Differential Diagnosis for Friable Cervix (Cervicitis)
The most common infectious causes of a friable cervix are Chlamydia trachomatis and Neisseria gonorrhoeae, though the majority of cervicitis cases have no identifiable organism, particularly in women over 30 years old. 1, 2
Cardinal Clinical Signs
A friable cervix presents with two key diagnostic features:
- Sustained endocervical bleeding induced by gentle passage of a cotton swab through the cervical os (cervical friability) 1
- Purulent or mucopurulent endocervical exudate visible in the endocervical canal 3, 1
Infectious Etiologies
Most Common Pathogens (When Identified)
- Chlamydia trachomatis – the most frequently isolated organism in cervicitis when a pathogen is found 3, 1, 2
- Neisseria gonorrhoeae – second most common identifiable cause 3, 1, 2
- Trichomonas vaginalis – causes cervicitis especially when concurrent trichomoniasis is present 1, 2, 4
- Herpes simplex virus type 2 (HSV-2) – particularly during primary infection 1, 2, 5
- Mycoplasma genitalium – emerging pathogen, though standardized commercial diagnostic tests are not widely available 1, 6, 5
Less Common Infectious Causes
- Ureaplasma urealyticum 5
- Cytomegalovirus 5
- Human papillomavirus (HPV) – can cause cervical warts and is associated with cervical inflammation 3, 7
Non-Infectious Etiologies
- Frequent douching – strongly associated with persistent cervicitis 1, 2
- Chemical irritants from feminine hygiene products or spermicides 1, 2
- Persistent abnormality of vaginal flora including bacterial vaginosis 1, 2
- Idiopathic inflammation in the zone of ectopy – can occur without identifiable cause 1, 2
- Cervical ectopy itself may be related to many cases of mucopurulent cervicitis 5
Critical Diagnostic Context
The majority of cervicitis cases remain of unknown etiology even after comprehensive testing. 1, 2, 8 This is especially true in:
- Women over 30 years old 1, 2
- Patients in stable relationships with low STD risk 2
- Cases where initial testing for gonorrhea and chlamydia is negative 8
Conversely, identifiable STD pathogens are more likely in:
- Women under 25 years old 1
- Patients with new or multiple sexual partners 1
- Those reporting unprotected intercourse 1
- Individuals in communities with high STD prevalence 1
Essential Diagnostic Evaluation
Immediate Testing Required
- Nucleic acid amplification tests (NAATs) for C. trachomatis and N. gonorrhoeae on cervical or urine specimens – these have markedly higher sensitivity (≈50%) than microscopy 1
- Wet-mount microscopy of vaginal secretions to assess for ≥10 WBC per high-power field and detect Trichomonas vaginalis 1
- Testing for bacterial vaginosis when present, with concurrent treatment 1
- Syphilis and HIV testing for every patient diagnosed with a new sexually transmitted infection 1
Additional Considerations
- Gram stain of endocervical fluid showing gram-negative intracellular diplococci is specific for gonococcal infection but only 50% sensitive 3
- Leukorrhea (>10 WBC per high-power field on vaginal fluid microscopy) has high negative predictive value for chlamydial and gonococcal cervical infection 3
- M. genitalium testing via NAAT on first-void urine (men) or vaginal/endocervical swabs (women) should be considered when available, though no FDA-cleared commercial test currently exists 6
Common Pitfalls
Do not assume persistent cervicitis after treatment represents treatment failure or reinfection with chlamydia or gonorrhea – the majority of persistent cases have other causes including abnormal vaginal flora, chemical irritants, or idiopathic inflammation. 1
Avoid continuing empiric antibiotics indefinitely without an identified pathogen – this has no proven benefit and risks adverse effects. 1
Remember that cervicitis frequently is asymptomatic – some women complain of abnormal vaginal discharge and intermenstrual bleeding (especially after intercourse), but many have no symptoms. 3, 4