Acute cervicitis refers to a condition characterized by localized congestion, edema, epithelial degeneration, necrosis of the cervix, and infiltration of neutrophils in the mucosa, submucosal tissues, and surrounding glands, often accompanied by purulent discharge in the glandular lumen. Acute endocervicitis specifically involves infection of columnar epithelium, including the columnar epithelium lining the endocervical canal and that which has extended or everted onto the ectocervix.
Etiology and Pathogens
The primary pathogens associated with acute endocervicitis include:
- Sexually transmitted pathogens: Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, herpes simplex virus, and cytomegalovirus, most commonly seen in individuals at high risk for sexually transmitted infections (STIs).
- Endogenous pathogens: Aerobic and anaerobic bacteria, particularly those associated with bacterial vaginosis, can also play a role in the development of this condition.
- Unclear etiology in some patients: Cases without identifiable pathogens may be related to abnormalities in the vaginal microbiota.
Both Neisseria gonorrhoeae and Chlamydia trachomatis specifically infect the columnar epithelium of the endocervical canal, spreading superficially along the mucosal surface and predominantly affecting the endocervix. In addition to the columnar epithelium of the cervix, these pathogens frequently invade transitional epithelium in the urethra and other locations, leading to urinary symptoms.
Clinical Manifestations
Most patients are asymptomatic. Symptomatic cases are primarily characterized by an increase in vaginal discharge, typically mucopurulent, which may irritate the vulva, causing pruritus and a burning sensation. Additional symptoms may include intermenstrual bleeding or postcoital bleeding. If urinary tract infection occurs as a complication, symptoms such as urinary urgency, frequency, or dysuria may present. During gynecological examination, findings may include cervical congestion, edema, mucosal ectropion, and mucopurulent discharge adhered to or flowing from the cervical canal. The mucosa of the endocervical canal or the everted columnar epithelium often appears fragile, with contact bleeding easily induced. In cases of Neisseria gonorrhoeae infection, involvement of the paraurethral or vestibular glands can result in congestion and edema of the urethral or vaginal mucosa, with significant purulent discharge present.
Diagnosis
A preliminary diagnosis of acute cervicitis can be made when at least one of two characteristic clinical signs is observed, in conjunction with microscopic evidence of increased leukocytes in cervical or vaginal secretions. Following a diagnosis of cervicitis, further testing for sexually transmitted pathogens and vaginal inflammation is necessary.
Characteristic Clinical Signs
One or both of the following signs are considered significant:
- Visible purulent or mucopurulent discharge at the cervical os or on a cervical swab specimen.
- Easy induction of bleeding when wiping the cervical os with a swab.
Leukocyte Detection
An increased number of leukocytes in cervical or vaginal secretions is indicative, although leukocytosis caused by conditions like trichomoniasis or aerobic vaginitis must be excluded.
- Smears of purulent cervical discharge with Gram staining show >30 neutrophils per high-power field (HPF).
- Wet mount microscopy of vaginal secretions reveals >10 leukocytes per HPF.
Pathogen Testing
Common methods to detect sexually transmitted pathogens include:
- Nucleic Acid Amplification Tests (NAATs): Highly sensitive and specific, NAATs are the primary diagnostic method for Neisseria gonorrhoeae, Chlamydia trachomatis, and Mycoplasma genitalium.
- Culture Methods: Neisseria gonorrhoeae can be cultured to identify resistant strains and perform antimicrobial susceptibility testing, although culture sensitivity is lower compared to NAATs and requires stringent conditions. Chlamydia trachomatis and Mycoplasma genitalium are difficult to culture and are rarely used in clinical practice.
- Antigen Detection: Enzyme-linked immunosorbent assays (ELISAs) are available for Neisseria gonorrhoeae, though not widely used clinically. For Chlamydia trachomatis, options include ELISA, direct immunofluorescence, and rapid immunochromatographic assays. Antigen testing for Mycoplasma genitalium has not been developed.
In addition to testing for sexually transmitted pathogens, investigations for vaginal inflammation should be conducted. Methods for evaluating vaginal microecology can be used to detect trichomoniasis, aerobic vaginitis, and bacterial vaginosis. Trichomoniasis and aerobic vaginitis can cause increased leukocytes in vaginal secretions, while bacterial vaginosis-associated pathogens can contribute to cervicitis.
Cervicitis can lead to ascending infections, so it is important to assess for upper genital tract involvement in patients diagnosed with this condition.
Treatment
The treatment primarily involves the use of antimicrobial agents. Depending on the clinical presentation, either empirical antimicrobial therapy or targeted regimen based on identified pathogens may be utilized.
Empirical Antimicrobial Therapy
Patients with high-risk factors for sexually transmitted infections (STIs) (such as being under 25 years of age, having a new sexual partner within the past 60 days, having a partner with multiple sexual partners, or a new partner with an STI) are recommended to receive empirical antimicrobial therapy before obtaining pathogen test results. Since Chlamydia trachomatis infection is clinically common, broad-spectrum antibiotics that cover Chlamydia may be administered. Suggested regimens include doxycycline 0.1 g, twice daily for 7 days, or a single-dose of azithromycin 1 g. For patients with a strong suspicion of Neisseria gonorrhoeae infection or those living in areas with high prevalence rates, additional antibiotics targeting Neisseria gonorrhoeae are recommended.
Pathogen-Specific Antimicrobial Therapy
Once the causative pathogen is identified, specific antimicrobial treatment may be selected.
Uncomplicated Acute Gonococcal Cervicitis
High-dose, single-administration therapies are preferred. Options include:
- Cephalosporins: Ceftriaxone 0.5–1 g as a single intramuscular injection; cefotizoxime 0.5 g as a single intramuscular injection; cefotaxime 0.5–1 g as a single intramuscular injection; or cefixime 0.8 g as a single oral dose.
- Cephamycin Antibiotics: Cefoxitin 2 g as a single intramuscular injection, combined with oral probenecid 1 g.
- Aminoglycosides: Spectinomycin 4 g as a single intramuscular injection.
Cervicitis Caused by Chlamydia trachomatis
Common treatment options include:
- Tetracyclines: Doxycycline 0.1 g, twice daily for 7–10 days; or minocycline 0.1 g, twice daily for 7–10 days.
- Macrolides: Azithromycin 1 g on the first day, followed by 0.5 g daily on days 2 and 3, or alternatively, a single dose of 1 g; clarithromycin 0.25 g twice daily for 7–10 days; or erythromycin 0.5 g four times daily for 7–10 days.
- Quinolones: Ofloxacin 0.3 g twice daily for 7–10 days; levofloxacin 0.5 g once daily for 7–10 days; or moxifloxacin 0.4 g once daily for 7 days.
Since Neisseria gonorrhoeae infections are often co-present with Chlamydia trachomatis infections, treatment of gonococcal cervicitis typically includes antibiotics targeting Chlamydia as well.
Concomitant Bacterial Vaginosis
Concurrent bacterial vaginosis should be treated as its presence may lead to persistent cervicitis.
Management of Sexual Partners
For patients diagnosed with cervicitis caused by Neisseria gonorrhoeae or Chlamydia trachomatis, corresponding examination and treatment should be undertaken for their sexual partners.