What is the most likely diagnosis and initial management for a patient with two weeks of intermittent spotting and an erythematous, friable cervix?

Diagnosis and Management of Cervicitis

The most likely diagnosis is mucopurulent cervicitis, most commonly caused by Chlamydia trachomatis or Neisseria gonorrhoeae, and you should initiate empiric treatment with azithromycin 1 g orally as a single dose (or doxycycline 100 mg orally twice daily for 7 days if not pregnant) while awaiting NAAT results. 1

Diagnostic Approach

The clinical presentation of intermittent spotting with an erythematous, friable cervix represents the two cardinal signs of cervicitis: 1

• Sustained endocervical bleeding easily induced by gentle passage of a cotton swab (cervical friability) 1
• Purulent or mucopurulent endocervical exudate visible in the endocervical canal (the erythematous appearance suggests inflammation) 1

Essential Diagnostic Testing

Obtain NAATs for C. trachomatis and N. gonorrhoeae immediately - these are the preferred diagnostic tests and can be performed on either cervical or urine samples. 1 NAATs are far superior to older methods, with microscopy for detection having only approximately 50% sensitivity. 1

Additional testing should include: 1

• Wet mount microscopy of vaginal secretions to assess for white blood cells (>10 WBC per high-power field suggests endocervical inflammation) and to detect Trichomonas vaginalis 1
• Testing for bacterial vaginosis if present, as it should be treated concurrently 1
• Syphilis and HIV testing for all patients diagnosed with a new STD 1

Most Likely Etiologic Agents

When an organism is identified in cervicitis, the most common pathogens are: 1, 2

• Chlamydia trachomatis - the single most common identifiable cause 2, 3
• Neisseria gonorrhoeae 2
• Trichomonas vaginalis - especially if concurrent trichomoniasis 2
• Herpes simplex virus type 2 (HSV-2) - particularly during primary infection 2
• Mycoplasma genitalium - emerging pathogen, though standardized tests are not commercially available 2, 4

Critical caveat: In the majority of cervicitis cases, no organism is isolated, especially in women at relatively low risk for recent STD acquisition (e.g., women aged >30 years). 1 However, this does not change initial empiric management in symptomatic patients.

Empiric Treatment Strategy

When to Treat Presumptively (Without Awaiting Test Results)

Initiate empiric antibiotic therapy immediately if: 1

• Age <25 years 1
• New or multiple sex partners 1
• Unprotected sexual intercourse 1
• Follow-up cannot be ensured 1
• High community prevalence setting 1

Recommended Treatment Regimens

For non-pregnant patients: 1

• Azithromycin 1 g orally as a single dose
  • OR
• Doxycycline 100 mg orally twice daily for 7 days 1, 5

For pregnant patients: 6

• Azithromycin 1 g orally as a single dose (preferred - ensures compliance with directly observed therapy) 6
• Doxycycline is absolutely contraindicated in pregnancy 6, 5

Concurrent Gonococcal Coverage

Add treatment for N. gonorrhoeae if: 1

• Local prevalence is >5% in the patient population (young age and facility prevalence) 1
• This is particularly important in high-risk settings 1

Concurrent Infections

Treat concomitant conditions if detected: 1

• Trichomoniasis - metronidazole 2 g orally as a single dose 1
• Symptomatic bacterial vaginosis 1

Partner Management

All sexual partners within the preceding 60 days must be: 1, 6

• Notified and examined 1
• Treated with the same regimen as the index patient, even if asymptomatic 1, 6
• Instructed to abstain from sexual intercourse until therapy is completed (7 days after single-dose regimen or after completion of 7-day regimen) 1, 6

This is critical to prevent reinfection, which is the most common cause of persistent infection. 4

Follow-Up Protocol

Patients should return for reevaluation if: 1

• Symptoms persist after completing therapy 1
• New symptoms develop 1

For women with persistent cervicitis after initial treatment: 1, 2

• Reevaluate for possible reexposure to an STD 1
• Reassess vaginal flora 1
• Exclude relapse or reinfection with specific STDs 1
• Ensure sex partners have been evaluated and treated 1

Critical Pitfalls to Avoid

Do not continue empiric antibiotics indefinitely without an identified pathogen - the value of repeated or prolonged antibiotic therapy for persistent symptomatic cervicitis is unknown and has no proven benefit. 2 Most persistent cases are NOT caused by relapse or reinfection with C. trachomatis or N. gonorrhoeae. 2

Other causes of persistent cervicitis include: 2

• Frequent douching (should be discontinued) 2
• Chemical irritants from feminine hygiene products 2
• Persistent abnormality of vaginal flora 2
• Idiopathic inflammation in the zone of ectopy 2

Do not use doxycycline in pregnant women - it is absolutely contraindicated. 6, 5

Do not forget partner treatment - reinfection rates are significantly higher when partners are not adequately treated. 6

Do not delay treatment while awaiting culture results in high-risk populations or when follow-up is uncertain. 6 Prevention of long-term sequelae (including progression to pelvic inflammatory disease with risk of infertility, ectopic pregnancy, and chronic pelvic pain) has been linked directly with immediate administration of appropriate antibiotics. 1, 7