical Gram stain (though this criterion is not standardized)
  • Gram-negative intracellular diplococci (GNID) on Gram stain (specific but insensitive for gonococcal infection, observed in only 50% of women with this infection) 1

Associated Symptoms

While cervicitis is frequently asymptomatic, some women may experience:

• Abnormal vaginal discharge
• Intermenstrual vaginal bleeding, particularly after sexual intercourse
• Urinary frequency (less common) 2, 3

Etiology

Cervicitis is typically caused by:

• Common infectious agents:

  • Chlamydia trachomatis
  • Neisseria gonorrhoeae

• Other potential causes:

  • Trichomonas vaginalis
  • Herpes simplex virus (especially primary HSV-2 infection)
  • Mycoplasma genitalium
  • Bacterial vaginosis-associated organisms
  • Frequent douching
  • Chemical irritants 1, 2, 3

It's important to note that in the majority of cervicitis cases, no specific organism is isolated, especially in women at relatively low risk for recent acquisition of STDs (e.g., women >30 years of age) 1.

Diagnostic Approach

When cervicitis is suspected based on the above signs:

• Test for C. trachomatis and N. gonorrhoeae using nucleic acid amplification tests (NAATs) as these are the most sensitive and specific tests available
• Evaluate for bacterial vaginosis and trichomoniasis
• Consider testing for HSV-2, particularly in cases of primary infection
• For women with negative microscopy for trichomonads but with symptoms, further testing (culture or antigen-based detection) is recommended 1, 4

Clinical Significance

Cervicitis is clinically important because:

• It may be a sign of upper genital tract infection (endometritis)
• If untreated, it can lead to serious complications including pelvic inflammatory disease (PID), which may result in:
  • Infertility
  • Ectopic pregnancy
  • Chronic pelvic pain 5, 2, 6

Common Pitfalls and Caveats

1. Asymptomatic presentation: Many women with cervicitis are asymptomatic, highlighting the importance of screening high-risk populations 1, 3

2. Low predictive value of certain signs: The presence of polymorphonuclear leukocytes on endocervical Gram stain has a low positive-predictive value for infection with C. trachomatis and N. gonorrhoeae 1

3. Persistence despite treatment: Cervicitis can persist despite repeated courses of antimicrobial therapy, suggesting that non-infectious causes (e.g., persistent abnormality of vaginal flora, chemical irritants, or idiopathic inflammation in the zone of ectopy) may be involved 1

4. Risk factors: Risk factors for cervicitis among women with bacterial vaginosis include older age, lower educational level, new male sex partner, female sex partner, recent oral sex, and absence of vaginal H2O2-producing Lactobacillus species 7

5. Absence of H2O2-producing lactobacilli: This may contribute to the development of cervicitis and is an important factor to consider in women with bacterial vaginosis 7